Saturday, December 31, 2022

Acetylcysteine effect on kidney in acetaminophen toxicity

Q: Acetylcysteine given during acetaminophen toxicity to protect the liver - also has a protective effect on the kidney?

A) True
B) False

Answer: B

About half of patients with acetaminophen-induced liver failure may also develop some degree of acute kidney injury (AKI). Patient may develop proteinuria and/or hematuria. This injury occurs via two mechanisms - direct effect with acute tubular necrosis and ischemia due to vascular endothelial damage.

AKI is usually reversible. Unfortunately, despite a robust protective effect on the liver, acetylcysteine has no renal protective effect.



1. Mazer M, Perrone J. Acetaminophen-induced nephrotoxicity: pathophysiology, clinical manifestations, and management. J Med Toxicol 2008; 4:2.

2. Blakely P, McDonald BR. Acute renal failure due to acetaminophen ingestion: a case report and review of the literature. J Am Soc Nephrol 1995; 6:48.

Friday, December 30, 2022

Prone position complications

Q: Name at least five major potential complications while patient gets treated in prone position.

Answer: In last few years, particularly during COVID pandemic, prone position has become a major modality to treat severe ARDS. Said that it comes with its own set of major and sometimes fatal complications. Some are described below.
  • Nerve compressions (particularly brachial plexus injury)
  • Crush injury
  • Venous stasis (close monitoring needed for facial edema)
  • Dislodging endotracheal and other tubes
  • Diaphragm limitation
  • Pressure sores 
  • Dislodgment of central lines or drainage tubes
  • Retinal damage
  • Gastrointestinal intolerance
  • Increased abdominal compartment pressure 
  • arrhythmias



1.Ryan DW, Pelosi P. The prone position in acute respiratory distress syndrome. BMJ 1996; 312:860.

2. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368:2159.

Thursday, December 29, 2022

Liver injury and function - biomarkers

Q: Which are the three biomarkers of liver injury, and three biomarkers of liver function?

Answer: There are three biomarkers each for liver injury and hepatocellular function.

Liver injury
  • alanine aminotransferase (ALT)
  • aspartate aminotransferase (AST)
  • alkaline phosphatase (AP)

Hepatocellular function
  • albumin
  • bilirubin
  • prothrombin time (PT-INR)

Bilirubin may also be counted as a manifestation of liver injury, but it it represents more of overall hepatic function.



1. Lee TH, Kim WR, Poterucha JJ. Evaluation of elevated liver enzymes. Clin Liver Dis. 2012 May;16(2):183-98. doi: 10.1016/j.cld.2012.03.006. PMID: 22541694; PMCID: PMC7110573.

2. Gowda S, Desai PB, Hull VV, Math AA, Vernekar SN, Kulkarni SS. A review on laboratory liver function tests. Pan Afr Med J. 2009 Nov 22;3:17. PMID: 21532726; PMCID: PMC2984286.

Wednesday, December 28, 2022

hookworm Rx

Q: 54 years old construction worker is admitted to ICU with lower GI bleed. Subsequent workup lead to the diagnosis of hookworm infestation. What is the treatment? 

Answer: There are three options to treat hookworm infestation
  • albendazole 400 mg once on an empty stomach 
  • Mebendazole 100 mg twice daily for three days (can be give as a single dose of 500 mg) 
  • pyrantel pamoate, 11 mg/kg per day for three days, max - 1 g/day 
Contrary to popular belief, Ivermectin is not an effective treatment for hookworm infestation. 



1. Chhabra P, Bhasin DK. Hookworm-Induced Obscure Overt Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2017; 15:e161. 

2. Wei KY, Yan Q, Tang B, et al. Hookworm Infection: A Neglected Cause of Overt Obscure Gastrointestinal Bleeding. Korean J Parasitol 2017; 55:391. 

3. Moser W, Schindler C, Keiser J. Efficacy of recommended drugs against soil transmitted helminths: systematic review and network meta-analysis. BMJ 2017; 358:j4307. 

Tuesday, December 27, 2022

Drug Induced Gingival Overgrowth

Q: Which drugs are more prone to cause gingival overgrowth? (select one)

A) Beta-blockers (BB)
B) Calcium Channel Blockers (CCB)

Answer: B

 Gingival overgrowth is popularly known as "gingival hyperplasia." Although phenytoin is well known to cause gingival overgrowth, CCB, i.e., nifedipine, diltiazem, verapamil, and amlodipine, can also cause gingival overgrowth. In transplant patients, cyclosporine is known to do this. 

These drugs may cause the gingival tissues to grow disproportionally by several millimeters and cover almost one-third or even more of teeth crowns. This leads to gingival inflammation and bleeding. 

Most of the time, it is reversible when the drug is discontinued. Another option is to perform gingivectomy.



1. Straka M, Varga I, Erdelský I, Straka-Trapezanlidis M, Krňoulová J. Drug-induced gingival enlargement. Neuro Endocrinol Lett. 2014;35(7):567-76. PMID: 25617879.

