Phenytoin and albumin

Q: Phenytoin level needs to be corrected with serum albumin level?

A) Yes

B) No

Answer: A

Phenytoin is protein-bound, and clinical symptoms correlate well with its level. Although not very precise, hypoalbuminemia needs to be corrected using the Sheiner-Tozer formula.

Corrected total phenytoin concentration = Observed total phenytoin concentration/([0.2 x Albumin]+0.1)

A major criticism of the Sheiner-Tozer equation is that it depends on various factors, such as temperature, timing of concentration sampling, steady-state dosing conditions, renal function, age, concomitant medications, and patient type. 

Other option is to use free phenytoin level, but usually it's not widely available in all hospitals' laboratories.

#pharmacology

References:

1. Kiang TK, Ensom MH. A Comprehensive Review on the Predictive Performance of the Sheiner-Tozer and Derivative Equations for the Correction of Phenytoin Concentrations. Ann Pharmacother. 2016 Apr;50(4):311-25. doi: 10.1177/1060028016628166. Epub 2016 Jan 29. PMID: 26825643.

2. Dager WE, Inciardi JF, Howe TL. Estimating phenytoin concentrations by the Sheiner-Tozer method in adults with pronounced hypoalbuminemia. Ann Pharmacother. 1995 Jul-Aug;29(7-8):667-70. doi: 10.1177/106002809502907-802. PMID: 8520077.

3. Bolt J, Gorman SK. Precision, bias, and clinical utility of the Sheiner-Tozer equation to guide phenytoin dosing in critically ill adults. J Clin Pharmacol. 2013 Apr;53(4):451-5. doi: 10.1002/jcph.27. Epub 2013 Feb 22. PMID: 23436385.

ORD

Case: 22 years old female is admitted to ICU for suicidal watch. She attempted suicide as she was unable to get rid of her foul-smelling odor despite assurances from friends and family that she had no such issue. The patient was diagnosed with Olfactory reference disorder (ORD). 

Discussion: ORD is a disease where a patient has a persistent preoccupation with emitting a foul body odor about himself. It can be an occupation with bad breath, sweat, flatulence, urine, or the genital area.

In psychiatric literature, it has been described as olfactory delusional syndrome, olfactory paranoid syndrome, delusional halitosis, imaginary halitosis, monosymptomatic hypochondriacal psychosis, and bromidrosiphobia. 

It is not entirely clear that ORD is purely a psychiatric disorder or has underlying neurological pathophysiology. Single-photon emission computed tomography (SPECT) imaging in these patients found decreased perfusion in the left frontotemporal region with multiple additional perfusion defects.

SSRI (Selective Serotonin Reuptake Inhibitor) may be effective.

#psychiatry

References:

1. Begum M, McKenna PJ. Olfactory reference syndrome: a systematic review of the world literature. Psychol Med 2011; 41:453.

2. Stein DJ, Le Roux L, Bouwer C, Van Heerden B. Is olfactory reference syndrome an obsessive-compulsive spectrum disorder?: two cases and a discussion. J Neuropsychiatry Clin Neurosci 1998; 10:96.

3. Konuk N, Atik L, Atasoy N, Ugur MB. Frontotemporal hypoperfusion detected by 99mTc HMPAO SPECT in a patient with olfactory reference syndrome. Gen Hosp Psychiatry 2006; 28:174.

4. Skimming KA, Miller CWT. Transdiagnostic Approach to Olfactory Reference Syndrome: Neurobiological Considerations. Harv Rev Psychiatry. 2019 May/Jun;27(3):193-200. doi: 10.1097/HRP.0000000000000215. PMID: 31082994.

signet / cabochon ring sign

Q: The presence of Signet or Cabochon ring sign on CT chest is mainly associated with which lung disease?

Answer: Bronchiectasis

Bronchiectasis can be diagnosed on CT chest by some of the hallmark signs such as:

1. their continuity with an airway

2. tendency to form clusters

3. formation of tramlines or honeycombing

4. signet  or Cabochon ring sign

Tramlines' appearance is due to dilated, thickened bronchial walls, and a signet or cabochon ring sign appears when the bronchus becomes larger than the corresponding vessel. In normal lungs, the vessel is larger than the corresponding bronchus.

Fig. A - Tramline sign - dilated, thickened bronchial walls (blue arrows)

Fig. B - Signet ring - The bronchi (red arrows) are larger than their corresponding arteries (white arrows)

#pulmonary

#radiology

References:

1. Ledda RE, Balbi M, Milone F, Ciuni A, Silva M, Sverzellati N, Milanese G. Imaging in non-cystic fibrosis bronchiectasis and current limitations. BJR Open. 2021 Jul 29;3(1):20210026. doi: 10.1259/bjro.20210026. PMID: 34381953; PMCID: PMC8328081.

2. Sawada H, Kudoh R, Yokoyama A, Hagiwara A, Hiramatsu K, Kadota JI, Komiya K. Chest X-Ray Features in 130 Patients with Bronchiectasis. Diseases. 2024 Dec 10;12(12):323. doi: 10.3390/diseases12120323. PMID: 39727653; PMCID: PMC11726920.

3. Bird K, Memon J. Bronchiectasis. 2023 May 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 28613561.

Snoring and associated conditions

Q: Which of the following (so far) is NOT found to be associated with snoring (Obstructive Sleep Apnea- OSA)? - Select one

A) Carotid atherosclerosis

B) Hypertension

C) Ischemic heart disease 

Answer: C

Although conventionally it is believed that patients with snoring, either due to OSA or simple upper airway narrowing, will develop ischemic heart disease, evidence has failed to show such an association.

In contrast, carotid atherosclerosis and hypertension are found to be very well associated with snoring.

