Monday, August 8, 2022


Q: What is the mechanism of Right Ventricular Failure (RVF) in Pulmonary Embolism (PE)?

Answer: The objective of this question is to underline the fact that understanding the pathophysiology of any systemic disease goes a long way in clinicians' management of disease down the line. 

RVF occurs in PE via stepwise systemic failure. It largely depends on the clot burden and the physical obstruction of the vascular bed. This leads to hypoxia and subsequently vasoconstriction within the pulmonary arterial system, called hypoxic response. Increased vasoconstriction increases pulmonary vascular resistance (PVR). Increased PVR impedes right ventricular outflow., which progressively leads to right ventricular dilation, and flattening or bowing of the intraventricular septum. RV dilatation and decreased flow from RV eventually lead to cardiogenic collapse.

In conclusion, pulmonary hypoxic vasoconstriction plays an integral role in RV failure due to PE.



1. Bryce YC, Perez-Johnston R, Bryce EB, Homayoon B, Santos-Martin EG. Pathophysiology of right ventricular failure in acute pulmonary embolism and chronic thromboembolic pulmonary hypertension: a pictorial essay for the interventional radiologist. Insights Imaging. 2019 Feb 13;10(1):18. doi: 10.1186/s13244-019-0695-9. PMID: 30758687; PMCID: PMC6375098.

2. Arrigo M, Huber LC, Winnik S, Mikulicic F, Guidetti F, Frank M, Flammer AJ, Ruschitzka F. Right Ventricular Failure: Pathophysiology, Diagnosis and Treatment. Card Fail Rev. 2019 Nov 4;5(3):140-146. doi: 10.15420/cfr.2019.15.2. PMID: 31768270; PMCID: PMC6848943.

Sunday, August 7, 2022

Cyanide toxicity

Case: 42 years old male is brought to ED with suspected cyanide poisoning after ingesting a large amount of apricot. While putting Central Venous Catheter (CVC), blood is expected to be? (select one)

A) dark purple
B) bright red

Answer: B

This question's objective is to look for clues in cyanide poisoning. Pertinent history plays an important role. On physical exam, patient may appear flushed with "cherry red" color. Labs may show a high anion gap and elevated lactic acid. Arterial and venous blood gas (ABG and VBG) may have a narrowed venous-arterial PO2 gradient, and venous blood may appear bright red. Hydroxocobalamin is the preferred antidote.



1. Hall AH, Rumack BH. Clinical toxicology of cyanide. Ann Emerg Med 1986; 15:1067.

2. Gracia R, Shepherd G. Cyanide poisoning and its treatment. Pharmacotherapy. 2004 Oct;24(10):1358-65. doi: 10.1592/phco.24.14.1358.43149. PMID: 15628833.

Saturday, August 6, 2022

Sodium and potassium channel blockade

Q: Blockade of sodium channel leads to prolongation of QT interval on EKG?

A) True
B) False

Answer: B

The rule of thumb is
  • Sodium channel blockade causes prolongation of the QRS interval
  • Potassium channel blockade causes prolongation of the QT interval
Cocaine is a classic example of sodium channel blockade. and antipsychotics are classic examples of potassium channel blockade.



1. Roden DM, George AL Jr. Structure and function of cardiac sodium and potassium channels. Am J Physiol. 1997 Aug;273(2 Pt 2):H511-25. doi: 10.1152/ajpheart.1997.273.2.H511. PMID: 9277464.

2. Balser JR. The cardiac sodium channel: gating function and molecular pharmacology. J Mol Cell Cardiol. 2001 Apr;33(4):599-613. doi: 10.1006/jmcc.2000.1346. PMID: 11273715.

3. Starmer CF, Reddy MR, Namasivayam A, Singh M. Potassium channel blockade amplifies cardiac instability numerical studies of torsades de pointes. Indian J Physiol Pharmacol. 1994 Oct;38(4):259-66. PMID: 7883289.

Friday, August 5, 2022

Riedel's lobe

Q: What is Riedel's lobe of liver?

Answer: Riedel's lobe is an anatomic variation. It can easily deceive a clinician as hepatomegaly as it extends below the level of the umbilicus. It is a right-sided tail or tongue-like downward projection from the right lobe of the liver. It is a benign condition but should be watched for as 30 percent of the population may carry it. 

Further reading with pictures can be obtained from the given reference below.



Savopoulos C, Kakaletsis N, Kaiafa G, Iliadis F, Kalogera-Fountzila A, Hatzitolios AI. Riedel's lobe of the liver: a case report. Medicine (Baltimore). 2015 Jan;94(3):e430. doi: 10.1097/MD.0000000000000430. PMID: 25621695; PMCID: PMC4602636.

Thursday, August 4, 2022

ACE-I and ARBs in CKDs

Q: The use of angiotensin converting enzyme (ACE) inhibitor is absolutely contraindicated in patients with serum creatinine concentrations more than 3 mg/dL? 

A) True 
B) False 


The objective of this question is to highlight the fact that angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are relatively contraindicated even in patients with serum creatinine concentrations above 3 mg/dL. This is due to their beneficial effect on patients with impaired left ventricular function. It has a survival benefit with lower mortality. This benefit is seen in all kidney function strata. 



 1. Frances CD, Noguchi H, Massie BM, et al. Are we inhibited? Renal insufficiency should not preclude the use of ACE inhibitors for patients with myocardial infarction and depressed left ventricular function. Arch Intern Med 2000; 160:2645. 