2. Tungare S, Paranjpe AG. Drug Induced Gingival Overgrowth. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

Monday, December 26, 2022

Takotsubo (Stress) Cardiomyopathy age group

Q: Takotsubo cardiomyopathy is more common in? (select one)

A) younger people
B) older people

Answer: B

In the last three decades, since first described in Japan in 1990, there have been more cases reported worldwide for takotsubo cardiomyopathy, also known as broken heart syndrome or stress-induced cardiomyopathy. It has a specific characteristic of left ventricle, usually of apex as ballooning out without any known previous heart disease. It occurs under physiological or psychological stress. 

Female to male ratio is about 9:1, and the mean age of occurrence is around 66 years.



1. Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med 2015; 373:929.

2. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation 2008; 118:2754.

Saturday, December 24, 2022

Taking care of patients with active varicella

Q: While entering the room of a patient who has developed active varicella, an N95 mask should be worn?

A) Yes
B) No

Answer: A

Patients with varicella require airborne as well as contact precautions. Ideally, these patients should be assigned to staff with confirmed evidence of immunity against varicella. N95 mask is required both for the staff and the visitors. Although a negative pressure room has been suggested, the risk for people in the corridor is very low and is not cost-effective.



1. Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011; 60:1.

Friday, December 23, 2022


Q: High altitude pulmonary edema (HAPE) occurs due to? (select one)

A) hypoxic pulmonary vasoconstriction
B) hypoxic pulmonary vasodilatation

Answer: A

The most common cause of death in HAPE is noncardiogenic pulmonary edema. High altitude hypoxia leads to pulmonary vasoconstriction resulting in pulmonary edema.

It starts with nonproductive cough and shortness of breath (SOB) on exertion while walking uphill. It progressively culminates into productive pink, frothy sputum, and hemoptysis. Progressively, SOB stays on even at rest or walking on flat surface.

Generally, it takes about 48 to 96 hours to be evident after arriving at a high altitude, and symptoms tend to occur more at night! 

If untreated, or without de-escalation, to the lower altitude, it progresses to high-altitude cerebral edema (HACE).



1. Dunham-Snary KJ, Wu D, Sykes EA, et al. Hypoxic Pulmonary Vasoconstriction: From Molecular Mechanisms to Medicine. Chest 2017; 151:181.

2. Bärtsch P, Swenson ER. Acute high-altitude illnesses. N Engl J Med 2013; 369:1666.

Thursday, December 22, 2022

Define TBI

Q: What is the (official) definition of Traumatic Brain Injury (TBI)?

Answer: The international interagency initiative toward common data elements for research in TBI and psychological health proposed a simple definition of TBI in 2010. Definition states:

"TBI is an alteration in brain function, or other evidence of brain pathology, caused by an external force."

For clinicians, it is important to distinguish the difference between brain and the head injury!

Also, external force need to be under the following six categories:

1. The head being struck by an object
2. The head striking an object
3. Acceleration/deceleration of the brain without direct external impact
4. A foreign body penetrating the brain
5. The force from a blast/explosion
6. Other forces yet to be defined



Menon DK, Schwab K, Wright DW, et al. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil 2010; 91:1637.

Wednesday, December 21, 2022

succinylcholine in myasthenia gravis

Q: Patients with myasthenia gravis requires ____________ dose of succinylcholine? (select one)

A) higher
B) lower

Answer: A

Conventionally succinylcholine is not recommended for patients with myasthenia gravis due to the risk of hyperkalemia. Although it is true but described risk is overly exaggerated in literature Overll it can be used safely in patients with myasthenia gravis. These patients are relatively resistant to succinylcholine, and requires the higher dose. The recommended dose is 2 mg/kg.



1. Levitan R. Safety of succinylcholine in myasthenia gravis. Ann Emerg Med 2005; 45:225.

Tuesday, December 20, 2022

Other uses of nimodipine

Q; Besides its use to prevent vasospasm in subarachnoid hemorrhage, give at least one less common indication of Nimodipine?

Answer: seizure prophylaxis in Pregnancy Induced Hypertension (previously known as preeclampsia

Though not as effective, it can be used as an alternative or an adjuvant to magnesium for seizure prophylaxis in women with severe preeclampsia. Also, it has some adjuvant value in the treatment of intractable seizures.

Nimodipine has been originally designed to treat high blood pressure but is no longer in use for this indication. Also, FDA has a warning against converting Nimodipine capsules as an IV solution.



1. Belfort MA, Anthony J, Saade GR, Allen JC Jr; Nimodipine Study Group. A comparison of magnesium sulfate and nimodipine for the prevention of eclampsia. N Engl J Med. 2003 Jan 23;348(4):304-11. doi: 10.1056/NEJMoa021180. PMID: 12540643.

2. Meyer FB, Cascino GD, Whisnant JP, Sharbrough FW, Ivnik RJ, Gorman DA, Windschitl WL, So EL, O'Fallon WM. Nimodipine as an add-on therapy for intractable epilepsy. Mayo Clin Proc. 1995 Jul;70(7):623-7. doi: 10.4065/70.7.623. PMID: 7791383.

