Friday, October 18, 2019


Q: 54 year old male is admitted to ICU with shortness of breath (SOB). On exam, the lower part of the right ear lobe is found to be pulsating. What is the probable cause of SOB?

Answer: Exacerbation of CHF

Examination of Jugular Venous Pressure (JVP) is essential in exacerbation of congestive heart failure (CHF). The objective of the above question is to highlight the fact that frequently very high JVP can be missed as the pulsation may be hidden high up in the neck! In such patients, it is not unusual to have a pulsatile lower part of the ear lobe. JVP is a reliable prognostic sign and its presence or absence has been found to be correlated with a subsequent increased risk of death.




1. Ambrosy AP, Pang PS, Khan S, et al. Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial. Eur Heart J 2013; 34:835.

2. Sinisalo J, Rapola J, Rossinen J, Kupari M. Simplifying the estimation of jugular venous pressure. Am J Cardiol 2007; 100:1779.

Thursday, October 17, 2019

anticoagulation in APS

Q: In patients with antiphospholipid syndrome (APS) who require anticoagulation, which of the following is preferred drug? 

A) warfarin 
B) rivaroxaban 
C) dabigatran 
D) apixaban 
E) edoxaban

Answer: A

Direct oral anticoagulants (DOACs) are fastly getting popular but there are few instances where either warfarin or heparin is still preferred. These include prosthetic heart valves, pregnancy, renal impairment, severe liver disease and antiphospholipid syndrome. 

In antiphospholipid syndrome (APS), warfarin is still a preferred anticoagulation as there is no substantial supportive data available in the favor of DOACs.




Garcia D, Erkan D. Diagnosis and Management of the Antiphospholipid Syndrome. N Engl J Med 2018; 378:2010-2021

Wednesday, October 16, 2019


Q: The official consensus definition of dyspnea from the American Thoracic Society includes all of the following factors except

A) physiological
B) psychological
C) anatomical
D) social
E) environmental 

Answer: C

The consensus statement from the American Thoracic Society defines dyspnea as: 

 "Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioral responses."



Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012; 185:435.

Tuesday, October 15, 2019

Hydralazine in CHF

Q: 54 year old male is recovering in ICU from exacerbation of congestive heart failure (CHF). Hydralazine has been added to the drugs regimen. Which one test should be obtained?

Answer: Antinuclear antibody level

Hydralazine carries the risk of drug-induced lupus. It is recommended to check the baseline antinuclear antibody level before starting hydralazine. Also, it should be checked periodically while patient stays on hydralazine.




1. Finks SW, Finks AL, Self TH. Hydralazine-induced lupus: maintaining vigilance with increased use in patients with heart failure. South Med J. 2006;99(1):18-22. 

2. Mansilla-Tinoco R, Harland SJ, Ryan PJ, et al. Hydralazine, antinuclear antibodies, and the lupus syndrome. Br Med J. 1982;284(6320):936-939.

Monday, October 14, 2019

ASA poisoning

Q: Salicylate poisoning causes? (select one)

A) Hyperpnea and tachypnea
B) Hypopnea and tachypnea

Answer: A

The objective of the above question is to highlight that in salicylate (aspirin) poisoning, one of the physical signs is not only the increased rate but also the increased depth of the respiration, called hyperpnea. This becomes more vital to identify as this is one of the earliest sign of salicylate poisoning. Later it may culminate into hypoventilation and respiratory failure due to muscles fatigue. This is a central effect due to the activation of the respiratory center of the medulla.




1. Hill JB. Salicylate intoxication. N Engl J Med 1973; 288:1110. 

2. Greenberg MI, Hendrickson RG, Hofman M. Deleterious effects of endotracheal intubation in salicylate poisoning. Ann Emerg Med 2003; 41:583.

Sunday, October 13, 2019


Q: All of the following have been considered as risk factors for Nephrogenic systemic fibrosis (NSF) except

 A) high-dose erythropoietin treatment
B) metabolic acidosis
C) proinflammatory conditions
D) elevated calcium levels 
E) elevated phosphate levels

Answer: D 

Nephrogenic systemic fibrosis (NSF) though rare but can be a devastating side effect of gadolinium administration in patients with severe renal dysfunction. Awareness is still not very optimum for this condition. Literature is also very nascent as well. Few of the risk factors identified are high-dose erythropoietin treatment, metabolic acidosis, proinflammatory conditions, elevated iron, and phosphate levels. Gadolinium is itself a calcium channel blocker and high calcium level is not a risk factor identified yet.




Abu-Alfa AK. Nephrogenic systemic fibrosis and gadolinium-based contrast agents. Adv Chronic Kidney Dis 2011; 18:188.

Zhang B, Liang L, Chen W, et al. An Updated Study to Determine Association between Gadolinium-Based Contrast Agents and Nephrogenic Systemic Fibrosis. PLoS One 2015; 10:e0129720.

Saturday, October 12, 2019

resuscitation endpoints

Q: Which of the following is found to be a better target for  resuscitation endpoints for improved  blood supply to abdominal viscera?

A) arterial pH
B) base deficit
C) arterial lactate
D) hourly urinary output 
E) abdominal perfusion pressure

Answer: E

Abdominal perfusion pressure (APP) is defined/calculated as the

  • MAP = Mean Arterial Pressure, and 
  • IAP = Intra-Abdominal Pressure
Studies have shown that APP is better than all other resuscitation endpoints as described in the first four choices of the question above. APP of at least 60 mm Hg is correlated with improved survival from Abdominal Compartment Syndrome (ACS) reflecting the improved blood supply to abdominal viscera.