#sleep

#ENT

#pulmonary

#cardiology

References:

1. Yeboah J, Redline S, Johnson C, et al. Association between sleep apnea, snoring, incident cardiovascular events and all-cause mortality in an adult population: MESA. Atherosclerosis 2011; 219:963.

2. Marshall NS, Wong KK, Cullen SR, et al. Snoring is not associated with all-cause mortality, incident cardiovascular disease, or stroke in the Busselton Health Study. Sleep 2012; 35:1235.

3. Jennum P, Hein HO, Suadicani P, Gyntelberg F. Risk of ischemic heart disease in self-reported snorers. A prospective study of 2,937 men aged 54 to 74 years: the Copenhagen Male Study. Chest 1995; 108:138.

ETT and neck movement

Q: Extension of neck (Chin up) will cause Endotracheal tube (ETT) to migrate? - Select one

A) up 

B) down

Answer: A

Extending the neck (Chin up) causes ETT to migrate up, and flexion of the neck (Chin down) causes ETT to migrate down.

Rule:

Chin up - ETT up

Chin down - ETT down

Clinical application: During tracheostomy, operator has to extend the neck. This may inadvertently extubate the patient prior to insertion of tracheostomy tube. 

#procedures

#ENT

References:

1. Tsukamoto M, Yamanaka H, Hitosugi T, Yokoyama T. Endotracheal Tube Migration Associated With Extension During Tracheotomy. Anesth Prog. 2020 Spring;67(1):3-8. doi: 10.2344/anpr-66-04-05. PMID: 32191508; PMCID: PMC7083118.

2. Kim JT, Kim HJ, Ahn W, Kim HS, Bahk JH, Lee SC, Kim CS, Kim SD. Head rotation, flexion, and extension alter endotracheal tube position in adults and children. Can J Anaesth. 2009 Oct;56(10):751-6. doi: 10.1007/s12630-009-9158-y. Epub 2009 Jul 29. PMID: 19639372.

TRAS

Case: 54 years old male with history of kidney transplant 10 months ago presented to Emergency department with accelerated hypertension and flash pulmonary edema. On examination, an abdominal bruit over the transplanted site is heard. What is the most probable diagnosis?

Answer: TRAS (Transplant renal artery stenosis)

TRAS can occur in up to one in four renal transplanted recipient patients. It occurs at the site of the renal artery anastomosis. Interestingly, it can also occur in the donor's renal artery or the feeding native artery. The usual causes are difficulty during transplants, causing flow limitation through vascular clamping, kinking, or angulation of the artery. Major clinical signs are:  

• Worsening hypertension
• Unexplained and persistent Hypokalemia (secondary hyperaldosteronism)
• Kidney function decline
• Episodes of flash pulmonary edema
• Abdominal bruit over the allograft (may or may not be present)

The risk factors are

• Difficulties in organ procurement 
• Poor/complex operative techniques 
• Atherosclerotic disease
• Cytomegalovirus infection
• Delayed allograft function 

 Fortunately, it is reversible. 

#nephrology

#transplantation

References:

1. Audard V, Matignon M, Hemery F, et al. Risk factors and long-term outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty. Am J Transplant 2006; 6:95.

2. Bruno S, Remuzzi G, Ruggenenti P. Transplant renal artery stenosis. J Am Soc Nephrol 2004; 15:134.

3. Voiculescu A, Schmitz M, Hollenbeck M, et al. Management of arterial stenosis affecting kidney graft perfusion: a single-centre study in 53 patients. Am J Transplant 2005; 5:1731.

4. Pouria S, State OI, Wong W, Hendry BM. CMV infection is associated with transplant renal artery stenosis. QJM 1998; 91:185.

hallucinations in psychiatric disorders

Q: Which hallucination is more common in psychiatric illness? - select one

A) Auditory

B) Visual 

Answer: A

Auditory hallucinations are almost twice as common and can accompany the visual hallucinations. Most visual hallucinations are complex and usually disturbing and lack insight. 

A complete psychiatric evaluation is required.

#psychiatry

References:

1. Bowman KM, Raymond AF. A statistical study in the manic-depressive psychoses. Am J Psychiatry 1931; 88:299.

2. Black DW, Nasrallah A. Hallucinations and delusions in 1,715 patients with unipolar and bipolar affective disorders. Psychopathology 1989; 22:28.

3. Goodwin DW, Alderson P, Rosenthal R. Clinical significance of hallucinations in psychiatric disorders. A study of 116 hallucinatory patients. Arch Gen Psychiatry 1971; 24:76.

Hemothorax and hematocrit

Q: How is Hemothorax defined based on Hematocrit?

Answer: A pleural effusion with a hematocrit value of more than 50% of that of the circulating hematocrit is considered a hemothorax.

#pulmonary

References:

1. DiVietro ML, Huggins JT, Angotti LB, Kummerfeldt CE, Nestor JE, Doelken P, Sahn SA. Pleural Fluid Analysis in Chronic Hemothorax: A Mimicker of Infection. Clin Med Insights Case Rep. 2015 Aug 10;8:71-6. doi: 10.4137/CCRep.S12404. PMID: 26309422; PMCID: PMC4533848.

2. Zeiler J, Idell S, Norwood S, Cook A. Hemothorax: A Review of the Literature. Clin Pulm Med. 2020 Jan;27(1):1-12. doi: 10.1097/CPM.0000000000000343. Epub 2020 Jan 10. PMID: 33437141; PMCID: PMC7799890.

complex sleep-related behaviors

Q: 32 years old male is brought to the ED after a Motor Vehicle Accident (MVA). Patient does not remember driving. Per his wife, he went to bed normally, but she was awakened with a police call that her husband was in an MVA on highway. The patient was found by police at the accident site behind a vehicle, only in night gown without any shoes or slippers. Patient recalled that the very last thing he did was going to bed at his home. He acknowledges that recently he has increased the dose of his sleep medicine on his own. The patient was diagnosed with complex sleep-related behaviors. What are the few complex sleep-related behaviors with insomnia meds?