Monday, December 19, 2022

DVT vs May-Thurner syndrome

Q: 32 years old female is admitted to ICU with acute pain and swelling of the entire unilateral lower extremity. There is a concern for Deep Venous Thrombosis (DVT) vs "May-Thurner syndrome." Acute pain and swelling of which entire lower extremity favors the diagnosis of May-Thurner syndrome? - select one

A) Right
B) Left

Answer: B

The classic presentation of May-Thurner syndrome is the acute pain and swelling of the entire left lower extremity. It occurs mostly in females in the second or third decade. It occurs due to the compression of the left iliac vein between the overlying right common iliac artery and the fifth lumbar vertebrae. Said that May-Thurner syndrome may occur with or without venous thrombosis. 

This differential diagnosis is important as the management approach may differ entirely.



1. Mousa AY, AbuRahma AF. May-Thurner syndrome: update and review. Ann Vasc Surg. 2013 Oct;27(7):984-95. doi: 10.1016/j.avsg.2013.05.001. Epub 2013 Jul 10. PMID: 23850314.

2. Al Sinani A, Al Saadi W, Al Harthi S, Al Hajriy M. May-Thurner Syndrome: A Case Report and a Concise Review. Cureus. 2021 Jul 8;13(7):e16256. doi: 10.7759/cureus.16256. PMID: 34373817; PMCID: PMC8346263.

Sunday, December 18, 2022

Imaging in complicated UTI

Q: In patients with acute complicated pyelonephritis, a follow-up CT scan should be performed on transfer from ICU to assure resolution of the pathology?

A) Yes
B) No

Answer: B

Acute complicated pyelonephritis is a disease that can be mostly managed with symptoms and urine analysis/culture. Computed Tomography (CT) is the modality of choice in case of need. Patients who are sick and can not travel to the radiology department can be managed with renal ultrasound. For intensivists: a CT scan may show localized hypodense lesions consistent with ischemia, marked neutrophilic infiltration, and swelling (edema).

Patients do not require follow-up imaging, and clinical improvement is sufficient. Hypodensity on CT scan may take up to 12 weeks to resolve.



1. Kawashima A, LeRoy AJ. Radiologic evaluation of patients with renal infections. Infect Dis Clin North Am 2003; 17:433.

2. Demertzis J, Menias CO. State of the art: imaging of renal infections. Emerg Radiol 2007; 14:13.

Saturday, December 17, 2022

Azoles side effect

Q: Which of the following azoles carries the risk of a triad of hypertension, hypokalemia, and peripheral edema? (select one)

A) Fluconazole 
B) Voriconazole 
C) Posaconazole 
D) Isavuconazole
E) Itraconazole

Answer: E

Each azole antifungal comes with its unique side effect. Itraconazole may cause a triad of 
  • hypertension
  • hypokalemia, and
  • peripheral edema
Overall this triad may culminate into congestive heart failure (CHF). It should be used with caution in cardiac patients.

Fluconazole (choice A) is known for causing alopecia.
Voriconazole (choice B) is known for causing visual changes, neurological and dermal issues, periostitis, and QT prolongation.
Posaconazole (choice C) may cause adrenal insufficiency.
Isavuconazole (choice D) can cause a severe infusion reaction.



1. Sharkey PK, Rinaldi MG, Dunn JF, et al. High-dose itraconazole in the treatment of severe mycoses. Antimicrob Agents Chemother 1991; 35:707.

2. Pappas PG, Kauffman CA, Perfect J, et al. Alopecia associated with fluconazole therapy. Ann Intern Med 1995; 123:354.

3. Levine MT, Chandrasekar PH. Adverse effects of voriconazole: Over a decade of use. Clin Transplant. 2016 Nov;30(11):1377-1386. doi: 10.1111/ctr.12834. Epub 2016 Oct 14. PMID: 27581783.

4. Miller A, Brooks LK, Poola-Kella S, Malek R. Posaconazole-Induced Adrenal Insufficiency in a Case of Chronic Myelomonocytic Leukemia. Case Rep Endocrinol. 2018 Jan 16;2018:2170484. doi: 10.1155/2018/2170484. PMID: 29568655; PMCID: PMC5820546.

5. Kronig I, Masouridi-Levrat S, Chalandon Y, Glampedakis E, Vernaz N, Van Delden C, Neofytos D. Clinical Considerations of Isavuconazole Administration in High-Risk Hematological Patients: A Single-Center 5-Year Experience. Mycopathologia. 2021 Dec;186(6):775-788. doi: 10.1007/s11046-021-00583-9. Epub 2021 Aug 25. PMID: 34432216; PMCID: PMC8602163.

Friday, December 16, 2022

Oral Mg repletion

Q: Sustained-release oral preparations of Magnesium are better absorbed.

A) True
B) False

Answer: A

The objective of this question is to negate the perception that in the ICU, there should always be an intravenous (IV) magnesium be used due to the high risk of diarrhea from oral prep. The sustained-release preparations are slowly and better absorbed, minimizing the risk of diarrhea and excretion via kidneys. Another reason for less diarrhea from sustained release as the total dose required is usually much lower to replete.



1. Weiss D, Brunk DK, Goodman DA. Scottsdale Magnesium Study: Absorption, Cellular Uptake, and Clinical Effectiveness of a Timed-Release Magnesium Supplement in a Standard Adult Clinical Population. J Am Coll Nutr. 2018 May-Jun;37(4):316-327. doi: 10.1080/07315724.2017.1398686. Epub 2018 Feb 9. PMID: 29425476.