1. Schein M, Ivatury R. Intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg 1998; 85:1027. 

2. Caldwell CB, Ricotta JJ. Changes in visceral blood flow with elevated intraabdominal pressure. J Surg Res 1987; 43:14.

Friday, October 11, 2019

Anti-epilepsy drugs and suicide

Q: 21 year old female recently started on an anti-seizure medicine is admitted to ICU after a suicide attempt. Which of the anti-epilepsy drug is more associated with the increase suicidal ideation?

A) Carbamazepine 
B) Diazepam 
C) Phenytoin 
D) Lacosamide 
E) All of the anti-seizure drugs 

Answer: E

Unfortunately, less well known and very early side effect of any anti-seizure drug is an increased risk of suicidality. This effect is very high from day 7 to first six months of initiation of the treatment. This risk is shared by all antiseizure drugs and has been officially warned by the FDA. 




1. Bell GS, Gaitatzis A, Bell CL, et al. Suicide in people with epilepsy: how great is the risk? Epilepsia 2009; 50:1933. 

2. Andersohn F, Schade R, Willich SN, Garbe E. Use of antiepileptic drugs in epilepsy and the risk of self-harm or suicidal behavior. Neurology 2010; 75:335. 

3. Arana A, Wentworth CE, Ayuso-Mateos JL, Arellano FM. Suicide-related events in patients treated with antiepileptic drugs. N Engl J Med 2010; 363:542. 

4. Hesdorffer DC, Kanner AM. The FDA alert on suicidality and antiepileptic drugs: Fire or false alarm? Epilepsia 2009; 50:978. 

5. Mula M, Kanner AM, Schmitz B, Schachter S. Antiepileptic drugs and suicidality: an expert consensus statement from the Task Force on Therapeutic Strategies of the ILAE Commission on Neuropsychobiology. Epilepsia 2013; 54:199.

Thursday, October 10, 2019

Hinchey classification system

Q: Hinchey classification system is for which disease?

A) Perforated peptic ulcer
B) Perforated diverticulitis
C) Perforated appendicitis
D) Perforated esophagus
E) Perforated tympanic membrane

Answer: B

Almost all patients with free perforated diverticulitis need surgical intervention. But the choice of techniques depends largely on level of peritoneal contamination. Hinchey described stages of perforated diverticulitis almost 40 years ago and is still considered a standard: 

  • Stage I – Pericolic or mesenteric abscess 
  • Stage II – Walled-off pelvic abscess 
  • Stage III – Generalized purulent peritonitis 
  • Stage IV – Generalized fecal peritonitis



Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978; 12:85.

Wednesday, October 9, 2019

noninvasive measures of ICP

Q: How ocular sonography can provide noninvasive measurement of intracranial pressure (ICP)? 

Answer: Various noninvasive methods have been suggested to estimate higher ICP. These include 
  •  Transcranial Doppler (TCD) 
  •  Tissue resonance analysis (TRA) 
  •  Ocular sonography 
  •  Intraocular pressure 
  •  Tympanic membrane displacement
Ocular sonography provides a noninvasive estimate of high ICP by the measurement of optic nerve sheath diameter. Diameters of 5 to 6 mm is a reliable discriminate cutoff between normal and elevated ICP. This can be very helpful in patients with intracranial hemorrhage or traumatic brain injury.




1. Moretti R, Pizzi B, Cassini F, Vivaldi N. Reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial hemorrhage. Neurocrit Care 2009; 11:406. 

2. Dubourg J, Javouhey E, Geeraerts T, et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med 2011; 37:1059. 

3. Geeraerts T, Merceron S, Benhamou D, et al. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 2008; 34:2062. 

4. Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008; 15:201.

Tuesday, October 8, 2019


Case:  52 year old male is admitted to ICU with Right groin pain, fever, and palpable femoral artery. Patient had coronary angiogram via femoral artery a few months ago. Emergent duplex ultrasound shows Femoral Artery Aneurysm (FAA) with size 4 cm and of saccular morphology. What is the concern?

Answer: intramural FAA infection 

 The above question is designed to highlight the long term issues associated with femoral artery cannulation, a common procedure in ICU and other emergent settings. Studies have shown that the risk of complications related to FAA starts to increase once they start going beyond 3 cm and over 4 cm. As FAAs are more benign in nature, patients with smaller FAA can be followed clinically and with imagings. Any sign of rapid expansion, the development of intraluminal thrombus, or change of morphology to saccular aneurysm should prompt surgical evaluation, as this may be an indication of infection.




1. Lawrence PF, Harlander-Locke MP, Oderich GS, et al. The current management of isolated degenerative femoral artery aneurysms is too aggressive for their natural history. J Vasc Surg 2014; 59:343.

2. Dawson J, Fitridge R. Update on aneurysm disease: current insights and controversies: peripheral aneurysms: when to intervene - is rupture really a danger? Prog Cardiovasc Dis 2013; 56:26.

Monday, October 7, 2019

effective solute

Q: Which of the following is considered effective solute? (select one)

A) Glucose
B) Urea

Answer: A

Although this concept was determined six decades ago but still is very valid and clinically relevant. Glucose is considered an effective osmole because glucose osmotically shifts water from cells. In contrast, urea is an ineffective osmole since there is little or no water shift across the cells.

