Dig and EKG

Q: 57 years old male is admitted to ICU with syncope. Further workup led to the diagnosis of Digitalis overdose. PR interval on EKG is expected to be? - select one

A) prolonged

B) shortened

Answer: A

Digitalis overdose can affect the EKG in various ways. Most common are:

• Depression of the J point
• Depression or sagging of the ST segment, concave in an upward direction
• Flattened T waves 
• Shortened QT interval
• PR interval slightly prolonged due to enhanced vagal effect on the atrioventricular node
• Prominent or inverted U waves - This can be a direct digitalis itself, or can be secondary to hypokalemia

#cardiology

#pharmacology

References:

1. Djohan AH, Sia CH, Singh D, Lin W, Kong WK, Poh KK. A myriad of electrocardiographic findings associated with digoxin use. Singapore Med J. 2020 Jan;61(1):9-14. doi: 10.11622/smedj.2020005. PMID: 32043160; PMCID: PMC7900815.

2. Muñoz NL, Buendía AB, Manterola FA. Electrocardiographic Changes After Suicidal Digoxin Intoxication in a Healthy Woman. Open Cardiovasc Med J. 2017 May 16;11:58-60. doi: 10.2174/1874192401711010058. PMID: 28572865; PMCID: PMC5447925.

Pseudochylothorax

Q: What is Pseudochylothorax?

Answer: Chylothorax must be distinguished from pseudochylothorax, or cholesterol pleurisy, which results from the accumulation of cholesterol crystals in a chronic existing effusion. 

The most common causes of pseudochylothorax are

• chronic rheumatoid pleurisy
• tuberculosis 
• poorly treated empyema

#pulmonary

References:

1. Braun CM, Ryu JH. Chylothorax and Pseudochylothorax. Clin Chest Med. 2021 Dec;42(4):667-675. doi: 10.1016/j.ccm.2021.08.003. PMID: 34774173.

2. Lama A, Ferreiro L, Toubes ME, Golpe A, Gude F, Álvarez-Dobaño JM, González-Barcala FJ, San José E, Rodríguez-Núñez N, Rábade C, Rodríguez-García C, Valdés L. Characteristics of patients with pseudochylothorax-a systematic review. J Thorac Dis. 2016 Aug;8(8):2093-101. doi: 10.21037/jtd.2016.07.84. PMID: 27621864; PMCID: PMC4999702.

PTX and JVP

Q: 54 years old male with a previous history of COPD who has been on ventilator for the last few days due to severe ARDS, suddenly developed high peak pressure on the ventilator. CXR confirmed pneumothorax (PTX). In PTX, Jugular Venous Pressure (JVP) tends to be? - select one

A) higher

B) lower

Answer: A

JVP will increase in all situations whenever there is an increase in intrathoracic pressure, such as with positive pressure ventilation, a large pleural effusion, or a pneumothorax. 

Our patient has three reasons to have high intrathoracic pressure. His past history of COPD, presence of a positive pressure ventilator, and PTX.

#physical-exam

#ventilator

#cardiology

Reference:

Jolobe OM. Disproportionate elevation of jugular venous pressure in pleural effusion. Br J Hosp Med (Lond) 2011; 72:582.

PANOPTIC Trial

Q: The Pulmonary Nodule Plasma Proteomic Classifier (PANOPTIC) trial included all of the following clinical risk factors to differentiate between benign and malignant pulmonary nodules - EXCEPT? - select one

A) Age

B) Smoking status

C) Nodule circumference

D) Shape

E) Location

Answer: C

The multi-institutional PANOPTIC trial (published in 2018) is known for its seven components, including five clinical risk factors, and expression of two plasma proteins associated with lung cancer and cancer immune response, which can differentiate between benign and malignant pulmonary nodules with a high sensitivity of 97 percent and a high negative predictive value of 98 percent. Although experts advise further validating these findings. The seven components are:

• age
• smoking status
• nodule diameter (not circumference - choice C)
• shape
• location
• plasma protein - LG3BP
• plasma protein - C163A

#pulmonary

#oncology

References:

1. Silvestri GA, Tanner NT, Kearney P, Vachani A, Massion PP, Porter A, Springmeyer SC, Fang KC, Midthun D, Mazzone PJ; PANOPTIC Trial Team. Assessment of Plasma Proteomics Biomarker's Ability to Distinguish Benign From Malignant Lung Nodules: Results of the PANOPTIC (Pulmonary Nodule Plasma Proteomic Classifier) Trial. Chest. 2018 Sep;154(3):491-500. doi: 10.1016/j.chest.2018.02.012. Epub 2018 Mar 1. PMID: 29496499; PMCID: PMC6689113.