2. Blancquaert L, Vervaet C, Derave W. Predicting and Testing Bioavailability of Magnesium Supplements. Nutrients. 2019 Jul 20;11(7):1663. doi: 10.3390/nu11071663. PMID: 31330811; PMCID: PMC6683096.

Thursday, December 15, 2022

risk factors for mucormycosis

Q: Which of the following elemental overdose or even its antidote can be a risk factor for the development of mucormycosis?

A) Magnesium
B) Iron
C) Aluminum
D) Chromium

Answer: B

Iron, as well as its antidote deferoxamine, plays a role in the development of mucormycosis. Other well-known risk factors are
  • Diabetes, particularly the ketoacidosis phase
  • Steroids
  • Hematological malignancies
  • Transplantations 
  • COVID-19
  • AIDS
  • Trauma
  • Burns
  • Malnutrition
Treatment is surgical excision along with antifungal medications.



1. Roden MM, Zaoutis TE, Buchanan WL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis 2005; 41:634.

2. Patel A, Kaur H, Xess I, Michael JS, Savio J, Rudramurthy S, Singh R, Shastri P, Umabala P, Sardana R, Kindo A, Capoor MR, Mohan S, Muthu V, Agarwal R, Chakrabarti A. A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India. Clin Microbiol Infect. 2020 Jul;26(7):944.e9-944.e15. doi: 10.1016/j.cmi.2019.11.021. Epub 2019 Dec 4. PMID: 31811914.

3. Reid G, Lynch JP 3rd, Fishbein MC, Clark NM. Mucormycosis. Semin Respir Crit Care Med. 2020 Feb;41(1):99-114. doi: 10.1055/s-0039-3401992. Epub 2020 Jan 30. PMID: 32000287.

Wednesday, December 14, 2022

Duration of Bereavement

Q: What's the average time for any family to be bereaved after patient's death? (select one)

A) One year
B) Three years
C) Five years
D) Ten years

Answer: D

Bereavement is a lesser discussed subject amongst ICU workforce, but a patient's death has a prolonged effect on the family. It may be a surprise that, at any given point, up to 60 percent of the population can be bereaved at any given time. An average time of bereavement for a family is about ten years since the patient's demise. 



1. Kersting A, Brähler E, Glaesmer H, Wagner B. Prevalence of complicated grief in a representative population-based sample. J Affect Disord 2011; 131:339.

2. M Katherine Shear, Charles F Reynolds III, Naomi M Simon, Sidney Zisook - Bereavement and grief in adults: Clinical features - (last accessed November 30, 2022) - © 2022 UpToDate, Inc. and/or its affiliates. 

Tuesday, December 13, 2022

MOA of tramadol

Q: Tramadol _________________ the reuptake of serotonin? (select one)

A) blocks
B) Exacerbates

Answer: Although Tramadol is an opioid agonist, it is popular in postop care due to its characteristic of lesser frequency of constipation and dependency/addiction. It works via blocking reuptake of serotonin and norepinephrine.

Clinical significance: Its mechanism of action increases the risk of serotonin syndrome, particularly when other serotonergic agents are on board.



Beakley BD, Kaye AM, Kaye AD. Tramadol, Pharmacology, Side Effects, and Serotonin Syndrome: A Review. Pain Physician. 2015 Jul-Aug;18(4):395-400. PMID: 26218943.

electrolyte role in acute spinal shock syndrome

Q: Which electrolyte plays a role in acute spinal shock syndrome?

A) Sodium
B) Potassium
C) Chloride
D) Magnesium
E) Phosphate

Answer: B

Post spinal cord injury, there is flaccid paralysis below the injury, anesthesia, absent bowel, and bladder control, loss of reflex activity, bradycardia, and hypotension. Interestingly, it may cause priapism in males. Usually, many of these functions come back after a few hours or even days.

During state of shock, there is loss of potassium from the injured cells to the extracellular space. Once re-equilibrium of potassium occurs, most of spinal shock symptoms come back, but there could be a spastic paresis. All functions can be regained with proper rehabilitation and involvement of physical therapist, neurologist, neurosurgeon, and sports medicine physician.



1. Ditunno JF, Little JW, Tessler A, Burns AS. Spinal shock revisited: a four-phase model. Spinal Cord 2004; 42:383.

2. SOROKHTIN GN, CHUMAKOVA TA. K voprosu o prirode spinal'nogo shoka. II. Vliianie ionov kaliia i kal'tsiia na razvitie spinal'nogo shoka [Nature of spinal shock. II. Effect of potassium and calcium ions on the development of spinal shock]. Biull Eksp Biol Med. 1959 May;47(5):11-4. Russian. PMID: 13671029.

3. Wielopolski L, Ramirez LM, Spungen AM, Swaby S, Asselin P, Bauman WA. Measuring partial body potassium in the legs of patients with spinal cord injury: a new approach. J Appl Physiol (1985). 2009 Jan;106(1):268-73. doi: 10.1152/japplphysiol.90435.2008. Epub 2008 Nov 20. PMID: 19023024.

Monday, December 12, 2022

complicated acute diverticulitis

Q: Which pathologies qualify as complicated acute diverticulitis?