Clinical significance: Glucose osmotically shifts water out from the cells, expands the extracellular fluid volume, dilutes the sodium concentration and may give erroneously (pseudo) hyponatremia. This does not happen with a rise in urea concentration as there is little water shift.



1. EDELMAN IS, LEIBMAN J, O'MEARA MP, BIRKENFELD LW. Interrelations between serum sodium concentration, serum osmolarity and total exchangeable sodium, total exchangeable potassium and total body water. J Clin Invest 1958; 37:1236. 

2.  Roscoe JM, Halperin ML, Rolleston FS, Goldstein MB. Hyperglycemia-induced hyponatremia: metabolic considerations in calculation of serum sodium depression. Can Med Assoc J. 1975;112(4):452–453.

Sunday, October 6, 2019

Hy's law

Q: What is "Hy's law" of Drug-Induced-Liver-Injury (DILI)?

 Answer: "Hy's law" is named after Dr. Hyman Zimmerman who proposed that 'if serum bilirubin is > 2 times the upper limit of normal in association with > 3 times elevation in serum aminotransferases, it predicts worse prognosis in DILI.'




1. Reuben A. Hy's law. Hepatology 2004; 39:574.

2. Björnsson E. Drug-induced liver injury: Hy's rule revisited. Clin Pharmacol Ther 2006; 79:521. 

Saturday, October 5, 2019

plasma fibrinogen levels

Q: All of the following increase circulating plasma fibrinogen levels except? 

A) age
B) obesity
C) smoking
D) inflammation
E) alcoholism

Answer: E

Fibrinogen is an essential polypeptide in clot formation. It works via various mechanisms. It is the precursor to fibrin. It not only binds platelets but also supports platelet and thrombin aggregations. The most important thing is to be always mindful of the "fine balance" between fibrin clot formation and fibrinolysis. All other choices besides alcohol consumption increase the risk of clot formation and so of deep venous thrombosis (DVT).



Meade TW, Chakrabarti R, Haines AP, et al. Characteristics affecting fibrinolytic activity and plasma fibrinogen concentrations. Br Med J 1979; 1:153.

Friday, October 4, 2019

DVT prophylaxis in cirrhosis

Q: In patients with cirrhosis which of the following is preferred for Deep Venous Thrombosis (DVT) prophylaxis in ICU? (select one)

A) unfractionated heparin 

B) low molecular weight (LMW) heparin


 Unfractionated heparin requires antithrombin (AT) to inhibit thrombin and factor Xa. AT is synthesized in the liver. In patients with cirrhosis, their activity may be reduced. Low molecular weight (LMW) heparins are reliably effective for DVT prophylaxis in hospitalized patients. This also reinforce the fact that in patients with cirrhosis anti-factor Xa levels are not reliable to follow the anticoagulation activity.




1. Bechmann LP, Sichau M, Wichert M, et al. Low-molecular-weight heparin in patients with advanced cirrhosis. Liver Int 2011; 31:75. 

2. Fuentes A, Gordon-Burroughs S, Hall JB, et al. Comparison of anti-Xa and activated partial thromboplastin time monitoring for heparin dosing in patients with cirrhosis. Ther Drug Monit 2015; 37:40.

Thursday, October 3, 2019

ESR and CRP in GCA

Q74-year-old male is admitted to ICU with headache and high fever. Patient gets diagnosed with Giant Cell Arteritis (GCA). Which of the following is more reliable to follow on the progress of GCA? (select one)

A) Erythrocyte sedimentation rate (ESR)
B) C-reactive protein (CRP)

Answer: B

Although ESR and CRP are not the perfect biomarkers of GCA, but CRP is more reliable. The C-reactive protein (CRP) is an hepatically synthesized acute phase reactant and is a sensitive marker of systemic inflammation. Practically, CRP is used in conjunction with the ESR but for academic sake CRP is a better marker.



Kermani TA, Schmidt J, Crowson CS, et al. Utility of erythrocyte sedimentation rate and C-reactive protein for the diagnosis of giant cell arteritis. Semin Arthritis Rheum. 2012;41(6):866–871. 

Wednesday, October 2, 2019

Pharmacologic mydriasis

Q: Pharmacologic mydriasis is very common in ICU. How it can be confirmed?

AnswerMany drugs in ICU can cause mydriasis such as atropine, phenylephrine, clonidine, scopolamine patch, and aerosolized ipratropium. 

Pharmacologic mydriasis can be confirmed by demonstrating partial or no constriction by application of a 1% pilocarpine eye drop. In all other causes of the dilated pupil (except direct damage to pupillary sphincter from trauma or surgery), 1% pilocarpine will cause maximal pupillary constriction.




 Iosson N. Images in clinical medicine. Nebulizer-associated anisocoria. N Engl J Med 2006; 354:e8. 

CARTER JH: Diagnosis of pupillary anomalies. J. Am. Optom. Assoc. (1979) 50(6):671–680.

Tuesday, October 1, 2019

resistant depression

Q: Which of the following drug has shown efficacy as an adjuvant treatment in resistant depression?

A) Thyroid replacements
B) Corticosteroids
C) Growth hormone
D) Estrogen replacements
E) Testosterone replacements

Answer: A

The exact mechanism is not cleared but this is proposed that antidepressants may have iatrogenic effects on the thyroid. Antidepressants may induce a change in iodine capture by thyroid cells or can make it unavailable for thyroid hormone synthesis. T3 is preferred over T4.