Answer:

Complex sleep-related behaviors are common and very underappreciated. They are common with higher doses of all insomnia meds, but the most described culprits are

• zolpidem
• zaleplon
• eszopiclone
• triazolam

Patients may perform various activities outside of their will and may be potentially fatal (like our patient in the above case). Common activities while not awake are

• sleepwalking
• driving
• phone call
• eating
• sex 
• swimming

Interestingly, young people are prone to such incidents more than elderly people.

#sleep

#pharmacology

#psychiatry

References:

1. US Food and Drug Administration (FDA). FDA adds boxed warning for risk of serious injuries caused by sleepwalking with certain prescription insomnia medicines. FDA Drug Safety Communication, April 30, 2019. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-adds-boxed-warning-risk-serious-injuries-caused-sleepwalking-certain-prescription-insomnia (Accessed on March 31, 2025).

2. Chen CS, Huang MF, Hwang TJ, et al. Clinical correlates of zolpidem-associated complex sleep-related behaviors: age effect. J Clin Psychiatry 2014; 75:e1314.

3. Chen LF, Lin CE, Chou YC, et al. A comparison of complex sleep behaviors with two short-acting Z-hypnosedative drugs in nonpsychotic patients. Neuropsychiatr Dis Treat 2013; 9:1159.

4. Tsai JH, Yang P, Chen CC, et al. Zolpidem-induced amnesia and somnambulism: rare occurrences? Eur Neuropsychopharmacol 2009; 19:74.

5. Hwang TJ, Ni HC, Chen HC, et al. Risk predictors for hypnosedative-related complex sleep behaviors: a retrospective, cross-sectional pilot study. J Clin Psychiatry 2010; 71:1331.

equi-osmolarity of Mannitol vs. Salt bomb

Q: In the treatment of increased intracranial pressure (ICP), what is the equivalency of 23.4% of NaCl and Mannitol in terms of similar osmolar effect?

Answer: To be precise, 0.686 ml of 23.4% NaCl is equiosmolar to 1 gram/kg of 20% mannitol in effect. 

The usual dose is 30-50 ml of 23.4% NaCl or 50-70 grams of mannitol q3-q6 hours as needed. Dose can be adjusted per clinical situation and lab osmolarity findings.

#neurology

#pharmacology

References:

1. Ch. Lazaridis, R. Neyens, J. Bodle - High-osmolality saline in neurocritical care systematic review and meta-analysis - Crit Care Med, 41 (2013), pp. 1353-1360

2. Gisela Llorente, Maria Claudia Niño de Mejia, Mannitol versus hypertonic saline solution in neuroanaesthesia, Colombian Journal of Anesthesiology, Volume 43, Supplement 1, 2015, Pages 29-39,

ISSN 2256-2087, https://doi.org/10.1016/j.rcae.2014.07.010. (https://www.sciencedirect.com/science/article/pii/S2256208714000935)

Renal cyst and potassium

Case: 62 years old male presented to ED with flank pain and accelerated hypertension (HTN). He informed that his primary care doctor recently found him to have late-onset HTN. In the last few months, he has continued to have potassium issues in his lab work for no reason. The only positive finding so far, is a simple renal cyst on abdominal ultrasound, regarded as an incidental finding by the radiologist. If a simple cyst of the kidney becomes symptomatic, it tends to cause? - Select one

A) hyperkalemia

B) hypokalemia

Answer: B

The finding of a renal cyst on ultrasound is usually benign and an incidental finding. But, if it enlarges in size, it may become a cause of late-onset hypertension. The reason is persistent pain, discomfort, and possible excess renin secretion. This should be treated as secondary HTN, which many times presents as an acute rise in blood pressure in a normotensive person. 

These patients tend to have persistent hypokalemia, which remains unexplained due to any other cause.

#nephrology

#electrolytes

References:

1. Ferrari P. The challenge of renal cystic disease and its association with hypertension, age and abnormal potassium handling. J Hypertens. 2007 Jul;25(7):1347-9. doi: 10.1097/HJH.0b013e32814db544. PMID: 17563553.

2. Gamakaranage CS, Rodrigo C, Jayasinghe S, Rajapakse S. Hypokalemic paralysis associated with cystic disease of the kidney: case report. BMC Nephrol. 2011 Apr 18;12:16. doi: 10.1186/1471-2369-12-16. PMID: 21501478; PMCID: PMC3095547.

BP from lower extremities

Q: Blood Pressure (BP) obtained from the lower extremity is usually _______________ than the BP obtained from the arm? - select one

A) higher

B) lower

Answer: A

Although undesirable, BP from the lower extremities can be obtained if needed, particularly in End-Stage Renal Disease (ESRD) patients with vascular fistulae. Patients with a known history of coarctation of the aorta may also require that.

Systolic blood pressure in the lower extremity is usually higher than in the upper extremity (measured from the brachial artery). This is true for both the calf and the ankle. On an average, the difference is about 10 mmHg higher in the calf and 17 mmHg higher in the ankle.

While obtaining BP in the lower extremity, the cuff center should align with the popliteal artery. 

#cardiology

#procedures

References:

1. Sheppard JP, Lacy P, Lewis PS, Martin U; Blood Pressure Measurement Working Party of the British and Irish Hypertension Society. Measurement of blood pressure in the leg-a statement on behalf of the British and Irish Hypertension Society. J Hum Hypertens. 2020 Jun;34(6):418-419. doi: 10.1038/s41371-020-0325-5. Epub 2020 Apr 22. PMID: 32322006; PMCID: PMC7299841.