Answer: Any of the following major associated pathology qualifies acute diverticulitis as complicated:

1. frank perforation
2. obstruction
3. abscess
4. fistulization

Clinical significance: The rate of colonic cancer detection on follow-up colonoscopy after complicated diverticulitis is between 8 to 11 percent, whereas, in uncomplicated diverticulitis, it is only 0.5 to 0.7 percent.



1. Linzay CD, Pandit S. Acute Diverticulitis. 2022 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29083630.

2. Balk EM, Adam GP, Cao W, et al. Evaluation and Management After Acute Left-Sided Colonic Diverticulitis : A Systematic Review. Ann Intern Med 2022; 175:388.

3. Rottier SJ, van Dijk ST, van Geloven AAW, et al. Meta-analysis of the role of colonoscopy after an episode of left-sided acute diverticulitis. Br J Surg 2019; 106:988.

Sunday, December 11, 2022


Q: What is 'recrudescence' in Malignant Hyperthermia (MH)?

Answer: Out of five patients treated for MH, one may experience recrudescence after successful treatment of an acute event. Symptoms of recrudescence are tachycardia, respiratory rate doubling or tripling, and a re-rise of body temperature. If these symptoms occur two or more hours after the first acute event, it is described as recrudescence. Risk factors are patients with high muscle mass and level of high temperature in the first event. In contrast to the first acute MH event, recrudescence can be highly morbid with a vital organ failure.



1. Hopkins PM. Recrudescence of malignant hyperthermia. Anesthesiology. 2007 May;106(5):893-4. doi: 10.1097/ PMID: 17457116.

2. Larach MG, Gronert GA, Allen GC, Brandom BW, Lehman EB. Clinical presentation, treatment, and complications of malignant hyperthermia in North America from 1987 to 2006. Anesth Analg. 2010 Feb 1;110(2):498-507. doi: 10.1213/ANE.0b013e3181c6b9b2. PMID: 20081135.

Saturday, December 10, 2022

muscle weakness in Hypercortisolism

Q: Hypercortisolism, as in Cushing's syndrome, causes muscle weakness in? (select one)

A) distal part of the body 
B) proximal part of the body

Answer: B

The most common symptoms of Cushing's syndrome as in hypercortisolism are 
  • proximal muscle weakness
  • facial plethora
  • wasting of the extremities 
  • increased fat in the abdomen and face
  • wide purplish striae
  • bruising with no obvious trauma
  • supraclavicular fat pads

These symptoms usually develop over time, and sometime patient take it as normal life changes.



1. Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2008; 93:1526.

2. Nieman LK. Cushing's syndrome: update on signs, symptoms and biochemical screening. Eur J Endocrinol 2015; 173:M33.

3. Ross EJ, Linch DC. Cushing's syndrome--killing disease: discriminatory value of signs and symptoms aiding early diagnosis. Lancet 1982; 2:646.

Friday, December 9, 2022

TikToc Tics

Case: 23 years old female is admitted to ICU with anxiety, depression, and suicidal ideation. Family reported recent symptoms of tic. Psychology service was consulted, and they diagnosed patient with "TikTok tics."

Answer: Interestingly, there was an increase in reporting of functional tics during COVID-Pandemic. The probable cause is mental health issues while in isolation. A particular form is called "TikTok tics." Most young females between the ages of 15 and 25 have been reported to have acute, complex vocal and motor tics involving large-amplitude arm movements. Associated symptoms were a tendency to self-injury, anxiety, depression, and coprolalia (use of wide range of odd words and obscenities). The common underlying feature is the long hours of viewing online videos depicting tic-like behaviors.

Coprolalia is a prominent distinguishing feature between functional and nonfunctional tics. 



1. Pringsheim T, Ganos C, McGuire JF, et al. Rapid Onset Functional Tic-Like Behaviors in Young Females During the COVID-19 Pandemic. Mov Disord 2021; 36:2707.

2. Müller-Vahl KR, Edwards MJ. Mind the Difference Between Primary Tics and Functional Tic-like Behaviors. Mov Disord 2021; 36:2716.

3. Müller-Vahl KR, Pisarenko A, Jakubovski E, Fremer C. Stop that! It's not Tourette's but a new type of mass sociogenic illness. Brain 2022; 145:476.

Thursday, December 8, 2022

Anti-hypertensive combinations

Q: Describe at least three paired groups of antihypertensives that should be avoided simultaneously?

Answer:  Antihypertensives are the lifelines of hemodynamics, but care should be taken when more than two antihypertensives are indicated. Following are the three classic paired groups, which should not be prescribed together.

1. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) should not simultaneously be prescribed.
2. Beta-blockers should not be combined with nondihydropyridine calcium channel blockers (i.e., diltiazem, verapamil) due to their similar negative inotropic and chronotropic effects.

3. Alpha-blockers and central adrenergic inhibitors (e.g., clonidine) should not be prescribed together. They can cause life-threatening hypotension.



1. Guerrero-García C, Rubio-Guerra AF. Combination therapy in the treatment of hypertension. Drugs Context. 2018 Jun 6;7:212531. doi: 10.7573/dic.212531. PMID: 29899755; PMCID: PMC5992964.