Anorexia Nervosa

Q: 19 years old female is admitted to ICU due to severe electrolyte imbalance secondary to a long history of Anorexia Nervosa (AN). Patient tends to ________________ on exam? - select one

A) Bradycardic 

B) Tachycardic

Answer: A

Although patients with severe AN may feel frequent palpitations, on exam, they tend to be bradycardic. Severe electrolyte imbalance tends to increase the QTc to>480 msec, and subsequently leads to bradycardia. Any hemodynamic instability, particularly a heart rate less than 40 beats/minute or marked hypotension, calls for ICU admission.

Common symptoms of AN are:

• Amenorrhea (in females)
• Fatigue
• Weakness
• Cold intolerance
• Palpitations
• Dizziness
• Abdominal pain and bloating
• Early satiety
• Constipation
• Irritability or depression

Common signs are:

• Low body mass index (BMI)
• Emaciation 
• Hypothermia 
• Bradycardia 
• Hypotension 
• Hypoactive bowel sounds and distension (due to bowel edema)
• Xerosis (dry, scaly skin)
• Brittle hair and hair loss
• Lanugo hair growth
• Proximal muscle weakness
• Brittle nails
• Pressure sores
• Hypercarotenemia (especially palms)
• Cyanotic and cold hands and feet
• Generalized edema (ankle and periorbital)
• Heart murmur(possible mitral valve prolapse)

#electrolytes

#cardiology

References:

1. Eating Disorders: Core Interventions in the Treatment of and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. National Institute for Clinical Excellence, Clinical Guideline 9. http://guidance.nice.org.uk (Accessed on Jyly 22, 2025).

2. Mehler PS, Birmingham LC, Crow SJ, Jahraus JP. Medical complications of eating disorders. In: The Treatment of Eating Disorders: A Clinical Handbook, Grilo CM, Mitchell JE (Eds), The Guilford Press, New York 2010. p.66.

3. Mehler PS, Anderson AE. Eating disorders: A guide to medical care and complications, 4th ed, Johns Hopkins University Press, 2022.

Bleeding Time

Q: In which of the following PT, PTT, and Platelet count remains normal, and only bleeding time is prolonged  - select one

A) Uremia

B) DIC

C) Hemophilia

D) Von Willebrand disease

Answer:  A (Uremia)

Uremia and (in ASA overdose) - only bleeding Time (BT) is prolonged, but PT, PTT, and Platelet count remain normal.

DIC - PT, PTT, and bleeding time all become prolonged, and Platelet counts decrease.

Hemophilia - only the PTT is prolonged, but the PT, BT, and Platelet counts remain normal.

Von Willebrand disease -  PTT and BT are prolonged, but PT and Platelet counts remain normal.

#hematology

References:

1. Rodgers RPC, Levin J. A Critical Reappraisal of the Bleeding Time. Semin Thromb Hemost. 2024 Apr;50(3):499-516. doi: 10.1055/s-0043-1777307. Epub 2023 Dec 12. PMID: 38086409.

2. Burns ER, Lawrence C. Bleeding time. A guide to its diagnostic and clinical utility. Arch Pathol Lab Med. 1989 Nov;113(11):1219-24. PMID: 2535679.

3. Russeau AP, Vall H, Manna B. Bleeding Time. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 30725918.

Succinylcholine and contraindications

Q: Besides renal failure, name at least 5 conditions that may be risk factors for hyperkalemia with succinylcholine.

Answer: Conditions besides renal failure, having susceptibility to succinylcholine-induced hyperkalaemia are

• Burn
• Closed head injury
• CVAs
• Acidosis
• Guillain–Barré syndrome
• Drowning, and
• Massive trauma

#procedures

References:

1. Muñoz-Martínez T, Garrido-Santos I, Arévalo-Cerón R, Rojas-Viguera L, Cantera-Fernández T, Pérez-González R, Díaz-Garmendia E. Prevalencia de contraindicaciones a succinilcolina en unidades de cuidados intensivos [Contraindications to succinylcholine in the intensive care unit. A prevalence study]. Med Intensiva. 2015 Mar;39(2):90-6. Spanish. doi: 10.1016/j.medin.2014.07.002. Epub 2014 Sep 18. PMID: 25238994.