2. McDonagh STJ, Sheppard JP, Warren FC, Boddy K, Farmer L, Shore H, Williams P, Lewis PS, Baumber R, Fordham J, Martin U, Aboyans V, Clark CE; INTERPRESS-IPD Collaborators. Arm Based on LEg blood pressures (ABLE-BP): can systolic leg blood pressure measurements predict systolic brachial blood pressure? Protocol for an individual participant data meta-analysis from the INTERPRESS-IPD Collaboration. BMJ Open. 2021 Mar 19;11(3):e040481. doi: 10.1136/bmjopen-2020-040481. PMID: 33741659; PMCID: PMC7986760.

SJS/TEN and Na

Q: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) usually causes? - select one

A) hypernatremic dehydration

B) hyponatremic dehydration

Answer: B

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a serious and potentially fatal mucocutaneous drug reaction, characterized by extensive necrosis and detachment of the epidermis due to massive keratinocyte apoptosis. It usually starts as a prodrome of fever and influenza-like symptoms followed in one to three days by an eruption of ill-defined, coalescing, erythematous macules with atypical target lesions. As the disease progresses, vesicles and bullae form, and the skin begins to slough within days. Mucosal involvement occurs in over 90 percent of cases.

Morbidity (and mortality) occurs due to massive loss of fluids, electrolyte imbalance, hypovolemic shock with hyponatremic dehydration, sepsis, and multiple system organ failure (MSOF). These patients are usually managed in a burn unit because of extensive skin detachment. 

#dermatology

References:

1. Hung CC, Liu WC, Kuo MC, Lee CH, Hwang SJ, Chen HC. Acute renal failure and its risk factors in Stevens-Johnson syndrome and toxic epidermal necrolysis. Am J Nephrol. 2009;29(6):633-8. doi: 10.1159/000195632. Epub 2009 Jan 21. PMID: 19155617.

2. Huang SC, Tsai SJ. Hyponatremia and Stevens-Johnson syndrome in a patient receiving carbamazepine. Gen Hosp Psychiatry. 1995 Nov;17(6):458-60. doi: 10.1016/0163-8343(95)90049-7. PMID: 8714810.

3. Shah H, Parisi R, Mukherjee E, Phillips EJ, Dodiuk-Gad RP. Update on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Diagnosis and Management. Am J Clin Dermatol. 2024 Nov;25(6):891-908. doi: 10.1007/s40257-024-00889-6. Epub 2024 Sep 15. PMID: 39278968; PMCID: PMC11511757.

Mx of Delirium Tremens

Q: In refractory delirium tremens(R-DT), phenobarbital should be prescribed ___________ benzodiazepine. - Select one

A) With

B) Without

Answer: A

The probable pathophysiology behind refractory delirium tremens is the low endogenous GABA (gamma-aminobutyric acid) concentrations or acquired conformational changes in the GABA receptor.

Barbiturates and Benzodiazepines work synergistically in R-DT. Barbiturates increase the duration of channel opening, and benzodiazepines increase the frequency of GABA chloride channel opening.

Phenobarbital is the most effective barbiturate in refractory delirium tremens and is often referred to as 'phenobarb-coma.' It should be combined with benzodiazepine and monotherapy with phenobarb should be avoided.

#neurology

#toxicity

#pharmacology

References:

1. Lee CM, Dillon DG, Tahir PM, Murphy CE 4th. Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:515.

2. Grover S, Ghosh A. Delirium Tremens: Assessment and Management. J Clin Exp Hepatol. 2018 Dec;8(4):460-470. doi: 10.1016/j.jceh.2018.04.012. Epub 2018 May 5. PMID: 30564004; PMCID: PMC6286444.

3. Kafle P, Mandal AK, Shrestha B, Bhattrai B, Bhandari M, Bhagat S, Shankar Kar B, Sharma D, Gayam V. Twenty-Eight-Day-Long Delirium Tremens. J Investig Med High Impact Case Rep. 2019 Jan-Dec;7:2324709619847228. doi: 10.1177/2324709619847228. PMID: 31053040; PMCID: PMC6505229.

gland enlargement in alcoholic cirrhosis

Q: Which of the following gland enlargement can be seen in advanced alcohol-associated cirrhosis? - select one

A) Parotid gland 

B) Salivary Gland

Answer: A

This question aims to raise awareness of the clinical importance of physical exams and "a physician touch" in clinical medicine.

Even various stigmata of liver failure can guide physicians to the specific etiology of cirrhosis. Three primary organ dysfunctions are highly likely to be seen in advanced alcohol-associated cirrhosis (though they  can be present in other types of cirrhosis)

• Dupuytren contractures
• Parotid gland enlargement
• Testicular atrophy

Although parotid gland enlargement in chronic alcoholism is known since alcohol was known to humankind, it was first reported in present-day literature in 1957 and has been consistently described.

#hepatology

#physical-exam

References:

1. Stanley J. Wolfe, M.D., W. H. J. Summerskill, D.M., M.R.C.P., and Charles S. Davidson, M.D.- Parotid Swelling, Alcoholism and Cirrhosis, Published March 14, 1957, N Engl J Med 1957; VOL. 256 NO. 11,256:491-495, DOI: 10.1056/NEJM195703142561103

2. Dutta SK, Dukehart M, Narang A, Latham PS. Functional and structural changes in parotid glands of alcoholic cirrhotic patients. Gastroenterology. 1989 Feb;96(2 Pt 1):510-8. doi: 10.1016/0016-5085(89)91578-3. PMID: 2910764.