2. Mancia G, Rea F, Corrao G, Grassi G. Two-Drug Combinations as First-Step Antihypertensive Treatment. Circ Res. 2019 Mar 29;124(7):1113-1123. doi: 10.1161/CIRCRESAHA.118.313294. PMID: 30920930.

3. Flack JM, Sica DA, Bakris G, et al. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension 2010; 56:780.

Wednesday, December 7, 2022

Fleischner lines

Q: What are Fleischner lines on CXR?

Answer: Long linear bands of atelectasis in a hypoxic patient are called Fleischner lines. These are highly suspicious of unilateral or bilateral pulmonary embolism (PE), particularly if CXR is otherwise clear. These were described 50 years ago when CT angiographies to confirm PE were unavailable. 

Unilateral or bilateral pleural effusions may also be present.


 Baron MG. Fleischner lines and pulmonary emboli. Circulation. 1972 Jan;45(1):171-8. doi: 10.1161/01.cir.45.1.171. PMID: 5007031.

Tuesday, December 6, 2022


Q: OHAT serves which purpose at the end of life care?

Answer: Oral care

OHAT stands for Oral Health Assessment Tools. Although many oral health assessment tools have been developed, the most commonly used and validated one is the Kayser-Jones Brief Oral Health Status Examination tool. it has 10 components that objectively examine the full oral health care. It includes 

1. Lymph nodes
2. Lips
3. Tongue
4. Tissue inside cheek, floor, and roof of the mouth
5. Gums between teeth and/or under artificial teeth
6. Saliva effect on tissue
7. Condition of natural teeth
8. Condition of artificial teeth
9. Pairs of teeth in chewing position (natural or artificial)
10. Oral cleanliness

Each category has three levels of a score, i.e., 0, 1 or 2

It can be used by any trained healthcare worker. If a patient score 1 or 2  in any category, a dentist or a physician should be referred. Tool is easily available from any internet search engine.



1. Kayser-Jones J, Bird WF, Paul SM, et al. An instrument to assess the oral health status of nursing home residents. Gerontologist 1995; 35:814. 

2. Everaars B, Weening-Verbree LF, Jerković-Ćosić K, et al. Measurement properties of oral health assessments for non-dental healthcare professionals in older people: a systematic review. BMC Geriatr 2020; 20:4.

3. Chalmers JM, King PL, Spencer AJ, et al. The oral health assessment tool--validity and reliability. Aust Dent J 2005; 50:191.

4. Chalmers J, Johnson V, Tang JH, Titler MG. Evidence-based protocol: oral hygiene care for functionally dependent and cognitively impaired older adults. J Gerontol Nurs 2004; 30:5.

Monday, December 5, 2022

playboy sign of ultrasound

Q: What is the playboy bunny sign of ultrasound? 

 Answer: Any cause which results in hepatic congestion - portrays dilated hepatic vessels as a playboy bunny. This includes congestive heart failure (CHF), constrictive pericarditis, pericardial effusion, cardiomyopathy, or right-sided valvular disease involving the tricuspid or pulmonary valve. Hepatic venous congestion combined with inferior vena cava dilatation gave a classic 'playboy bunny' sign on liver ultrasound. 



1. Hokama A, Arakaki S, Shibata D, Maeshiro T, Kinjo F, Fujita J. "Playboy bunny" sign of congestive heart failure. West J Emerg Med. 2011 Nov;12(4):433-4. doi: 10.5811/westjem.2011.2.2226. PMID: 22224133; PMCID: PMC3236167.

2. Xiang H, Han J, Ridley WE, Ridley LJ. Playboy bunny and moose head sign: Hepatic veins in congestive heart failure. J Med Imaging Radiat Oncol. 2018 Oct;62 Suppl 1:99-100. doi: 10.1111/1754-9485.44_12784. PMID: 30309097.

Saturday, December 3, 2022

Haldol in burn patients

Q; Why Haldol (Haloperidol) should be used with caution in patients with thermal injury?

Answer: Neuropsychiatric complications are commonly seen in patients with burns/thermal patients. Haloperidol is frequently used to treat severe psychopathic behavior. In patients with thermal injury, there could be an increased tendency of severe muscle rigidity - an extrapyramidal side effect of the agent.

Haloperidol causes a relative imbalance of dopaminergic and cholinergic neuronal activity in the basal ganglia, with a relative increase in the cholinergic activity being responsible for EPS. The patient with burns/thermal injury may be more prone to extrapyramidal symptoms because of the increased sensitivity of skeletal muscle neuromuscular junctions to acetylcholine after thermal injury.



Haloperidol Complications in Burn Patients. Journal of Burn Care & Rehabilitation. 8(4):269-273

Friday, December 2, 2022


Q: What is the difference between relative, absolute, primary, and secondary polycythemia?

Answer: By definition, polycythemia means an elevation in the values of hemoglobin (Hb) and/or hematocrit (Hct). The accepted cut-off points are:
  • Hb:  >16.5 g/dL in men or >16.0 g/dL in women
  • Hct:  >49% in men or >48% in women
Various factors may affect these values.

Relative polycythemia is basically hemoconcentration due to decrease in plasma volume alone. It means there is no real increase in RBC mass.

Absolute polycythemia is an actual increase in RBC mass. It is further divided into primary and secondary polycythemia.