 2. Evans M, Carrero JJ, Szummer K, et al. Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Myocardial Infarction Patients With Renal Dysfunction. J Am Coll Cardiol 2016; 67:1687.

Wednesday, August 3, 2022

clubbing in IPF

Q: Clubbing in Interstitial Lung disease (ILD) is __________  manifestation? (select one)

A) early
B) late

Answer: B

Clinical history and physical exam plays an integral role in differential diagnosis of ILD, like clubbing is common in idiopathic pulmonary fibrosis (IPF) and asbestosis) but rare in sarcoidosis and hypersensitivity pneumonitis. If present in ILD, it suggests advanced pulmonary fibrosis.

Clubbing is also a feature of cystic fibrosis, pulmonary arteriovenous malformations, cyanotic heart disease, malignancies of the lung and pleura, and inflammatory bowel disease.



van Manen MJG, Vermeer LC, Moor CC, Vrijenhoeff R, Grutters JC, Veltkamp M, Wijsenbeek MS. Clubbing in patients with fibrotic interstitial lung diseases. Respir Med. 2017 Nov;132:226-231. doi: 10.1016/j.rmed.2017.10.021. Epub 2017 Nov 2. PMID: 29229102.

Tuesday, August 2, 2022


Q: Patients transferred from ICU to long-term acute care (LTAC) facilities may require to keep a length of stay (LOS) for at least how many days?

Answer: ≥25 days

ICU physicians on daily basis need to make decisions about the appropriateness of patient transfer to different facilities besides regular wards or step-down units. A large portion of these patients go to LTAC facilities, particularly those patients who are still dependent on ventilators or had multi-system organ failure (MSOF). Three major criteria usually required are
  • must maintain an average length of stay ≥25 days
  • must require daily monitoring 
  • must require complex medical interventions



Kahn JM, Benson NM, Appleby D, et al. Long-term acute care hospital utilization after critical illness. JAMA 2010; 303:2253.

Monday, August 1, 2022

primary hyperthyroidism

Q: All of the following favor the diagnosis of primary hyperparathyroidism EXCEPT?

A) asymptomatic patient 
B) chronic hypercalcemia
C) postmenopausal status (females)
D) evidence of sarcoidosis
E) evidence of multiple endocrine neoplasia (MEN)

Answer: D

The objective of this question is to highlight the importance of skill of history taking. In hyperparathyroidism, etiology and level of hypercalcemia play an integral part in determining the urgency, further diagnostic workup and management. For example, hypercalcemia due to cancer is usually very high, symptomatic, urgent, and responsive. 

Evidence of sarcoidosis (choice D) makes it secondary hyperparathyroidism. Following are the usual features of primary hyperparathyroidism:
  • an asymptomatic patient 
  • mild or borderline chronic hypercalcemia
  • a postmenopausal female
  • usually a normal physical examination
  • no cause of hypercalcemia 
  • family history of hyperparathyroidism
  • evidence of multiple endocrine neoplasia


1. Walker MD, Silverberg SJ. Primary hyperparathyroidism. Nat Rev Endocrinol. 2018 Feb;14(2):115-125. doi: 10.1038/nrendo.2017.104. Epub 2017 Sep 8. PMID: 28885621; PMCID: PMC6037987. 

2. Sun B, Guo B, Wu B, Kang J, Deng X, Zhang Z, Fan Y. Characteristics, management, and outcome of primary hyperparathyroidism at a single clinical center from 2005 to 2016. Osteoporos Int. 2018 Mar;29(3):635-642. doi: 10.1007/s00198-017-4322-7. Epub 2017 Dec 3. PMID: 29198075.

Sunday, July 31, 2022

Wolff-Chaikoff effect

Q: What is Wolff-Chaikoff effect?


Normal human continues to have a wide variation in dietary iodine intake and is normally autoregulated (called organification) by thyroid follicular cells. When the thyroid gland suddenly gets exposed to excess of iodine, it stops the biosynthesis of thyroid hormones, irrespective of Thyroid Stimulating Hormone (TSH). This phenomenon is called the Wolff-Chaikoff effect. 

The above principle remains the mainstay of treatment in hyperthyroidism particularly in thyroid storm. Large infusion of iodine suppresses the thyroid gland. Similarly, patients who are on iodine-containing drugs such as amiodarone become hypothyroid under the same effect.



1.  Wolff J, Chaikoff IL (1948). "Plasma inorganic iodide as a homeostatic regulator of thyroid function". J Biol Chem. 174 (2): 555–564. doi:10.1016/S0021-9258(18)57335-X. PMID 18865621. Link:

2. Markou K, Georgopoulos N, Kyriazopoulou V, Vagenakis AG. Iodine-Induced hypothyroidism. Thyroid. 2001 May;11(5):501-10. doi: 10.1089/105072501300176462. PMID: 11396709.

Saturday, July 30, 2022

PD-5 I and LUTS

Q: Male patients using Phosphodiesterase 5 (PDE-5) inhibitors may experience increased urinary frequency and urgency.

A) True
B) False

Answer: B

In contrast to the statement in the above question, irrespective of improvement in erectile dysfunction, PDE-5 inhibitors have been found to improve lower urinary tract Symptoms (LUTS), particularly in male patients. 



1. Liu L, Zheng S, Han P, Wei Q. Phosphodiesterase-5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review and meta-analysis. Urology 2011; 77:123.