Onn discovery of cryoprecipitate

A quote from history on the discovery of cryoprecipitate

Cryoprecipitate is cold-insoluble portion of plasma that precipitates when FFP has been thawed between 1- 6 °C. It is rich in fibrinogen and factor VIII. It also contains von Willebrand factor (vWF) and factor XIII.

"I made a mistake in an experiment, and instead of putting frozen plasma back in the freezer at the end of the day's experiment, I instead stuck it in the refrigerator. When I came in the next morning, there was all this junk in the bottom of the tube which I spun out, and I used the plasma for my experiment. My experiment didn't work because there was no Factor VIII in it. And I went back and fished the junk out of the trash and assayed the junk and got these outrageously high values for Factor VIII in the junk, and neither Charlie nor I believed it, and so it was one of those things. And sure enough, about a year later Judith Graham Pool discovered cryoprecipitate".

#hematology

Reference: 

Resnik, Susan (1999). Blood Saga: Hemophilia, AIDS, and the Survival of a Community. Berkeley: University of California Press. pp. 40–41

CGA

Q: What are the six domains of comprehensive geriatric assessment (CGA) in oncology patients?

Answer: More than half of the new cases and 70 percent of mortality from cancer occur in patients ≥65 years of age.

Many oncologists perform comprehensive geriatric assessments (CGAs) and make a shared decision about the extent of oncology treatment. 

Consensus guidelines from the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the International Society for Geriatric Oncology (SIOG) recommend its use. Over time, there were many modifications done either individually by a physician or by practice groups, but overall, the following domains of CGA should be considered:

• Functional status
• Comorbidity
• Nutrition 
• Medication review
• Psychological state and social support
• Cognitive function

#oncology

References:

1. Decoster L, Van Puyvelde K, Mohile S, et al. Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†. Ann Oncol 2015; 26:288.

2. Mohile SG, Dale W, Somerfield MR, Hurria A. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology Summary. J Oncol Pract 2018; 14:442.

3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Older adult oncology. https://www.nccn.org/professionals/physician_gls/pdf/senior.pdf 

4. Hurria A, Gupta S, Zauderer M, et al. Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 2005; 104:1998.

Acetazolamide and Potassium

Q: Diuresis with Acetazolamide causes? - Select one

A) hyperkalemia

B) hypokalemia

Answer: B

Acetazolamide is a carbonic anhydrase inhibitor often used to decrease serum bicarbonate levels in ICU.

Acetazolamide inhibits proximal sodium bicarbonate reabsorption and increases urinary bicarbonate excretion. This increase in sodium bicarbonate delivery to the potassium-secretory site in the collecting tubules generates kaliuresis, leading to clinically significant hypokalemia, which may require potassium repletion.

The usual dose of Acetazolamide is 250 to 500 mg, once or twice a day.

Interestingly, it is used in a wide array of diseases both on and off-label, including:

• Glaucoma
• Idiopathic intracranial hypertension
• Congestive heart failure
• Altitude sickness
• Periodic paralysis
• Epilepsy
• Central sleep apnea
• Marfan syndrome
• Prevention of high-dose methotrexate nephrotoxicity

#nephrology

#electrolytes

#acid-base

References:

1. Prieto de Paula JM, Villamandos Nicás V, Cancelo Suárez P, del Portillo Rubí A, Guillem Ares E, Prada Mínguez A, Sanz de la Fuente H. Eficacia del tratamiento con acetazolamida en pacientes con hipercapnia y alcalosis metabólica sobreimpuesta [Efficacy of acetazolamide treatment of patients with hypercapnia and superimposed metabolic alkalosis]. Rev Clin Esp. 1997 Apr;197(4):237-40. Spanish. PMID: 9254398.

2. Miller PD, Berns AS. Acute metabolic alkalosis perpetuating hypercarbia. A role for acetazolamide in chronic obstructive pulmonary disease. JAMA. 1977 Nov 28;238(22):2400-1. doi: 10.1001/jama.238.22.2400. PMID: 578870.

3. Van Berkel MA, Elefritz JL. Evaluating off-label uses of acetazolamide. Am J Health Syst Pharm. 2018 Apr 15;75(8):524-531. doi: 10.2146/ajhp170279. PMID: 29626002.

4. Farzam K, Abdullah M. Acetazolamide. [Updated 2023 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532282/

Contraindications of Bupropion

Q: 34 years old overweight male (BMI of 32) with previous history of smoking history, alcoholism, hypertension (HTN), and depression is admitted to ICU with new-onset seizures. Patient acknowledges that recently he used his friend's bupropion to decrease his weight. Name few contraindications for Bupropion?

Answer: In the last few years, off-label use of bupropion has risen due to its easy availability and relatively cheaper price. A few of the relative contraindications are

• Seizure disorders, including alcohol withdrawal seizures (bupropion decreases the seizure threshold)
• Bulimia nervosa
• Pregnancy
• Uncontrolled HTN
• Chronic opioid use
• Renal insufficiency
• Hepatic insufficiency
• Use of monoamine oxidase inhibitors within last two weeks

#neurology

#toxicity

#pharmacology

References:

1. Mother To Baby | Fact Sheets [Internet]. Brentwood (TN): Organization of Teratology Information Specialists (OTIS); 1994-. Bupropion. 2023 Jul. Available from: https://www.ncbi.nlm.nih.gov/books/NBK582611/

2. Beyens MN, Guy C, Mounier G, Laporte S, Ollagnier M. Serious adverse reactions of bupropion for smoking cessation: analysis of the French Pharmacovigilance Database from 2001 to 2004. Drug Saf. 2008;31(11):1017-26. doi: 10.2165/00002018-200831110-00006. PMID: 18840021.