Primary polycythemia is due to a mutation in RBC progenitor cells. In contrast, secondary polycythemia, as the name implies, is secondarily elevated serum erythropoietin for various reasons, such as smoking or living at high altitudes.



1. Pillai AA, Fazal S, Babiker HM. Polycythemia. 2022 Jul 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30252337.

2. Ayalew Tefferi - Diagnostic approach to the patient with polycythemia: © 2022 UpToDate : Link: (Last accessed:: November 18, 2022)

ACE-I and glucose

Q: Angiotensin-converting enzyme (ACE) inhibitors tend to cause? (select one)

A) hypoglycemia
B) hyperglycemia

Answer: A

Many of the commonly prescribed drugs in ICU tend to cause hypoglycemia. Some are known, and some are less well known. Some important drugs to remember are quinolones, pentamidine, quinine, beta-blockers, and ACE inhibitors. 

Said that insulin continued to be the primary cause of hypoglycemia in ICU, where automated protocols are applied in a quest to achieve tighter blood glucose control.



1. Murad MH, Coto-Yglesias F, Wang AT, et al. Clinical review: Drug-induced hypoglycemia: a systematic review. J Clin Endocrinol Metab 2009; 94:741.

2. Parekh TM, Raji M, Lin YL, et al. Hypoglycemia after antimicrobial drug prescription for older patients using sulfonylureas. JAMA Intern Med 2014; 174:1605.

3. Cryer PE, Axelrod L, Grossman AB, et al. Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2009; 94:709. 

Thursday, December 1, 2022

Shigella infection

Q: Which tends to be more common in Shigella infection? (select one)

A) Mucoid diarrhea
B) Watery diarrhea 

Answer: A

Shigella tends to affect the rectosigmoid portion of the colon. Shigella gastroenteritis is marked by high fever, abdominal cramps, tenesmus, and blood-stained mucoid diarrhea with frequent daily episodes. In terms of frequency, the following occurs in descending order:

Mucoid diarrhea – 70 to 85 percent
Blood-stained diarrhea – 35 to 55 percent
Watery diarrhea – 30 to 40 percent

Though diarrhea starts as watery but quickly turns into blood and mucus mixed. Tenesmus is a common complaint. This is more common with Shigella dysenteriae 1 or Shigella flexneri.

In contrast, large volumes of watery diarrhea with abdominal cramping, bloating, and gas usually occurs due to small bowel infections.



1. Khan WA, Griffiths JK, Bennish ML. Gastrointestinal and extra-intestinal manifestations of childhood shigellosis in a region where all four species of Shigella are endemic. PLoS One 2013; 8:e64097.

2. Zaidi MB, Estrada-García T. Shigella: A Highly Virulent and Elusive Pathogen. Curr Trop Med Rep. 2014 Jun 1;1(2):81-87. doi: 10.1007/s40475-014-0019-6. PMID: 25110633; PMCID: PMC4126259.

3. Niyogi SK. Shigellosis. J Microbiol. 2005 Apr;43(2):133-43. PMID: 15880088.

Wednesday, November 30, 2022

ARB and uricosuric effect

Q: Which of the following angiotensin II receptor blocker (ARB) has a direct uricosuric effect? (select one)

A) Losartan 
B) Candesartan 
C) Valsartan 
D) Irbesartan 
E) Olmesartan 

Answer: A

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) decrease the serum uric acid level. The mechanism of action is by revering the stimulatory effect of angiotensin II on proximal sodium and urate reabsorption. Moreover, out of all, losartan is found to have a direct uricosuric effect.

It may be of interest to clinicians that a combination of losartan or any ACE inhibitor with a thiazide diuretic has shown a better blood control effect and minimizes the side effects such as hypokalemia and/or hyperlipidemia.



1. Weinberger MH. Influence of an angiotensin converting-enzyme inhibitor on diuretic-induced metabolic effects in hypertension. Hypertension 1983; 5:III132.

2. Soffer BA, Wright JT Jr, Pratt JH, et al. Effects of losartan on a background of hydrochlorothiazide in patients with hypertension. Hypertension 1995; 26:112.

3. Manolis AJ, Grossman E, Jelakovic B, et al. Effects of losartan and candesartan monotherapy and losartan/hydrochlorothiazide combination therapy in patients with mild to moderate hypertension. Losartan Trial Investigators. Clin Ther 2000; 22:1186.

4. Shahinfar S, Simpson RL, Carides AD, et al. Safety of losartan in hypertensive patients with thiazide-induced hyperuricemia. Kidney Int 1999; 56:1879.

Tuesday, November 29, 2022

Mg in COPD

Q: Intravenous Magnesium (IV Mg) can be given in severe exacerbation of COPD? (select one)

A) as a bolus
B) over 20 minutes
C) over an hour
D) as continuous infusion

Answer: B

Magnesium sulfate has a Grade C recommendation for use as an adjuvant treatment in severe COPD exacerbation, particularly when response to short-acting inhaled bronchodilators is not robust. A single dose of 2 grams IV Mg can be given over 20 minutes. IV Mg has bronchodilator activity. It inhibits calcium influx into the airway smooth muscle cells. It shows some evidence of decreased hospitalizations in COPD exacerbations.