2. Gacci M, Corona G, Salvi M, et al. A systematic review and meta-analysis on the use of phosphodiesterase 5 inhibitors alone or in combination with α-blockers for lower urinary tract symptoms due to benign prostatic hyperplasia. Eur Urol 2012; 61:994.

Friday, July 29, 2022


Q: Melatonin is a chronobiotic?

A) True
B) false

Answer: A

Melatonin receptor agonists such as Ramelteon are increasingly used in ICUs. Ramelteon binds to the melatonin 1 and 2 receptors (MT1, MT2). It inhibits the wakefulness-promoting activity of the suprachiasmatic nucleus. It is most effective when patients have difficulty falling asleep. It reduces the time dedicated to light sleep but its efficacy on sleep continuity is not remarkable. Also, it has shown no improvement in daytime function.

Any hormone/chemical which helps to regulate circadian rhythm is called a chronobiotic.



1. Emens JS, Burgess HJ. Effect of Light and Melatonin and Other Melatonin Receptor Agonists on Human Circadian Physiology. Sleep Med Clin 2015; 10:435.

2. Dawson D, Armstrong SM. Chronobiotics--drugs that shift rhythms. Pharmacol Ther. 1996;69(1):15-36. doi: 10.1016/0163-7258(95)02020-9. PMID: 8857301.

Thursday, July 28, 2022


Q:  Crohn's Disease Activity Index (CDAI) in adults takes into account all of the following EXCEPT? (select one)

A) Gender
B) General wellbeing each day over 30 days
C) Iritis or uveitis
D) Anal fissure, fistula, or abscess
E) An abdominal mass

Answer; B

Crohn's Disease Activity Index (CDAI) in adults has been now widely used to determine the further line of management. Calculator (easily accessible on any search engine) is easy to put on data and gives points for various clinical signs and symptoms. 

0 - 149 points: Asymptomatic remission
150 - 220 points: Mildly to moderately active Crohn's disease
221 - 450 points: Moderately to severely active Crohn's disease
451 - 1100 points: Severely active to fulminant disease

The answer is B as CDAI counts for general well-being in only the last 7 days.

It takes into account of
  • Gender
  • Weight   
  • Height   
  • Hematocrit   
  • Average number of liquid or soft stools per day over 7 days (14 points per stool)   
  • Using diphenoxylate or loperamide for diarrhea
  • Average abdominal pain rating over 7 days
  • General wellbeing each day over 7 days
  • Arthritis or arthralgia
  • Iritis or uveitis
  • Erythema nodosum, pyoderma gangrenosum, or aphthous stomatitis
  • Anal fissure, fistula, or abscess
  • Other fistulae
  • Temperature over 100°F (37.8°C) in the last week
  • Finding an abdominal mass


1. Best WR. Predicting the Crohn's disease activity index from the Harvey-Bradshaw Index. Inflamm Bowel Dis 2006; 12:304.

2. Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn's disease activity index. National Cooperative Crohn's Disease Study. Gastroenterology 1976; 70:439.

3. Lichtenstein GR, Loftus EV, Isaacs KL, et al. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol 2018; 113:481.

4. Vermeire S, Schreiber S, Sandborn WJ, et al. Correlation between the Crohn's disease activity and Harvey-Bradshaw indices in assessing Crohn's disease severity. Clin Gastroenterol Hepatol 2010; 8:357.

Wednesday, July 27, 2022

Echo and IE

Q: For infective endocarditis (IE)Transthoracic echocardiography (TTE) has higher? (select one)

A) sensitivity
B) specificity

Answer: B

As per European Society of Cardiology (ESC) Guidelines, the estimated sensitivity of TTE for IE is around 70 percent for native valves and 50 percent for prosthetic valves. If noted, the specificity is around 90 percent. The visualization of vegetation can be compromised by thick chest wall (obesity), underlying valve thickening, valve calcification, redundant leaflet tissue, prosthetic shadowing, small vegetation or vegetation which has embolized. 

Interestingly, this is reverse for transesophageal echocardiography (TEE) due to better/clear visualization. TEE yields sensitivity of about 96 percent for native valves and 92 percent for prosthetic valves, and the specificity for both is about 90 percent.



1. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075.

2. Bai AD, Steinberg M, Showler A, et al. Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis. J Am Soc Echocardiogr 2017; 30:639.

Tuesday, July 26, 2022

Tranexamic acid in hyperacute primary intraCerebral Hemorrhage.

Q: Tranexamic acid is another very useful drug to improve long-term functional outcomes if given early in hyperacute primary Intra Cerebral Hemorrhage (ICH).

A) True
B) False

Answer: B

Tranexamic acid works via inhibiting fibrinolysis and the proteolytic activity of plasmin. Unfortunately, it failed to show any utility in hyperacute primary ICH. It failed to show any difference in 90-day functional status or mortality. 

Said that it has shown some favor towards early reductions in hematoma growth and early death.



1. Sprigg N, Flaherty K, Appleton JP, et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet 2018; 391:2107.

2. Meretoja A, Yassi N, Wu TY, et al. Tranexamic acid in patients with intracerebral haemorrhage (STOP-AUST): a multicentre, randomised, placebo-controlled, phase 2 trial. Lancet Neurol 2020; 19:980.

Monday, July 25, 2022

ACS and pulse-ox

Q: A good pulse-oximetry waveform indicates that the patient does not have acute compartment syndrome (ACS)?