3. Stahl SM, Pradko JF, Haight BR, Modell JG, Rockett CB, Learned-Coughlin S. A Review of the Neuropharmacology of Bupropion, a Dual Norepinephrine and Dopamine Reuptake Inhibitor. Prim Care Companion J Clin Psychiatry. 2004;6(4):159-166. doi: 10.4088/pcc.v06n0403. PMID: 15361919; PMCID: PMC514842.

Positive urinary pregnancy test in men

Case: A male undergoing lab tests came out positive for Beta-HCG. What could be the cause of positive Beta-HCG in a male?

Discussion: A positive pregnancy test in a man is a red flag for testicular cancer.

β-hCG is not usually present in males. Its presence suggests a tumor that produces β-hCG, such as Choriocarcinoma, Embryonal carcinoma, and mixed germ cell tumors. Rarely, some seminomas can secrete β-hCG.

Further Testing should be done.

 1. Serum tumor markers:

 • β-hCG (already elevated)

 • Alpha-fetoprotein (AFP) — elevated in NSGCTs except for pure seminomas and choriocarcinomas

 • Lactate dehydrogenase (LDH) — correlates with tumor burden

 2. Testicular ultrasound:

 • First-line imaging to identify testicular masses

 3. Scrotal and physical examination:

 • Palpate for masses or asymmetry

 4. CT scan of chest, abdomen, and pelvis:

 • To evaluate for metastasis (especially lungs, liver, retroperitoneum)

 5. Urology or oncology referral:

 • For surgical exploration (radical inguinal orchiectomy is both diagnostic and therapeutic)

#oncology

#endocrinology

References:

1. Groza D, Duerr D, Schmid M, Boesch B. When cancer patients suddenly have a positive pregnancy test. BMJ Case Rep. 2017 Jul 1;2017:bcr2017220493. doi: 10.1136/bcr-2017-220493. PMID: 28668822; PMCID: PMC5535187.

2. Tsai JR, Chong IW, Hung JY, Tsai KB. Use of urine pregnancy test for rapid diagnosis of primary pulmonary choriocarcinoma in a man. Chest. 2002 Mar;121(3):996-8. doi: 10.1378/chest.121.3.996. PMID: 11888991.

3. Paramore L, Chetwood AS. Role of urinary pregnancy testing in the diagnosis of men with testicular cancer. Ann R Coll Surg Engl. 2025 Jan;107(1):73. doi: 10.1308/rcsann.2023.0029. Epub 2024 Apr 2. PMID: 38563075; PMCID: PMC11658873.

Picture Diagnosis

Q: Patient presents with 10 years of difficulty swallowing food and water. It became worse over the last 3 months. Chest X-ray showed this. What is your diagnosis?

Answer:  The chest X-ray shows a significantly dilated esophagus filled with food and fluid, with an air-fluid level and absence of peristalsis. These findings are highly suggestive of achalasia, a primary esophageal motility disorder characterized by failure of the lower esophageal sphincter (LES) to relax.

Diagnosis: Achalasia

Supporting Features:

• Progressive dysphagia (starting with solids, later affecting liquids)
• Long duration (10 years, worsening over 3 months)
• 
  

Chest X-ray findings:

• Widely dilated esophagus
• Air-fluid level
• Mediastinal widening due to food stasis
• Absence of gastric air bubble (suggesting LES dysfunction)

Next Steps:

1. Confirm with Barium Swallow: "Bird-beak" narrowing at the gastroesophageal junction.

2. Esophageal Manometry: Absent peristalsis, high LES pressure, incomplete relaxation.

3. Endoscopy: Rule out malignancy (pseudoachalasia).

#GI

Further readings:

1. Ribolsi M, Andrisani G, Di Matteo FM, Cicala M. Achalasia, from diagnosis to treatment. Expert Rev Gastroenterol Hepatol. 2023 Jan;17(1):21-30. doi: 10.1080/17474124.2022.2163236. Epub 2023 Jan 1. PMID: 36588469.

2. Cappell MS, Stavropoulos SN, Friedel D. Updated Systematic Review of Achalasia, with a Focus on POEM Therapy. Dig Dis Sci. 2020 Jan;65(1):38-65. doi: 10.1007/s10620-019-05784-3. Epub 2019 Aug 27. PMID: 31451984.

Older age HIV

Q: What age is the cut-off age usually defined for "HIV infections in older adults"? - Select one

A) ≥50 years

B) ≥60 years

C) ≥65 years

D) ≥70 years

Answer: A

As patients with human immunodeficiency virus (HIV) infection are living almost as normal life expectancy as the general population, geriatric care with HIV has itself become a subspecialty of HIV treatment. So far, age ≥50 remains a defining cutoff for such care. Interestingly, more and more patients are getting diagnosed with HIV above this age due to a "taking life easy" attitude and conventional belief that they may have passed the age of practicing protected sex.

HIV care at this age remains complicated due to higher age-related comorbidities and higher risks of polypharmacy. Cumulating older age with HIV also creates a higher risk for malignancy. Other areas include the complex management of different body organs such as bone, liver, and lungs and hormonal changes. 

#ID

#epidemiology

References:

1. Wing EJ. HIV and aging. Int J Infect Dis. 2016 Dec;53:61-68. doi: 10.1016/j.ijid.2016.10.004. Epub 2016 Oct 15. PMID: 27756678.

2. Autenrieth CS, Beck EJ, Stelzle D, et al. Global and regional trends of people living with HIV aged 50 and over: Estimates and projections for 2000-2020. PLoS One 2018; 13:e0207005.

3. Li N, Zheng HY, He WQ, He XY, Li R, Cui WB, Yang WL, Dong XQ, Shen ZQ, Zheng YT. Treatment outcomes amongst older people with HIV infection receiving antiretroviral therapy. AIDS. 2024 May 1;38(6):803-812. doi: 10.1097/QAD.0000000000003831. Epub 2024 Jan 12. PMID: 38578958; PMCID: PMC10994140.