1. Gourgoulianis KI, Chatziparasidis G, Chatziefthimiou A, Molyvdas PA. Magnesium as a relaxing factor of airway smooth muscles. J Aerosol Med 2001; 14:301.

2. Ni H, Aye SZ, Naing C. Magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2022; 5:CD013506.

3. Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database Syst Rev 2014; :CD010909.

Monday, November 28, 2022

Nails in hyperthyroidism

Q: In hyperthyroidism, nails tend to get? (select one)

A) hard
B) soft

Answer: B

Physical exam plays an integral part in hyperthyroidism. Skin tends to be warm and possibly erythematous due to increased blood flow. Also, it becomes smoother due to thinning keratin layer. Onycholysis is a common finding in hyperthyroidism. Hyperpigmentation is usually evident due to accelerated cortisol metabolism, leading to increased corticotropin (ACTH) secretion.

Vitiligo, alopecia areata, and thinning of the hair may also occur.

#physical exam


1. Heymann WR. Cutaneous manifestations of thyroid disease. J Am Acad Dermatol 1992; 26:885.


3. Collet E, Petit JM, Lacroix M, et al. [Chronic urticaria and autoimmune thyroid diseases]. Ann Dermatol Venereol 1995; 122:413.

Sunday, November 27, 2022

Metronidazole vs Clindamycin CSF penetration

Q: Which of the following drug can cross blood-brain barrier more effectively? (pick one)

A) Metronidazole
B) Clindamycin

Answer: A

Although metronidazole and clindamycin both cover anaerobes, metronidazole penetrates the blood-brain barrier better. The penetration is about 45-50 percent. This makes metronidazole a preferred choice in brain abscesses. Moreover, metronidazole also distributes well into muscle tissues and is a good choice in patients with sepsis or undergoing surgery.



Warner JF, Perkins RL, Cordero L. Metronidazole therapy of anaerobic bacteremia, meningitis, and brain abscess. Arch Intern Med 1979; 139:167.

Karjagin J, Pähkla R, Karki T, Starkopf J. Distribution of metronidazole in muscle tissue of patients with septic shock and its efficacy against Bacteroides fragilis in vitro. J Antimicrob Chemother 2005; 55:341.

Karjagin J, Pähkla R, Starkopf J. Perioperative penetration of metronidazole into muscle tissue: a microdialysis study. Eur J Clin Pharmacol 2004; 59:809.

Saturday, November 26, 2022

cyanosis in methemoglobinemia

Q: How does cyanosis correlate with hemoglobin in methemoglobinemia?

Answer: In methemoglobinemia, cyanosis correlates with total amount of methemoglobin. The formula is

total hemoglobin x percent methemoglobin = total methemoglobin

Once the total methemoglobin >1.5 g/dL,  cyanosis occurs

●A patient with total hemoglobin of 9 g/dL who has 10 percent of methemoglobin will have total methemoglobin of 0.9 g/dL and will not be cyanotic.

●A patient with total hemoglobin of 16 g/dL who has 10 percent methemoglobin will have total methemoglobin of 1.6 g/dL and will be cyanotic.

In other words, anemia can mask cyanosis. This is why some individuals with acquired methemoglobinemia in anemia can be quite ill despite lack of cyanosis. 



Josef T Prchal- Methemoglobinemia - © 2022 UpToDate ; Link:

Friday, November 25, 2022

Treating Dig toxicity

Case: 74 years old male has been found to have arrhythmia with runs of wide complex ventricular tachycardia. The patient so far has remained hemodynamically stable. A crash cart is called near the bed, pads are applied to the chest, and STAT labs are sent. A review of the chart showed that: 4 days ago digoxin level was 1.9, and since then patient's serum creatinine level is steadily rising from 1.6 to 2.8. "Dig. toxicity" is suspected. STAT dig. level is ordered. Indeed, Dig. level is back with 3.4, and accompanied labs showed a K+ level of 6.9. "Digi-bind" (Digoxin Immune Fab) is ordered. Interim, the medical resident, ordered the following regimen to treat hyperkalemia: IV insulin, D-50, IV bicarb., IV calcium, and albuterol neb.. Pharmacy informed, "IV calcium is not available." What other electrolytes can be used instead of calcium to stabilize the cardiac membrane in hyperkalemia?

Answer: IV Magnesium

Some literature has shown a similar membrane stabilizing effect from magnesium and may be used instead of calcium in hyperkalemia. 

Also, caution should be sought not to treat hyperkalemia aggressively, or at least the potassium level should be followed very closely, particularly when DigiFab administration is planned. 

Digoxin causes a shift of potassium from inside to outside of the cell and may cause severe serum hyperkalemia, though overall, there is a whole-body deficit of potassium. With the administration of DigiFab (Digibind), potassium shifts back into the cell, and life-threatening serum hypokalemia may ensue rapidly.



 1. Slow-release potassium overdose: Is there a role for magnesium? Emergency Medicine 1999;11:263–71

2. Kinlay S, Buckley NA. Magnesium sulfate in the treatment of ventricular arrhythmias due to digoxin toxicity. J Toxicol Clin Toxicol. 1995;33(1):55-9. doi: 10.3109/15563659509020216. PMID: 7837314.