 1. Nierenberg AA, Fava M, Trivedi MH, et al. A comparison of lithium and T(3) augmentation following two failed medication treatments for depression: a STAR*D report. Am J Psychiatry 2006; 163:1519.

2. Joffe RT, Singer W. A comparison of triiodothyronine and thyroxine in the potentiation of tricyclic antidepressants. Psychiatry Res 1990; 32:241.

3. Cooper-Kazaz R, Lerer B. Efficacy and safety of triiodothyronine supplementation in patients with major depressive disorder treated with specific serotonin reuptake inhibitors. Int J Neuropsychopharmacol 2008; 11:685.

4. Shelton RC, Osuntokun O, Heinloth AN, Corya SA. Therapeutic options for treatment-resistant depression. CNS Drugs 2010; 24:131.

5.  Sauvage MF, Marquet P, Rousseau A, Raby C, Buxeraud J, Lachâtre G. Relationship between psychotropic drugs and thyroid function: a review. Toxicol Appl Pharmacol. 1998 Apr;149(2):127-35.

Monday, September 30, 2019

pyogenic liver abscess

Q: Which of the following drugs has shown to cause pyogenic liver abscess?

A) beta-blockers
B) calcium channel blockers
C) proton-pump inhibitors
D) acetaminophen
E) thyroid replacement agents

Answer: C

Treatment with proton pump inhibitors has shown to be associated with increased mortality in patients with pyogenic liver abscess. Proton pump inhibitors increase the gastric pH resulting in impaired defense mechanisms against ingested pathogens. Klebsiella pneumoniae is reported to be the most notorious with overgrowth in the intestine and subsequent liver abscess.


1. Lin HF, Liao KF, Chang CM, et al. Correlation between proton pump inhibitors and risk of pyogenic liver abscess. Eur J Clin Pharmacol 2017; 73:1019.

2. Wang YP, Liu CJ, Chen TJ, Lin YT, Fung CP. Proton pump inhibitor use significantly increases the risk of cryptogenic liver abscess: a population-based study. Aliment Pharmacol Ther. 2015 Jun;41(11):1175-81. doi: 10.1111/apt.13203. Epub 2015 Apr 13.

Sunday, September 29, 2019

cephalosporins and renal insuff

Q: Which of the following cephalosporins does not need any dose adjustment in renal insufficiency/failure? 

A) Cefazolin
B) Cefotaxime
C) Ceftriaxone
D) Ceftazidime
E) Cefepime

Answer: C

The objective of above question is to highlight two important facts regarding ceftriaxone. This is the only cephalosporin which does not require renal adjustment. Its elimination half-life and plasma clearance does not correlate linearly with creatinine clearance. Also, ceftriaxone is the only drug which does note get removed via hemodialysis.

This is true till ceftriaxone dosage stays 2 grams or less per day.



1.  Patel IH, Sugihara JG, Weinfeld RE, Wong EG, Siemsen AW, Berman SJ. Ceftriaxone pharmacokinetics in patients with various degrees of renal impairment. Antimicrob Agents Chemother. 1984;25(4):438–442. 

2. Livornese LL Jr, Slavin D, Gilbert B, Robbins P, Santoro J. Use of antibacterial agents in renal failure. Infect Dis Clin North Am 2004;18:556–67 

3. Aronoff GR. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults. 4th ed. Philadelphia, Pa.: American College of Physicians, 1999.

Saturday, September 28, 2019

Misplaced central line

Case report: "Emergency Physician intubated the patient and inserted a central line in the right subclavian vein....Pulmonologist ordered to continue IV fluids and maintain the patient’s central venous pressure (CVP) at 6 to 8 cm of water. At 10 a.m., a nurse contacted Pulmonologist and told him the patient’s CVP was in the 70s.....The radiologist read the chest films from July 24-28. On each of her reports, she recommended the subclavian line be repositioned as the tip of the catheter crossed the midline....When the patient’s sedation was lightened in anticipation of possible extubation, she was found to have weakness and decreased mobility on her left side.".

Read full case at

Friday, September 27, 2019


Q: Who is at higher risk of Post Dural Puncture Headache (PDPH)? 

A) Males 
B) Females 

Answer: B

Lumbar puncture (LP) is a common procedure in ICU. There are many risk factors for PDPH. Female gender, pregnancy,  and young age are the major risk factors. This has been attributed to high levels of circulating estrogen.



1. Wu CL, Rowlingson AJ, Cohen SR, et al. Gender and post-dural puncture headache. Anesthesiology 2006; 105:613.

2. Khlebtovsky A, Weitzen S, Steiner I, et al. Risk factors for post lumbar puncture headache. Clin Neurol Neurosurg 2015; 131:78. 

3. Amorim JA, Gomes de Barros MV, Valença MM. Post-dural (post-lumbar) puncture headache: risk factors and clinical features. Cephalalgia 2012; 32:916. 

Thursday, September 26, 2019

'maternal cause-specific' mortality in cardiac arrest

Q: Which of the following is found to be the leading 'maternal cause-specific' mortality in cardiac arrest in the United States?

A) Postpartum hemorrhage
B) Antepartum hemorrhage
C) Amniotic fluid embolism
D) Sepsis
E) Anesthesia complications

Answer: A

The Nationwide Inpatient Sample (NIS) over fifteen years from 1998 to 2011 from 4843 patients looked for 'maternal cause-specific' mortalities in cardiac arrest. Although there was a long list of causes but almost 28% of women die due to postpartum hemorrhage followed by about 17% due to antepartum hemorrhage. Other three leading causes were heart failure, amniotic fluid embolism, and sepsis.