Spontaneous, nontraumatic gangrene

Q: Which system amongst the following is more prone to origniate spontaneous (nontraumatic) gas gangrene? - Select one

A) Muscles

B) Genitourinary (GU) tract

C) Respiratory tract

D) Gastrointestinal (GI) tract

E) Hematologic source

Answer: D

Gastrointestinal lesions or undiagnosed adenocarcinoma of the colon should be suspected in patients who develop spontaneous gas gangrene.

The major predisposing factors:

• Colonic malignancy
• Inflammatory bowel disease (IBD)
• Diverticulitis
• GI surgery
• Leukemia
• Lymphoproliferative disorders
• Chemotherapy
• Neutropenia
• Radiation therapy
• Advanced AIDS
• Necrotizing enterocolitis, cecitis, or distal ileitis

#ID

#GI

#oncology

References:

1. Stevens DL, Musher DM, Watson DA, et al. Spontaneous, nontraumatic gangrene due to Clostridium septicum. Rev Infect Dis 1990; 12:286.

2. Johnson S, Driks MR, Tweten RK, et al. Clinical courses of seven survivors of Clostridium septicum infection and their immunologic responses to alpha toxin. Clin Infect Dis 1994; 19:761.

3. Alpern RJ, Dowell VR Jr. Clostridium septicum infections and malignancy. JAMA 1969; 209:385.

4. Srivastava I, Aldape MJ, Bryant AE, Stevens DL. Spontaneous C. septicum gas gangrene: A literature review. Anaerobe. 2017 Dec;48:165-171. doi: 10.1016/j.anaerobe.2017.07.008. Epub 2017 Aug 2. PMID: 28780428.

Torsades de pointes and polymorphic VT

Q: What is the difference between Torsades de Pointes and polymorphic Ventricular Tachycardia (VT)?

Answer: 

Torsades de Pointes, meaning "twisting of points,"  is a rapid and distinct polymorphic VT associated with baseline prolonged QTc interval.

If baseline QTc interval is normal, it is technically called polymorphic VT, not torsades de pointes.

In Torsades de Pointes, continuously changing axis of polymorphic QRS morphologies is observed during each episode. It is typically initiated by bradycardia or, as called, 'pause dependent,' with a short-long-short coupling interval, i.e., PVC (short RR interval), a compensatory pause (long RR interval), and a second PVC (short RR interval).

#cardiology

References:

1. Passman R, Kadish A. Polymorphic ventricular tachycardia, long Q-T syndrome, and torsades de pointes. Med Clin North Am. 2001 Mar;85(2):321-41. doi: 10.1016/s0025-7125(05)70318-7. PMID: 11233951.

2. Tsuji Y, Yamazaki M, Shimojo M, Yanagisawa S, Inden Y, Murohara T. Mechanisms of torsades de pointes: an update. Front Cardiovasc Med. 2024 Mar 5;11:1363848. doi: 10.3389/fcvm.2024.1363848. PMID: 38504714; PMCID: PMC10948600.

3. Rosso R, Hochstadt A, Viskin D, Chorin E, Schwartz AL, Tovia-Brodie O, Laish-Farkash A, Havakuk O, Gepstein L, Banai S, Viskin S. Polymorphic ventricular tachycardia, ischaemic ventricular fibrillation, and torsade de pointes: importance of the QT and the coupling interval in the differential diagnosis. Eur Heart J. 2021 Oct 7;42(38):3965-3975. doi: 10.1093/eurheartj/ehab138. PMID: 33693589.

Harmless Score

Q: The Harmless score applies to? - Select one

A) Acute Aphasia (stroke)

B) Acute Breathing problem

C) Acute Cardiac event

D) Acute Pancreatitis

E) Acute Liver failure

Answer: D

Although the "Harmless acute pancreatitis score" is not a well-known entity, it is an interesting quick-to-do test that can be calculated within 30 minutes of admission to predict mortality/severity. It comprises of three parameters - and if all three are negative, pancreatitis is probably harmless: 

1. Lack of rebound tenderness or guarding
2. Normal hematocrit 
3. Normal serum creatinine

Only one study of 204 patients is available in this regard, but it correctly identified harmlessness with 98 percent accuracy.

#GI

Reference:

Lankisch PG, Weber-Dany B, Hebel K, et al. The harmless acute pancreatitis score: a clinical algorithm for rapid initial stratification of nonsevere disease. Clin Gastroenterol Hepatol 2009; 7:702.

ADEs

Q: Adverse Drug Events (ADEs) are more common in? - Select one

A) Outpatient

B) Emergency Room(ER)

C) Inpatient Ward

D) ICU 

Answer: D

Studies have shown that ICU is the most common place to have ADEs, particularly during night shifts and on weekends. Some of the primary reasons for these mishaps are:

1. ICU patients usually receive more medications than in other medical settings.

2. Many medications are new, and patients' profiles are not yet documented for drug-drug interactions.

3. Most medications in the ICU are given intravenously (IV), which can lead to higher reactions and miscalculations of doses/infusion rates. 

4. ICU patients have multiple severe comorbidities.

5. ICU patients are often sedated and can't check/question/report their own drugs.

6. Upon arrival in the ICU, long-term and often essential drugs are frequently held or discontinued, such as antiplatelets in stent patients or anticoagulants in atrial fibrillation or thrombus patients.

7. In ICUs, patients' levels of care remain the same during night shifts and on weekends, but there is less staffing and supervision.

#pharmacology

#patient-safety

References:

1.Wilmer A, Louie K, Dodek P, et al. Incidence of medication errors and adverse drug events in the ICU: a systematic review. Qual Saf Health Care 2010; 19:e7.