A) Yes
B) No

Answer: B

Despite prolonged and severe ACS, arterial pulses and capillary refill can stay normal and should not be read as negative indicators of ACS. On the same note, open fractures should not be automatically assumed as contradicting ACS. 

Any suspicion of ACS should be properly evaluated clinically, radiologically, and ideally quantified by measurement.



1. Mars M, Hadley GP. Failure of pulse oximetry in the assessment of raised limb intracompartmental pressure. Injury 1994; 25:379.

2. DeLee JC, Stiehl JB. Open tibia fracture with compartment syndrome. Clin Orthop Relat Res 1981; :175.

3. Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003; 85:625.

Sunday, July 24, 2022

daptomycin and myopathy

Q: When should daptomycin be considered discontinued in regards to myopathy?

Answer: The three major side effects which need to be watched during daptomycin therapy are
  • myopathy
  • peripheral neuropathy, and 
  • eosinophilic pneumonia 
Regarding myopathy, treatment should be guided by the creatine phosphokinase (CPK) level.

- In symptomatic patients, daptomycin should be discontinued if CPK ≥5 times the upper limit of normal.
- In asymptomatic patients, daptomycin should be discontinued if CPK ≥10 times the upper limit of normal.



1. Skiest DJ. Treatment failure resulting from resistance of Staphylococcus aureus to daptomycin. J Clin Microbiol 2006; 44:655.

2. Veligandla SR, Louie KR, Malesker MA, Smith PW. Muscle pain associated with daptomycin. Ann Pharmacother. 2004 Nov;38(11):1860-2. doi: 10.1345/aph.1D639. Epub 2004 Sep 14. PMID: 15367725.

Saturday, July 23, 2022

Cancer and COVID

Q: Cancer survivors who do not have active cancer have a higher risk for severe COVID-19? 

A) True
B) False

Answer: A

Although data is not very robust, it suggests that cancer survivors are prone to severe COVID-19 disease. The odd ratio can be up to 1.8. Unfortunately, patients with hematologic malignancy may have an even higher risk, up to fourfold. The risk decreases depending on the time difference between previous cancer and COVID infection.



1. Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020; 584:430.

2. van Doesum J, Chinea A, Pagliaro M, et al. Clinical characteristics and outcome of SARS-CoV-2-infected patients with haematological diseases: a retrospective case study in four hospitals in Italy, Spain and the Netherlands. Leukemia 2020; 34:2536.

3. Mangone L, Gioia F, Mancuso P, et al. Cumulative COVID-19 incidence, mortality and prognosis in cancer survivors: A population-based study in Reggio Emilia, Northern Italy. Int J Cancer 2021.

Friday, July 22, 2022

tinnitus in acute salicylates toxicity

Q: 44 years old female is admitted to ICU with acute salicylates toxicity. The patient is complaining of severe tinnitus. Emergent Ear-Nose-Throat (ENT) consult is required.

A) True
B) False

Answer: B

Tinnitus is a very common finding in acute salicylate toxicity. It may even occur when salicylate is in the therapeutic range. The presence of tinnitus helps in confirming the diagnosis but it is almost always reversible and no further workup is usually needed. Patients may also complain of alterations in the perception of sound and/or transient hearing loss. Similarly, they are reversible and usually do not require any major intervention.



1. Wecker H, Laubert A. Reversible Hörminderung bei akuter Salizylatintoxikation [Reversible hearing loss in acute salicylate intoxication]. HNO. 2004 Apr;52(4):347-51. German. doi: 10.1007/s00106-004-1065-5. PMID: 15143764.

2. Stolzberg D, Salvi RJ, Allman BL. Salicylate toxicity model of tinnitus. Front Syst Neurosci. 2012 Apr 20;6:28. doi: 10.3389/fnsys.2012.00028. PMID: 22557950; PMCID: PMC3341117.

Thursday, July 21, 2022

Methamphetamine-induced toxicity: hyperthermia

Q: Acetaminophen is the first line of drugs in hyperthermia from acute methamphetamine intoxication.

A) True
B) False

Answer: B

Acetaminophen has no impact on acute intoxication from methamphetamine. This is because hyperthermia in this situation is due to high muscular activity and not a disturbance in hypothalamic temperature set point. Benzodiazepines and plus/minus neuromuscular blockade may be required. High muscular activity causes dehydration and requires aggressive fluid resuscitation.

Non-pharmacological interventions such as cooling blankets or evaporative cooling techniques are highly helpful. Lipid emulsion therapy is also suggested.



1. Pillai S, Cesarz B, Boulware C, Khan A. Hypotension, Severe Hyperthermia (42°C), Rhabdomyolysis, and Disseminated Intravascular Coagulation Induced by Lethal Dose of Methamphetamine. Cureus. 2019;11(7):e5245. Published 2019 Jul 26. doi:10.7759/cureus.5245

2. Matsumoto RR, Seminerio MJ, Turner RC, et al. Methamphetamine-induced toxicity: an updated review on issues related to hyperthermia. Pharmacol Ther. 2014;144(1):28-40. doi:10.1016/j.pharmthera.2014.05.001

Wednesday, July 20, 2022

IABP effects

Q: Which of the following doesn't occur during Inflation and deflation of the intra-aortic balloon pump (IABP)?