Causes also include anesthesia complications, aspiration pneumonitis, venous thromboembolism, eclampsia, magnesium toxicity, status asthmaticus, aortic dissection, and others.



Mhyre JM, Tsen LC, Einav S, et al. Cardiac Arrest during Hospitalization for Delivery in the United States, 1998-2011. Anesthesiology 2014; 120:810

Wednesday, September 25, 2019

Diuresis in AKI

Q: Diuresis during resolution of acute kidney injury (AKI) is due to?

A) Glucosuria
B) Urea diuresis
C) Sodium diuresis
D) Water diuresis
E) Formation of new nephrons

Answer: B

Resolution of AKI causes diuresis due to urea as azotemia gets resolved. Urea is an osmotic agent. There are two other major causes of urea diuresis in ICU beside resolution of AKI. One is steroid therapy which causes tissue catabolism, and the second is the addition of high amounts of protein orally via a feeding tube or parenteral nutrition.

 Glucosuria also causes solute diuresis alike urea diuresis but it is in the setting of hyperglycemia (choice A).

 Sodium diuresis occurs during intravenous (IV) saline administration. A similar mechanism occurs when bilateral urinary tract obstruction is relieved. This should be distinguished from urea diuresis and is not exactly due to the resolution of AKI (choice C).

Water diuresis occurs during primary polydipsia, central Diabetes Insipidus, and nephrogenic Diabetic Insipidus (choice D).

Formation of new nephrons does not occur during resolution of AKI (choice E).



Forni LG, Darmon M, Ostermann M, et al. Renal recovery after acute kidney injury. Intensive Care Med. 2017;43(6):855–866. doi:10.1007/s00134-017-4809-x

Tuesday, September 24, 2019

coccidioidomycosis meningitis. in pregnancy

Q: 32 year old female with 12 weeks of pregnancy is admitted to ICU with coccidioidomycosis meningitis. CSF pressure reported normal on Lumbar Puncture (LP). What would be the first line of therapy

A) fluconazole 
B) Itraconazole 
C) Intrathecal amphotericin B 
D) echinocandins
E) Repeated LP

Answer: C

Azoles may have teratogenic effects on fetal bone formation. They are contraindicated in the first trimester of pregnancy. In such scenarios, intrathecal amphotericin B deoxycholate is the recommended therapy. Experts recommend avoiding azoles throughout the pregnancy.

Fluconazole and Itraconazole are azoles (choices A & B).

Interestingly, despite being very potent antifungals, echinocandins have no role in coccidioidal meningitis (choice D).

Repeated LPs are recommended for symptomatic relief only if CSF pressure is high (choice E).




1. Bercovitch RS, Catanzaro A, Schwartz BS, et al. Coccidioidomycosis during pregnancy: a review and recommendations for management. Clin Infect Dis 2011; 53:363. 

2. Mølgaard-Nielsen D, Svanström H, Melbye M, et al. Association between use of oral fluconazole during pregnancy and risk of spontaneous abortion and stillbirth. JAMA 2016; 315:58.

3. Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis 2016; 63:e112.

Monday, September 23, 2019

Korsakoff syndrome

Q: Korsakoff syndrome (KS) is characterized by? (select one)

A) selective anterograde amnesia
B) selective retrograde amnesia
C) both of the above
D) none of the above
E) generalized amnesia

Answer: C

Korsakoff syndrome (KS) is nothing but a distinct advanced neuropsychiatric manifestation of Wernicke encephalopathy (WE) with the same cause i.e., thiamine loss. This is more pronounced in ETOH abusers. It has its own specific MRI findings. It is a disorder of selective anterograde and retrograde amnesia. It is characteristically different from general amnesia (Choice E) as there is an intact sensorium, and preservation of long-term memory and other cognitive skills. Interestingly, attention and social behavior are usually preserved. Although confabulation is more common, patients with KS stay unaware of their illness. 

 KS is irreversible but Acetylcholinesterase inhibitors & memantine have been tried with some success.



1. Blansjaar BA, Van Dijk JG. Korsakoff minus Wernicke syndrome. Alcohol Alcohol 1992; 27:435.

2. Bowden SC. Separating cognitive impairment in neurologically asymptomatic alcoholism from Wernicke-Korsakoff syndrome: is the neuropsychological distinction justified? Psychol Bull 1990; 107:355. 

3. Cochrane M, Cochrane A, Jauhar P, Ashton E. Acetylcholinesterase inhibitors for the treatment of Wernicke-Korsakoff syndrome--three further cases show response to donepezil. Alcohol Alcohol 2005; 40:151. 

4.  Rustembegović A, Kundurović Z, Sapcanin A, Sofic E. A placebo-controlled study of memantine (Ebixa) in dementia of Wernicke-Korsakoff syndrome. Med Arh 2003; 57:149.

Sunday, September 22, 2019


Q: Which of the following thermometers is most accurate during the rewarming phase in hypothermia?

A) rectal thermometers 
B) probe in lower one-third of the esophagus 
C) probe in upper one-third of the esophagus 
D) infrared tympanic thermometers 
E) bladder probes

Answer: B

Temperature probe inserted in the lower one-third of the esophagus - or to be precise - about 24 cm below the larynx) provides the best approximation of cardiac temperature. 