2. Kane-Gill S, Weber RJ. Principles and practices of medication safety in the ICU. Crit Care Clin 2006; 22:273.

3. Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA 2011; 306:840.

4. Miller AD, Piro CC, Rudisill CN, et al. Nighttime and weekend medication error rates in an inpatient pediatric population. Ann Pharmacother 2010; 44:1739.

Dental trauma during intubation

Q: 52 years old male has an accidental tooth avulsion during intubation in a small rural town where no emergency dental help is available on short notice. An attempt should be made to reimplant. 

A) Yes

B) No

Answer: A

Although it is true that, ideally, a dentist, oral-maxillofacial surgeon, or trauma surgeon should perform tooth reimplantation, dentists are generally unavailable in acute ICU/ER/trauma-field situations. In minor, partial, or lateral avulsion (not major facial trauma), where reimplantation seems easy, it should be attempted. A tooth reimplanted within one hour has a better chance of healing and becoming functional over a period of time. This advantage is lost once the three-hour markup is over. A few precautions that need to be taken care of are:

• Try not to disturb the socket 
• Handle the tooth by the crown 
• Root should not be wiped or even handled
• Rinse the tooth and socket with tap water or saline
• Attempt to replace the tooth in the socket (it may "click" into place!)

If an operator seems uncomfortable or reimplantation seems complicated, the tooth should be preserved preferably in a culture medium (Hank's Balanced Salt Solution) or in milk if the culture medium is not available. 

If a tooth is intruded, reimplantation should not be attempted; instead, it should not be manipulated, as this may lead to significant trauma. Reimplantation can be painful, so 1% lidocaine WITHOUT epinephrine should be applied to the region. If doable, a regional dental block is preferred.

If an avulsed tooth cannot be located, a CXR should be performed. It should be retrieved via scope if it's found in the bronchus or esophagus. The probability of salvaging is low if it is below the diaphragm.

In any case, a dentist, trauma surgeon, or oral-maxillofacial surgeon should be called as soon as possible.

#trauma

#procedures

#dental-medicine

References:

1. Belmonte FM, Macedo CR, Day PF, et al. Interventions for treating traumatised permanent front teeth: luxated (dislodged) teeth. Cochrane Database Syst Rev 2013; :CD006203.

2. Jones LC. Dental Trauma. Oral Maxillofac Surg Clin North Am 2020; 32:631.

3. Schatz JP, Hausherr C, Joho JP. A retrospective clinical and radiologic study of teeth re-implanted following traumatic avulsion. Endod Dent Traumatol 1995; 11:235.

4. Petrovic B, Marković D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol 2010; 26:52.

B symptoms

Q: Which of the following is not considered a "B" symptom in lymphoma? - Select one

A) Fever

B) Night sweats 

C) Weight loss

D) Pruritus

Answer: D

The criteria for B symptoms is the presence of all of the following symptoms:

• Unexplained fever >38°C during the previous month
• Recurrent drenching night sweats during the previous month
• Weight loss >10 percent of body weight within six months of diagnosis

Less known is that if patients don't meet any of the above-mentioned, then they are categorized as "A."

These patients may have other symptoms such as fatigue, pruritus, pain (mainly when drinking ETOH), or any other symptoms, but are not considered B symptoms.

#oncology

References:

1. Shadman M. Diagnosis and Treatment of Chronic Lymphocytic Leukemia: A Review. JAMA. 2023 Mar 21;329(11):918-932. doi: 10.1001/jama.2023.1946. PMID: 36943212.

2. Mamgain G, Singh PK, Patra P, Naithani M, Nath UK. Diffuse large B-cell lymphoma and new insights into its pathobiology and implication in treatment. J Family Med Prim Care. 2022 Aug;11(8):4151-4158. doi: 10.4103/jfmpc.jfmpc_2432_21. Epub 2022 Aug 30. PMID: 36353039; PMCID: PMC9638643.

3. Dehghani M, Haddadi S, Vojdani R. Signs, Symptoms and Complications of Non-Hodgkin's Lymphoma According to Grade and Stage in South Iran. Asian Pac J Cancer Prev. 2015;16(8):3551-7. doi: 10.7314/apjcp.2015.16.8.3551. PMID: 25921177.

melanoptysis

Q; What is Melanoptysis?

Answer: Black pigmented  airway secretions

This question aims to guide students to use proper medical terms when describing, writing, and presenting patients, reports, and scientific papers.

Melena and Ptysis are Greek words meaning black and to spit.

The quality and density of soot-containing airway secretions during fire exposure, smoke inhalation, or pollution exposure can give a clinician clue to the level of exposure. Clinically, this is an important term to understand, as dense soot-containing airway secretions during fire and smoke may call for early intubation. Delay may cause vocal cord edema and lead to fatal airway collapse.

Melanoptysis is often described as exposure to pollution, coal dust, and smog. It is usually accompanied by Pneumoconiosis, as these patients typically have long-term lung exposure, which causes lung parenchyma to become pathologically blackened.

Other symptoms of fire exposure besides melanoptysis are cough, wheezing, hyperventilation followed by hypoventilation, erythema, hyperemia, and increased pulmonary shunting from lobar collapse or atelectasis.

#fire

#pulmonary

References/further readings:

1. Rehberg S, Maybauer MO, Enkhbaatar P, et al. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283.

2. Kurahara Y, Shimatani Y. Melanoptysis. QJM. 2023 Jul 28;116(7):540-541. doi: 10.1093/qjmed/hcad042. PMID: 36944265.

3. Martínez-Girón R, Mosquera-Martínez J, Martínez-Torre S. Black-pigmented sputum. J Cytol. 2013 Oct;30(4):274-5. doi: 10.4103/0970-9371.126667. PMID: 24648674; PMCID: PMC3945631.