A) Blood is displaced to the proximal aorta by inflation during diastole
B) Blood is displaced to the proximal aorta by deflation during diastole
C) Aortic volume is reduced during diastole
D) Vacuum effect is created by rapid balloon deflation during systole

Answer: B

IABP creates two major consequences for hemodynamics:

1. During diastole of the heartbeat cycle, the pump gets inflated and displaces the blood to the proximal aorta (choice A)

2. During the systole phase of the heartbeat cycle, aortic volume is decreased (choice C). This occurs due to an interesting phenomenon of a vacuum effect created by rapid balloon deflation (Choice D).

Choice B is wrong as IABP inflates during diastole (not deflate)



Gajanan G, Brilakis ES, Siller-Matula JM, Zolty RL, Velagapudi P. The Intra-Aortic Balloon Pump. J Vis Exp. 2021 Feb 5;(168). doi: 10.3791/62132. PMID: 33616109.

Tuesday, July 19, 2022

DVT after ortho surgery

Q: The highest risk of Deep Vein Thrombosis (DVT) after orthopedic surgery is? (select one)

A) 1 - 6 days
B) 7- 14 days
C) 14 - 30 days

Answer: B

The high risk of DVT is well known after total hip arthroplasty (THA), total knee arthroplasty (TKA), and hip fracture surgery (HFS). This risk is highest between the first 7 to 14 days. 

Some of the less well-appreciated factors leading to DVT in postop period are injury to deep veins from the positioning of the extremity, compression of the femoral vein due to flexion, adduction of the hip during hip surgery, the anatomic position of the extremity, use of a thigh tourniquet during knee surgery, and bilateral arthroplasty.



1. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e278S.

2. White RH, Gettner S, Newman JM, et al. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med 2000; 343:1758.

Monday, July 18, 2022

Renal US

 Q: Increased echogenicity and length <10 cm of kidney almost always indicates untreatable disease?

A) True

B) False

Answer: A

Ultrasound at the bedside is an increasingly common method to confirm diagnoses in ICU. So far kidneys have not been as popular as lungs, heart, and vessels to evaluate pathologies. The objective of this question is to bring to attention the fact that ultrasound is an effective tool for other organs in getting leads to diagnosis. 

Increased echogenicity let alone is a nonspecific finding but if it exists with kidney length <10 cm, it almost always indicates untreatable disease.




Moghazi S, Jones E, Schroepple J, et al. Correlation of renal histopathology with sonographic findings. Kidney Int 2005; 67:1515.

Sunday, July 17, 2022

DD of purpura

Q: How the purpura of thrombocytopenia and purpura of vasculitis can be differentiated on physical exam?

Answer: Physical exam plays an integral role in differentiating purpura from thrombocytopenia and vasculitis.

Purpura secondary to thrombocytopenia 
  • flat 
  • non-blanching 
  • in dependent areas
Purpura secondary to vasculitis 
  • palpable 
  • pruritic
  • does not follow dependent areas


1. 1. KAWAKITA Y. [MEDICAL EXAMINATION AND TREATMENT OF PURPURA]. Nihon Ishikai Zasshi. 1964 Mar 1;51:781-809. Japanese. PMID: 14144733.

2. Stevens GL, Adelman HM, Wallach PM. Palpable purpura: an algorithmic approach. Am Fam Physician. 1995 Oct;52(5):1355-62. PMID: 7572558.

Saturday, July 16, 2022

Albumin-Ca connection

Q: In hyperalbuminemia ____________ is expected? (select one)

A) hypocalcemia
B) hypercalcemia

Answer: B

In hyperalbuminemia total serum calcium level is expected to be high due to the calcium-albumin binding situation. This is not real hypercalcemia as ionized calcium stays normal. This is called pseudo or factitious hypercalcemia.

About half of the calcium in serum is bound to albumin. The best to have a calcium level is to measure ionized calcium. Unfortunately, it may not be readily available. Formulae have been developed to adjust calcium per albumin level. As a rule of thumb, for every 1 g/dL drop in the serum albumin the serum calcium drops by 0.8 mg/dL.



1. Thode J, Juul-Jørgensen B, Bhatia HM, Kjaerulf-Nielsen M, Bartels PD, Fogh-Andersen N, Siggaard-Andersen O. Comparison of serum total calcium, albumin-corrected total calcium, and ionized calcium in 1213 patients with suspected calcium disorders. Scand J Clin Lab Invest. 1989 May;49(3):217-23. Erratum in: Scand J Clin Lab Invest 1990 Feb;50(1):113. PMID: 2662382.

2. Lian IA, Åsberg A. Should total calcium be adjusted for albumin? A retrospective observational study of laboratory data from central Norway. BMJ Open. 2018;8(4):e017703. Published 2018 Apr 7. doi:10.1136/bmjopen-2017-017703

Thursday, July 14, 2022

VRA and liver

Q: Which of the following vasopressin receptor antagonists should not be used in patients with liver cirrhosis?

A) tolvaptan
B) mozavaptan
C) satavaptan
D) lixivaptan
E) conivaptan

Answer: A

Vasopressin receptor antagonists act on three receptors i.e., V1a, V1b, and V2 receptors. 
  • V1a and V1b receptors cause vasoconstriction and adrenocorticotropic hormone (ACTH) release
  • V2 receptors mediates the antidiuretic response
All oral formulations i.e., tolvaptan, mozavaptan, satavaptan, and lixivaptan are V2 selective. Conivaptan is the only parenteral formulation, and acts on both V2 and V1a receptors. 

Tolvaptan is contraindicated in patients with liver issues.