 Rectal temperature becomes unreliable during rewarming as it may be adjacent to cold feces, which may lag in rewarming (choice A).  Esophageal probes in the upper one-third area become unreliable due to heated humidified oxygen in endotracheal (ETT) (choice C). Similarly, infrared tympanic thermometers (temporal artery thermometers) are too superficial to be accurate (choice D). Bladder probe also lags behind during rewarming (choice E).



1. Danzl D. Accidental hypothermia. In: Wilderness Medicine, 6th ed, Auerbach PS (Ed), Elsevier, Philadelphia 2012. p.115.

2. Kempainen RR, Brunette DD. The evaluation and management of accidental hypothermia. Respir Care 2004; 49:192.

Saturday, September 21, 2019


Q: All of the following electrolyte/lab abnormalities are part of Cairo-Bishop definition of laboratory tumor lysis syndrome except

A) Uric acid
B) Potassium 
C) Phosphorus
D) Calcium
E) Sodium


Cairo-Bishop laboratory definition is the easiest way to establish the diagnosis of tumor lysis syndrome. If two or more laboratory values of uric acid, potassium, phosphorus, and calcium change > 25% at presentation or seven days after cytotoxic therapy.



1. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol 2004; 127:3. 

2. Coiffier B, Altman A, Pui CH, et al. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol 2008; 26:2767

Friday, September 20, 2019

The risk of suicide

Q: 20 years old male with no previous history is admitted to ICU after a suicide attempt. Psychiatry service diagnosed him with schizophrenia. All of the following are risk factors for suicide except

A) Male 
B) High school drop-out
C) Active hallucinations 
D) Family history of suicide 
E) Substance Abuse 

Answer: B

The risk of suicide is high especially at the onset of schizophrenia. The risk goes further high in young and highly educated males with the presence of insight. Other risk factors include prior suicide attempts, depression, active hallucinations and delusions, family history of suicide and substance abuse.



Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors. J Psychopharmacol 2010; 24:81.

Thursday, September 19, 2019

Sexually Inappropriate Behavior in Dementia

Q: 72 year old male with senile dementia is admitted in ICU with community-acquired pneumonia. While recovering from pneumonia, he continues to display episodes of agitation and sexually inappropriate behavior. Which of the following gastro-intestinal (GI) drug is found to be effective in Sexually Inappropriate Behavior in Dementia?

A) Cimetidine 
B) Bismuth subsalicylate 
C) Omeprazole 
D) Metoclopramide

Answer: A

Cimetidine is an H2 receptor antagonist but also carries anti-androgen effects via blocking the androgen receptor in the pituitary or the hypothalamus. It reduces both arousal and orgasm.



1. Knigge U, Dejgaard A, Wollesen F, Ingerslev O, Bennett P, Christiansen PM. The acute and long term effect of the H2- receptor antagonist cimetidine and ranitidine on the pituitary gonadal axis in men. Clin Endocrinol (Oxf). 1983;18(3):307-313.

2. Anand Beri, Alan Smith. Cimetidine Treatment of Sexually Inappropriate Behavior in Dementia: A Case Report and Literature Review. Annals of Long-Term Care: Clinical Care and Aging. 2015;23(6):39-42.

Wednesday, September 18, 2019


Q: 24 year old female with DiGeorge syndrome (DGS) is admitted to ICU after her cardiac surgery for postop care. Which electrolyte abnormality should be carefully watched?

A) Hyperkaelemia
B) Hypokalemia
C) Hypernatremia
D) Hypocalcemia
E) Hypermagnesemia

Answer: D

DiGeorge syndrome (DGS) is caused by a heterozygous chromosomal deletion at 22q11.2. DiGeorge syndrome (DGS) is associated with defective development of the pharyngeal pouch system. It consists of a triad

  • conotruncal cardiac anomalies,
  • hypoplastic thymus (causing T cells deficit)
  • parathyroid hypoplasia (causing hypocalcemia) 

Although the disease is mostly limited to children, a large number of adults reach adulthood and many get diagnosed as a parent of DGS! Adults have relatively lower cardiac anomalies but higher palatal and mental disabilities.



1. Bassett AS, McDonald-McGinn DM, Devriendt K, et al. Practical guidelines for managing patients with 22q11.2 deletion syndrome. J Pediatr 2011; 159:332. 

2. Cohen E, Chow EW, Weksberg R, Bassett AS. Phenotype of adults with the 22q11 deletion syndrome: A review. Am J Med Genet 1999; 86:359.

Tuesday, September 17, 2019


Q; Which of the following drug causes Drug-Induced Liver Injury (DILI) by ischemic necrosis?

A) Ergot
B) Amiodarone
C) Lisinopril
D) Oral Contraceptives
E) Ethanol

Answer: A

The objective of the above question is to highlight that, it is not only necessary to know which drugs cause DILI but it is also important to know their mechanism of action (MOA). It helps in the differential diagnosis of DILI from other possible causes of liver injury in complex ICU patients.

 In the above question, Ergot is the only drug known to cause ischemic necrosis and pattern is usually more like 'shock liver'. In contrast, oral contraceptives (OCs) are the only group of drugs known to cause hepatic venous outflow obstruction, popularly known as Budd-Chiari syndrome (choice D), and can be confirmed by imaging. OCs may cause neoplasms too. Ethanol is known to cause DILI via various mechanisms including direct hepatocellular parenchymal damage, acute cholestasis, fibrosis, and microvesicular steatosis (choice E). Here AST is usually double of ALT. Lisinopril may cause acute parenchymal damage as well as chronic hepatitis, and often get ignored (choice C). Amiodarone injury mostly occurs via cholestasis, steatohepatitis, phospholipidosis, and microvesicular steatosis - and transaminases injury pattern would be different as it is less prone to cause direct hepatocellular injury (choice B).