2. Blanié A, Ract C, Leblanc PE, Cheisson G, Huet O, Laplace C, Lopes T, Pottecher J, Duranteau J, Vigué B. The limits of succinylcholine for critically ill patients. Anesth Analg. 2012 Oct;115(4):873-9. doi: 10.1213/ANE.0b013e31825f829d. Epub 2012 Jul 4. PMID: 22763904.

3. Hager HH, Patel P, Burns B. Succinylcholine Chloride. 2025 Feb 15. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 29763160.

Hamburger thyroiditis

Q: What is hamburger thyroiditis?

Answer: The terms hamburger thyroiditis or hamburger hyperthyroidism became popular after community outbreaks of thyrotoxicosis. This interesting form of thyrotoxicosis occurs when thyroid tissue is ingested while eating a hamburger prepared with meat from the neck. If thyroid tissue gets inadvertently removed and ground up with neck muscle in slaughterhouses, it may cause thyrotoxicosis. It is usually a transient form of hypothyroidism, and mimics painless thyroiditis. Interestingly, case reports have described after ingestion of beef or sausage.

#endocrinology

References:

1. Hedberg CW, Fishbein DB, Janssen RS, et al. An outbreak of thyrotoxicosis caused by the consumption of bovine thyroid gland in ground beef. N Engl J Med 1987; 316:993.

2. Kinney JS, Hurwitz ES, Fishbein DB, et al. Community outbreak of thyrotoxicosis: epidemiology, immunogenetic characteristics, and long-term outcome. Am J Med 1988; 84:10.

3. Hendriks LE, Looij BJ. Hyperthyroidism caused by excessive consumption of sausages. Neth J Med 2010; 68:135.

4. Parmar MS, Sturge C. Recurrent hamburger thyrotoxicosis. CMAJ 2003; 169:415.

Falsely low pulse oximetry

Q: All of the following may falsely give a low reading of pulse-oximetry EXCEPT? - Select one

A) Methemoglobinemia

B) Sickle cell disease

C) Severe anemia 

D) Arterial pulsation  

E) Nail polish

Answer: D

Although pulse-Ox can be generally trusted in patient monitoring, clinicians need to be aware that there are many conditions where the monitor may display falsely low readings. In an Inpatient setting, one of the frequently ignored situations is in patients with venous congestion (instead of arterial congestion/pulsation - choice D) due to tricuspid valve insufficiency or severe cardiomyopathy. Any hemodynamic condition that leads to venous congestion may generate falsely low SaO2 readings. To make things more complicated, even arterial blood gas may not be completely reliable due to 'backing up' of pulsatile venous blood as part of the arterial sample.

Venous pulsations may also occur when an adhesive around the probe is too tight on the finger, the probe is in a dependent position (e.g., a forehead probe in a patient in the Trendelenburg position), and in cases of arteriovenous shunting. In such situations, loosening or repositioning the probe may resolve the issue.

#hemodynamic

#oxygenation

References:

1. Secker C, Spiers P. Accuracy of pulse oximetry in patients with low systemic vascular resistance. Anaesthesia 1997; 52:127.

2. Stewart KG, Rowbottom SJ. Inaccuracy of pulse oximetry in patients with severe tricuspid regurgitation. Anaesthesia 1991; 46:668.

3. Torp KD, Modi P, Pollard EJ, et al. Pulse Oximetry. [Updated 2023 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470348/

Pericardiocentesis in PH

Q: 47 years old female with history of pulmonary hypertension (PH) is admitted to ICU with chest pain, shortness of breath, and hypoxemia. Bedside Focal Cardiac Ultrasound (FoCUS) showed a large pericardial effusion with tamponade physiology. Which group of PH patients has the highest risk of collapse with bedside pericardiocentesis? - Select one

A) Group 1 - Pulmonary Arterial Hypertension (PAH)

B) Group 2 - PH due to Left Heart Disease 

C) Group 3 - PH due to Lung Diseases and/or Hypoxemia 

D) Group 4 - PH due to Chronic Thromboembolic Disease (CTEPH) 

E) Group 5 - PH with unclear or multifactorial mechanisms 

Answer: A

Overall, all patients with PH are at risk of hemodynamic collapse due to pericardial fluid drainage. Risk is similar to either bedside pericardiocentesis or surgical drainage, but the latter is preferred due to a more controlled environment in the OR. Statistically, the adjusted odds ratio (aOR) for mortality is 1.40, and for postprocedure shock is 1.53.