1. Verbalis JG, Goldsmith SR, Greenberg A, et al. Hyponatremia treatment guidelines 2007: expert panel recommendations. Am J Med 2007; 120:S1.

2. Greenberg A, Verbalis JG. Vasopressin receptor antagonists. Kidney Int 2006; 69:2124.

3. Schrier RW, Gross P, Gheorghiade M, et al. Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med 2006; 355:2099.

Wednesday, July 13, 2022

acetazolamide in severe exacerbation of COPD requiring invasive vent

Q: Acetazolamide is an effective way to counteract metabolic alkalosis in patients with acute exacerbation of COPD who requires intubation?

A) True
B) False

Answer: B

Despite theoretical benefit, acetazolamide failed to show any major impact in acute exacerbation of COPD. In ICUs, these patients frequently go into metabolic alkalosis due to nasogastric (NG) suctioning, diuretic and steroid use. Metabolic alkalosis may lead to suppression of central respiratory drive. Unfortunately, acetazolamide is not of much help in reducing days on ventilators.



1. Faisy C, Meziani F, Planquette B, et al. Effect of Acetazolamide vs Placebo on Duration of Invasive Mechanical Ventilation Among Patients With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial. JAMA 2016; 315:480.

2. Bahloul M, Chaari A, Tounsi A, et al. Impact of acetazolamide use in severe exacerbation of chronic obstructive pulmonary disease requiring invasive mechanical ventilation. Int J Crit Illn Inj Sci 2015; 5:3.

Tuesday, July 12, 2022

postprandial angina

Q: Postprandial angina is usually associated with severe coronary vessel disease? 

A) True
B) False

Answer: A

Postprandial chest pain is in general of gastrointestinal origin. If associated with coronary origin, it can be an alarming situation. It signifies possible left main or multi-vessel coronary disease. For reason not entirely clear, it usually occurs after dinner. 

Also, it may occur postprandially at rest making diagnosis even harder.



1. Chung WY, Sohn DW, Kim YJ, et al. Absence of postprandial surge in coronary blood flow distal to significant stenosis: a possible mechanism of postprandial angina. J Am Coll Cardiol 2002; 40:1976.

2. Berlinerblau R, Shani J. Postprandial angina pectoris: clinical and angiographic correlations. J Am Coll Cardiol. 1994 Mar 1;23(3):627-9. doi: 10.1016/0735-1097(94)90746-3. PMID: 8113544.

Monday, July 11, 2022


Q: Which one intervention may decrease the risk of torsades de pointes with ibutilide? 

Answer: Pretreatment with intravenous (IV) magnesium 

Ibutilide is not very popular for use as chemical agent for cardioversion in acute atrial fibrillation. This is due to it's risk to cause torsades de pointes. A less known fact is that it is more effective to convert atrial flutter to sinus rhythm. Pretreatment with IV magnesium decreases the risk of ibutilide-induced torsades de pointes. Risk factors for ibutilide-induced torsades de pointes are heart failure, baseline prolong QTc interval, hypokalemia or hypomagnesemia. 

The dose of Ibutilide in average adult patient is 1 mg over 10 minutes. If no or partial response, a second bolus of 1 mg over 10 minutes can be used. 



1. Stambler BS, Wood MA, Ellenbogen KA, et al. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Circulation 1996; 94:1613.

2. Abi-Mansour P, Carberry PA, McCowan RJ, et al. Conversion efficacy and safety of repeated doses of ibutilide in patients with atrial flutter and atrial fibrillation. Study Investigators. Am Heart J 1998; 136:632.

3. Vinson DR, Lugovskaya N, Warton EM, Rome AM, Stevenson MD, Reed ME, Nagam MR, Ballard DW; Pharm CAFÉ Investigators of the CREST Network. Ibutilide Effectiveness and Safety in the Cardioversion of Atrial Fibrillation and Flutter in the Community Emergency Department. Ann Emerg Med. 2018 Jan;71(1):96-108.e2. doi: 10.1016/j.annemergmed.2017.07.481. Epub 2017 Sep 29. PMID: 28969929.

Sunday, July 10, 2022

magnesium and morphine

Q: Intravenous Magnesium (IV Mg) potentiates the opioid effect? 

A) True
B) False

Answer: A

IV Mg is considered a usual adjuvant with opioids. It potentiates the opioid effect and so reduces it's dose requirement. This is due to its antagonist property of N-methyl-D-aspartate(NMDA) receptor. If utilized in perioperative time, it reduces opioid consumption as well as pain scores in first 24 hours postop period. IV Mg can be given as bolus and/or continuous infusion.



1. Albrecht E, Kirkham KR, Liu SS, Brull R. Peri-operative intravenous administration of magnesium sulphate and postoperative pain: a meta-analysis. Anaesthesia 2013; 68:79.

2. De Oliveira GS Jr, Castro-Alves LJ, Khan JH, McCarthy RJ. Perioperative systemic magnesium to minimize postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology 2013; 119:178.

Saturday, July 9, 2022

BP from legs

Q; Lower extremity blood pressure measurement is usually _________ than upper extremity blood pressure? 

A) higher
B) lower

Answer: A

It is a common scenario in ICU when nursing staff has to rely on blood pressure (BP) measurement from lower extremities, particularly in patients with vascular fistulae or grafts. By default, the systolic pressure (SBP) in legs is usually higher than that in the arms (brachial artery). The difference on an average is by about 10 mmHg in the calf. It is even higher in the ankle by 17 mmHg. 