Chang CY, Schiano TD. Review article: drug hepatotoxicity. Aliment Pharmacol Ther 2007; 25:1135.

Monday, September 16, 2019

Ramsay Hunt syndrome

Case: 47 year old immunocompromised m patient is in ICU with septic shock. The patient developed vesicles in the auditory canal. The infectious disease (ID) service wrote in the note: 'probable Ramsay Hunt syndrome' and added the treatment plan. What is Ramsay Hunt syndrome?

Answer:  Herpes Zoster Oticus, popularly known as Ramsay Hunt syndrome is a major otologic complication of Varicella-Zoster Virus reactivation. It may cause hearing loss. It is a triad of
  • ipsilateral facial paralysis
  • ear pain, and 
  • vesicles in the auditory canal and auricle
Treatment is valacyclovir and prednisone.



Coulson S, Croxson GR, Adams R, Oey V. Prognostic factors in herpes zoster oticus (ramsay hunt syndrome). Otol Neurotol 2011; 32:1025.

Sunday, September 15, 2019

Cocaine, VQ scan and PE

Q: What makes cocaine-induced pulmonary injury appears like pulmonary embolism (PE) on ventilation-perfusion (V/Q) lung scan?

Answer:  Cocaine causes a high degree of pulmonary arterial vasospasm. This results in V/Q scan to appear like PE. This can be highly deceiving and can lead to inappropriate anti-coagulation of patient.



Ramachandaran S, Khan AU, Dadaparvar S, Sherman MS. Inhalation of crack cocaine can mimic pulmonary embolism. Clin Nucl Med 2004; 29:756.

Saturday, September 14, 2019

Suicide terms

Q; What is the difference between suicidal ideation, suicide threat, and suicide gesture?

Answer: Patients with any slightest clue of suicide are usually admitted to ICU for 24/7 monitoring till cleared by psychiatry service or transferred to the appropriate facility. Few terminologies are important to know as they may make a difference in clinical management. 

Suicidal ideation is the most worrisome phenomenon as a patient may not only have thoughts about killing himself but may have developed a plan to execute it. In contrast, patients with a suicide threat just intend others to believe that they want to die without any intention to die. Suicide gesture is a more organized form of threat where self-injurious behavior is displayed for others to believe that they want to die without any intention to die.



1. Nock MK. Self-injury. Annu Rev Clin Psychol 2010; 6:339.

2. McCullumsmith C. Laying the groundwork for standardized assessment of suicidal behavior. J Clin Psychiatry 2015; 76:e1333.

Friday, September 13, 2019


Q: Hemodialysis? (select one)

A) Increases the level of Antithrombin iii (AT-3)
B) Reduces the level of Antithrombin iii (AT-3)

Answer: B

AT-3 deficiency can be either hereditary or acquired. There are many clinical situations which reduce the level of AT-3 and consequently make it hard for effective anticoagulation with heparin. Some of such important clinical scenarios are:
  • Disseminated intravascular coagulation (DIC) 
  • Acute thrombosis 
  • Cirrhosis 
  • Nephrotic syndromes 
  • Extracorporeal membrane oxygenation (ECMO) 
  • Hemodialysis 
  • Trauma 
  • Preeclampsia and eclampsia



1. Mammen EF. Antithrombin: its physiological importance and role in DIC. Semin Thromb Hemost 1998; 24:19. 

2. Raya-Sánchez JM, González-Reimers E, Rodríguez-Martín JM, et al. Coagulation inhibitors in alcoholic liver cirrhosis. Alcohol 1998; 15:19. 

3. Kauffmann RH, Veltkamp JJ, Van Tilburg NH, Van Es LA. Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome. Am J Med 1978; 65:607. 

4. Alegre A, Vicente V, Gonzalez R, Alberca I. Effect of hemodialysis on protein C levels. Nephron 1987; 46:386. 

5. Weenink GH, Treffers PE, Vijn P, et al. Antithrombin III levels in preeclampsia correlate with maternal and fetal morbidity. Am J Obstet Gynecol 1984; 148:1092.

Thursday, September 12, 2019

IV adenosine

Q; IV push of 6-12 mg of Adenosine should ideally be given via? (select one)

A) peripheral line
B) central line

Answer: A

The recommended IV dose of 6 or 12 mg of Adenosine is recommended for rapid push via peripheral IVs. Dose should be drastically cut down to 3 or even 1 mg if central venous, particularly upper body access is used.



Ferguson JD, DiMarco JP. Contemporary management of paroxysmal supraventricular tachycardia. Circulation 2003; 107:1096. 

 Link MS. Clinical practice. Evaluation and initial treatment of supraventricular tachycardia. N Engl J Med 2012; 367:1438.

Wednesday, September 11, 2019


Q: 32 year old female is admitted to ICU with lupus associated pulmonary embolism. Rheumatology service diagnosed her lupus secondary to her prescription of hydralazine. Various 'panels' of lab tests have been send. In Hydralazine-associated-lupus, Anti-double stranded (ds) DNA antibodies is supposed to be? (select one)

A) Negative
B) Positive

Answer: A

Although Anti-ds-DNA are usually positive in drug-induced disease with other agents, they are typically absent in drug-induced lupus due to procainamide, hydralazine, and isoniazid.