This does not apply to people with peripheral vascular disease (PVD) who usually have SBP lower at the ankle than the arm. Also, it is important that proper cuff size is applied.



1. Measurement of Blood Pressure: Taking Blood Pressure in the Thigh. In: Kaplan's Clinical Hypertension, Kaplan NM, Victor RG (Eds).

2. Sheppard JP, Albasri A, Franssen M, et al. Defining the relationship between arm and leg blood pressure readings: a systematic review and meta-analysis. J Hypertens 2019; 37:660.

3. Allison MA, Hiatt WR, Hirsch AT, et al. A high ankle-brachial index is associated with increased cardiovascular disease morbidity and lower quality of life. J Am Coll Cardiol 2008; 51:1292.

Friday, July 8, 2022

cholesterol emboli

Q: Skin findings in cholesterol crystal emboli are more pronounced at? (select one)

A) arterial area
B) venous area

Answer: A

The classic cutaneous manifestations of cholesterol emboli are livedo reticularis, gangrene, cyanosis, ulcer, purpura, petechiae, splinter, and/or firm, painful erythematous nodules.

Contrary to popular belief, these signs tend to occur around/at palpable arterial pulse. The most common etiology for cholesterol emboli is manipulation of an artery like angiography, and embolization occurring in smaller arteries down the system.



1. Donohue KG, Saap L, Falanga V. Cholesterol crystal embolization: an atherosclerotic disease with frequent and varied cutaneous manifestations. J Eur Acad Dermatol Venereol 2003; 17:504.

2. Fine MJ, Kapoor W, Falanga V. Cholesterol crystal embolization: a review of 221 cases in the English literature. Angiology 1987; 38:769.

3. Falanga V, Fine MJ, Kapoor WN. The cutaneous manifestations of cholesterol crystal embolization. Arch Dermatol 1986; 122:1194.

Thursday, July 7, 2022

Delirium per DSM-5

Q) Hypo or hyperactivity is required to have a diagnosis of delirium?

A) True
B) False

Answer: B

Conventionally, delirium has been divided into hypo, hyper, or mixed activity types but is not required as a diagnosis per the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). The five key features described are:

1. Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness.

2. The disturbance develops over a short period of time (usually hours to days), represents a change from baseline, and tends to fluctuate during the course of the day.

3. An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception).

4. The disturbances are not better explained by another preexisting, evolving, or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma.

5. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect.



American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed, APA Press, Washington, DC 2013.

Wednesday, July 6, 2022

Acetaminophen toxicity with tobacco

Q: Acetaminophen toxicity corelates in direct proportion with tobacco consumption (means higher the cigarettes per day higher the chances of toxicity)?

A) True
B) false

Answer: B

Although tobacco is an independent risk factor for acetaminophen toxicity, it has no direct correlation with the amount of tobacco or number of cigarettes per day. Even a small amount of tobacco consumption can increase acetaminophen toxicity. This is due to the fact that tobacco smoke contains CYP1A2 inducers which increases oxidative metabolism. 

A large number of smokers are simultaneously regular users of alcohol which further increases the risk of mortality.



1. Dong SX, Ping ZZ, Xiao WZ, et al. Effect of active and passive cigarette smoking on CYP1A2-mediated phenacetin disposition in Chinese subjects. Ther Drug Monit 1998; 20:371.

2. Seo KW, Park M, Kim JG, et al. Effects of benzothiazole on the xenobiotic metabolizing enzymes and metabolism of acetaminophen. J Appl Toxicol 2000; 20:427.

3. Schmidt LE, Dalhoff K. The impact of current tobacco use on the outcome of paracetamol poisoning. Aliment Pharmacol Ther 2003; 18:979.

Tuesday, July 5, 2022

Post thoracentesis CXR

Q: A follow-up CXR despite an uncomplicated ultrasound (US) guided thoracentesis in an unventilated patient should be performed as occult pneumothorax (PTX) may occur? 

A) True
B) False

Answer: B

In an uncomplicated US-guided thoracentesis, chances of PTX are extremely low, particularly in an unventilated patient. Said that it should be performed if a patient displays any symptoms or if the air is noted in a syringe while performing thoracentesis. It is a good practice to quickly scan a patient's chest with an ultrasound probe after the procedure to establish the sliding of pleurae. Also, documenting post-procedure US images in the medical chart is desirable.



1. Thomsen TW, DeLaPena J, Setnik GS. Videos in clinical medicine. Thoracentesis. N Engl J Med 2006; 355:e16.

2. Petersen WG, Zimmerman R. Limited utility of chest radiograph after thoracentesis. Chest 2000; 117:1038.

Friday, July 1, 2022

Wheeze and stridor

Q: Stridor is usually predominantly? (select one)

A) expiratory
B) inspiratory

Answer: B

The objective of this question is to appreciate the difference between wheezing and stridor on physical exam. There are two major differences:
  • Wheezing usually occurs in expiration. In contrast, stridor is predominantly inspiratory.
  • Wheezing sounds like a continuous musical sound with single or multiple notes. Stridor is mostly monophonic.
Also, stridor is best heard over the anterior neck.



1. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med 2014; 370:744.

2. Loudon R, Murphy RL Jr. Lung sounds. Am Rev Respir Dis 1984; 130:663.

3. Forgacs P. The functional basis of pulmonary sounds. Chest 1978; 73:399.

Thursday, June 30, 2022

Uhl's anomaly

Q: What is Uhl's anomaly in the heart?

Answer: Uhl's anomaly is also called parchment right ventricle. It was first described seven decades ago by Dr. Uhl. This condition is characterized by extremely thin and devoid of muscle fiber right ventricle (RV), or part of RV. This makes RV in complete apposition of endocardium and epicardium.

Caution: In some places, it has been described as arrhythmogenic right ventricular cardiomyopathy (ARVC) or arrhythmogenic right ventricular dysplasia (ARVD).  Uhl's anomaly is different from ARVC/ARVD with its own pathologic features, clinical findings, and presentations. Uhl anomaly is more common in childhood and marked by heart failure in contrast to ARVC, which is marked by arrhythmia, syncope, and/or sudden death.



1. UHL HS. A previously undescribed congenital malformation of the heart: almost total absence of the myocardium of the right ventricle. Bull Johns Hopkins Hosp 1952; 91:197.

2. Gerlis LM, Schmidt-Ott SC, Ho SY, Anderson RH. Dysplastic conditions of the right ventricular myocardium: Uhl's anomaly vs arrhythmogenic right ventricular dysplasia. Br Heart J 1993; 69:142.

Wednesday, June 29, 2022

GCA - risks and protections

Q: Q: Fever and elevations of the acute phase reactants are indicators for higher risk of vision loss in Giant Cell Arteritis (GCA)?

A) True
B) False

Answer: B

In paradox to expectations that high inflammatory status as fever, elevations of the acute phase reactants such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and interleukin (IL) 6, as well as anemia will increase the risk of vision loss in GCA - they are found to be protective. This is due to two reasons. IL-6 has angiogenic properties and counteracts arteritis-induced ischemia. Second, severe inflammatory responses lead patients to seek medical care early in the process.



1. González-Gay MA, García-Porrúa C, Llorca J, et al. Visual manifestations of giant cell arteritis. Trends and clinical spectrum in 161 patients. Medicine (Baltimore) 2000; 79:283.

2. Liozon E, Dalmay F, Lalloue F, et al. Risk Factors for Permanent Visual Loss in Biopsy-proven Giant Cell Arteritis: A Study of 339 Patients. J Rheumatol 2016; 43:1393.

3. Cid MC, Font C, Oristrell J, et al. Association between strong inflammatory response and low risk of developing visual loss and other cranial ischemic complications in giant cell (temporal) arteritis. Arthritis Rheum 1998; 41:26.

4. Nesher G, Nesher R, Mates M, et al. Giant cell arteritis: intensity of the initial systemic inflammatory response and the course of the disease. Clin Exp Rheumatol 2008; 26:S30.

Tuesday, June 28, 2022

Hyponatremia in SAH

Q: The first step of management in hyponatremia related to subarachnoid hemorrhage (SAH) is fluid restriction?

A) True
B) False

Answer: B

 Although it is true that syndrome of inappropriate antidiuretic hormone secretion (SIADH) is more coomon in SAH than cerebral salt wasting (CSW), fluid restriction in SAH increases the risk of cerebral vasospasm. On the contrary, these patients benefit from volume expansion. 

Hypertonic (usually 3 percent) saline is preffered.



1. Woo CH, Rao VA, Sheridan W, Flint AC. Performance characteristics of a sliding-scale hypertonic saline infusion protocol for the treatment of acute neurologic hyponatremia. Neurocrit Care 2009; 11:228.

Sunday, June 26, 2022

Palliative care definition

Q: What is the Center to Advance Palliative Care's definition of palliative care?

Answer: For readers' benefit three important definitions of palliative care are given below:

The Center to Advance Palliative Care definition: “Specialized medical care for people with serious illnesses…focused on providing patients with relief from the symptoms, pain and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.”

WHO definition: “An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”

The Centers for Medicare and Medicaid Services (CMS) definition: “Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy, access to information, and choice.”



1. Center to Advance Palliative Care. About palliative care: What is palliative care? Available at: (Accessed on June 11, 2022).

2. World Health Organization (WHO) definition of palliative care, available online at

3. Federal Register 2008 - 73 FR 32204, June 5, 2008.

Saturday, June 25, 2022

LFT in acute HCV

Q: Normalization of the serum aminotransferases signifies resolution of acute Hepatitis C infection?

A) True
B) False

Answer: B

Aminotransferase i.e., alanine transaminase (ALT) and aspartate transaminase (AST) can be very deceiving in acute Hepatitis C virus (HCV) infection. It can vary widely during acute infection with short periods of time. It can vary from  20 times the upper limit of normal to within normal range. Elevation of LFTs starts prior to symptoms.



1. Loomba R, Rivera MM, McBurney R, et al. The natural history of acute hepatitis C: clinical presentation, laboratory findings and treatment outcomes. Aliment Pharmacol Ther 2011; 33:559.

2. Maheshwari A, Thuluvath PJ. Management of acute hepatitis C. Clin Liver Dis 2010; 14:169.

3. McGovern BH, Birch CE, Bowen MJ, et al. Improving the diagnosis of acute hepatitis C virus infection with expanded viral load criteria. Clin Infect Dis 2009; 49:1051.

4. Santantonio T, Sinisi E, Guastadisegni A, et al. Natural course of acute hepatitis C: a long-term prospective study. Dig Liver Dis 2003; 35:104.