Iyer P, Dirweesh A, Zijoo R. Hydralazine Induced Lupus Syndrome Presenting with Recurrent Pericardial Effusion and a Negative Antinuclear Antibody. Case Rep Rheumatol. 2017;2017:5245904. doi:10.1155/2017/5245904

Tuesday, September 10, 2019

HeRO graft

Q: What is HeRO graft?

Answer: HeRO graft stands for Hemodialysis Reliable Outflow (HeRO) graft. HeRO graft is the last salvage access for patients who have exhausted all other conventional upper extremities Arterio-Venous (AV) fistula graft sites. The objective is to preserve the thigh access sites for future use. HeRO graft provides outflow for patients with central venous stenosis or occlusion. At one end it is anastomosed proximally to the brachial artery or another inflow artery, and another end to central venous circulation through the internal jugular vein, subclavian vein, or other veins that provides access into the central circulation with the distal tip of the catheter is positioned in the right atrium. 



Al Shakarchi J, Houston JG, Jones RG, Inston N. A Review on the Hemodialysis Reliable Outflow (HeRO) Graft for Haemodialysis Vascular Access. Eur J Vasc Endovasc Surg 2015; 50:108.

Monday, September 9, 2019

Femoral line

Q: For femoral central line, it helps to? (select one)

A) abduct the leg
B) adduct the leg

Answer; A

Positioning to place any CVC plays an important role in its success. For femoral central line, few tricks may help. Ideally, the patient should be placed supine. Abducting the target leg and rotating externally 15 degrees open the femoral triangle. Also, elevating the buttock with rolled bed-sheets or pillows helps in better exposure to femoral vessels.



1. Kim W, Chung RK, Lee GY, Han JI. The effects of hip abduction with external rotation and reverse Trendelenburg position on the size of the femoral vein; ultrasonographic investigation. Korean J Anesthesiol. 2011;61(3):205–209. doi:10.4097/kjae.2011.61.3.205

2. Bannon MP, Heller SF, Rivera M. Anatomic considerations for central venous cannulation. Risk Manag Healthc Policy 2011; 4:27.

Sunday, September 8, 2019


Q: Effect of hypothermia on platelet dysfunction starts at what temperature?

A) 36°C
B) 34°C 
C) 32°C 
D) 30°C 

Answer: B

Hypothermia induces thrombocytopathy via two mechanisms. Primarily, hypothermia reduces the enzymatic activity of plasma coagulation proteins. Secondarily, by preventing the activation of platelets via traction on the glycoprotein Ib/IX/V complex by von Willebrand factor. The onset of this effect is seen as core temperatures drops to 34°C.



Kermode JC, Zheng Q, Milner EP. Marked temperature dependence of the platelet calcium signal induced by human von Willebrand factor. Blood 1999; 94:199. 

Jurkovich GJ, Greiser WB, Luterman A, Curreri PW. Hypothermia in trauma victims: an ominous predictor of survival. J Trauma 1987; 27:1019.

Saturday, September 7, 2019

BC via CVC

Q: Drawing blood cultures from 'just inserted' central venous catheter (CVC)? (select one) 

A) decreases the likelihood of false-positive blood culture 
B) increases the likelihood of false-positive blood culture

Answer: B

Unfortunately, the 'bad' practice of drawing blood cultures from the just inserted CVC is on the rise under the perception that the site is clean and will not affect the result of blood culture. On the contrary, it falsely increases the chances of positive blood culture. If it's not possible to obtain both cultures 'peripherally', an attempt should be made at least to get one culture peripherally - and labeled properly before sending to the laboratory.



Boyce JM, Nadeau J, Dumigan D, et al. Obtaining blood cultures by venipuncture versus from central lines: impact on blood culture contamination rates and potential effect on central line-associated bloodstream infection reporting. Infect Control Hosp Epidemiol 2013; 34:1042.

Friday, September 6, 2019


Q: During bag-mask ventilation (BMV), what is the best way to reduce the likelihood of decreasing gastric inflation? 

 Answer: Squeezing the bag slowly over one full second reduces the likelihood of decreasing gastric inflation. A slowly delivered tidal volume prevents sufficient pressure to open the gastroesophageal sphincter.

It also helps to prevent a dramatic impact on the cardiac output of a patient.



Fitz-Clarke JR. Fast or Slow Rescue Ventilations: A Predictive Model of Gastric Inflation. Fitz-Clarke JR1. Respir Care. 2018 May;63(5):502-509. doi: 10.4187/respcare.05620.

Thursday, September 5, 2019


Q: Which of the following is not part of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score?

A) C-reactive protein 

B) White blood cell  
C) Hemoglobin  
D) Potassium 
E) Creatinine

Answer: D

NF at the base is a clinical diagnosis. If suspicion for necrotizing fasciitis is high on clinical grounds, the patient should proceed straight to the OR. LRINEC should be calculated in equivocal cases. All of the above are the part of score except potassium. Instead, sodium is included in the score. 135 meq/L is the cutoff point for sodium in LRINEC score. 

LRINEC calculators are available at various web search engines (Ref#2) and very easy to calculate with only five components. A score of 8 has a PPV of 93.4% for NF.



1. Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004; 32:1535.