Patients with pulmonary arterial hypertension (PAH) have been found to have higher mortality rates compared with other non-PAH groups, with aOR 2.35.

#hemodynamics

#pulmonary

References:

1. Vasquez MA, Iskander M, Mustafa M, et al. Pericardiocentesis Outcomes in Patients With Pulmonary Hypertension: A Nationwide Analysis from the United States. Am J Cardiol 2024; 210:232.

2. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.

Quick bedside tests for Methemoglobinemia

Case: 54 years old farmer is admitted to ICU with severe exacerbation of congestive heart failure (CHF). Intrinsic nitric oxide (iNO) is started for right heart support, and sodium nitroprusside (Nipride) is started as an intravenous infusion. 48 hours later, there is a concern for Methemoglobinemia (MetHb) due to bluish discoloration of the skin and low pulse oximetry level on the monitor. What bedside tests can be performed to quickly detect MetHb?

Answer: Although labs can perform methemoglobin levels, the turnaround time varies. Most hospitals establish protocols to check methemoglobin levels daily in patients who are on iNO or high-risk medications. Our patient has three such high risks, i.e., as a farmer, potential exposure to pesticides, iNO, and sodium nitroprusside infusion. A clinician can establish MetHb by performing the following two tests:

1. Bubble 100% oxygen in a tube with the patient's dark blood. No change in Color strongly predicts Methemoglobinemia. If blood turns red on exposure to oxygen, the cause is probably a hemodynamic issue. 

2. Apply 2 drops of the patient's blood on white filter paper and expose it to atmospheric oxygen. A change in color rules out Methemoglobinemia.

On a side note, though co-oximetry is an accurate method for measuring Methemoglobinemia, not all machines can (some newer versions can) differentiate it from another rare disorder called sulfhemoglobinemia.

#hematology

References:

1. Senthilkumaran S, Senthilraj MP, Jena NN, Thirumalaikolundusubramanian P. Methaemoglobinaemia: Recognition and realisation at bedside. Indian J Anaesth. 2018 Jun;62(6):475-476. doi: 10.4103/ija.IJA_138_18. PMID: 29962533; PMCID: PMC6004751.

2. Dipen B Khanapara, Ronald A Sacher - Methemoglobinemia - Updated: Dec 07, 2023 - Link: https://emedicine.medscape.com/article/204178-overview (Last accessed July 18, 2025)

3. Demedts P, Wauters A, Watelle M, Neels H. Pitfalls in discriminating sulfhemoglobin from methemoglobin. Clin Chem. 1997 Jun;43(6 Pt 1):1098-9. PMID: 9191578.

4. Wu C, Kenny MA. A case of sulfhemoglobinemia and emergency measurement of sulfhemoglobin with an OSM3 CO-oximeter. Clin Chem. 1997 Jan;43(1):162-6. PMID: 8990240.

STOP-Bang Questionnaire

Q: Which of the following is NOT part of the STOP-Bang Questionnaire?

A) Bed partner elbowing for snoring

B) Daytime tiredness or sleepiness 

C) Hypertension

D) Shirt collar size 16 inches or larger

E) Age older than 30 years

Answer: E

STOP-Bang questionnaire is designed to assess the risk of Obstructive Sleep Apnea (OSA)

It consists of eight yes-or-no questions.

1. Do you Snore loudly (loud enough to be heard through closed doors, or your bed partner elbows you for snoring at night)
2. Do you often feel Tired, fatigued, or sleepy during the daytime (such as falling asleep during driving or talking to someone)?
3. Has anyone Observed you stop breathing or choking/gasping during sleep?
4. Do you have or are you being treated for high Blood Pressure?
5. Body mass index more than 35 kg/m2?
6. Are you older than 50 years old?
7. Neck size large? (measured around Adam's apple)  - shirt collar 16 inches or larger?
8. Gender (biological sex) = Male?

Scoring criteria:

Low risk of OSA: Yes to 0 to 2 questions

Intermediate risk of OSA: Yes to 3 to 4 questions

High risk of OSA: 

• Yes to 5 to 8 questions
• Yes to 2 or more of 4 STOP questions + male gender (biological sex)
• Yes to 2 or more of 4 STOP questions + BMI >35 kg/m2
• Yes to 2 or more of 4 STOP questions + neck circumference ≥ 16 inches/ 40 cm

#pulmonary

#ENT

References:

1. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812.

2. Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth 2012; 108:768.

3. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea. Chest 2016; 149:631.

Corticosteroid Therapy for Critically Ill Patients with Middle East Respiratory Syndrome

Q: Like COVID-19 virus, Decadron is recommended as treatment in patients with severe Middle East respiratory syndrome coronavirus (MERS-CoV).

A) True

B) False

Answer: B (False)

In patients with severe MERS-CoV glucocorticoid treatment showed no difference in mortality; instead, it was associated with a delay in clearance of the virus. It is not recommended in MERS-CoV infections.

#ID

Reference:

Arabi YM, Mandourah Y, Al-Hameed F, et al. Corticosteroid Therapy for Critically Ill Patients with Middle East Respiratory Syndrome. Am J Respir Crit Care Med 2018; 197:757.

DKA and lipids

Q: The plasma triglyceride level in patients with Diabetic ketoacidosis (DKA) and Hyperglycemic Hyperosmolar State (HHS) would be? - select one

A) lower

B) elevated

Answer: B

DKA or HHS can cause hyperlipidemia to the point where the serum appears lactescent. This effect is more pronounced in DKA. Levels fall back to normal with insulin therapy.

This occurs due to Lipolysis secondary to insulin deficiency. It also causes elevation of lipolytic hormones such as catecholamines, growth hormone, corticotropin [ACTH], and glucagon. Insulin is the most potent anti-lipolytic hormone; therefore, if DKA or HHS is not treated promptly, ongoing lipolysis releases glycerol and free fatty acids, which cause insulin resistance at both the peripheral and hepatic levels, and serve as substrates for ketoacid generation in hepatocyte mitochondria. In severe cases, it may require plasma exchange.

Another implication of this hyperlipidemia is pseudohyponatremia and/or pseudohyperchloremia. 

#endocrinology

References:

1. Chreitah A, Hijazia K, Doya L, Salloum A. Severe dyslipidemia associated with diabetic ketoacidosis in newly diagnosed female of type 1 diabetes mellitus. Oxf Med Case Reports. 2021 Oct 26;2021(10):omab036. doi: 10.1093/omcr/omab036. PMID: 34729187; PMCID: PMC8557415.

2. Weidman SW, Ragland JB, Fisher JN Jr, et al. Effects of insulin on plasma lipoproteins in diabetic ketoacidosis: evidence for a change in high density lipoprotein composition during treatment. J Lipid Res 1982; 23:171.

3. Huang S, Song F, Gao K, Song Y, Chen X. Plasma exchange treatment of a diabetic ketoacidosis child with hyperlipidemia to avoid pancreatitis: a case report. Front Pediatr. 2024 Jun 5;12:1280330. doi: 10.3389/fped.2024.1280330. PMID: 38903770; PMCID: PMC11188404.

Intravenous fluid resuscitation: and Poiseuille law

Q: 18-gauge (G) peripheral is considered a large-bore intravenous line.

A) True

B) False

Answer: B (False)

A large bore IV line for active resuscitation should be at least 16 G or preferably 14 G. Said that 18 G is considered standard as in trauma and other emergent situations, and provides a good balance of flow rate and ease of insertion. Additionally, it is suitable for blood transfusions.

The objective of this question is to remind students of the Poiseuille's law which states that: "The flow rate is directly proportional to the pressure difference and the fourth power of the radius, and inversely proportional to the viscosity and length of the tube  the flow rate is directly proportional to the pressure difference and the fourth power of the radius, and inversely proportional to the viscosity and length of the tube."

A mere 2-point increase in the G size of the IV line can significantly increase the flow.

#hemodynamic

References:

1. Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J. 2011 Mar;28(3):201-2. doi: 10.1136/emj.2009.083485. Epub 2010 Jun 26. PMID: 20581377.

2. Rajkumar JS, Chopra P, Chintamani. Basic Physics Revisited for a Surgeon. Indian J Surg. 2015 Jun;77(3):169-75. doi: 10.1007/s12262-015-1308-6. PMID: 26246696; PMCID: PMC4522253.

3. Traylor S, Bastani A, Butris-Daut N, Christensen M, Marsack P, Rodgers L, Todd B. Are three ports better than one? An evaluation of flow rates using all ports of a triple lumen central venous catheter in volume resuscitation. Am J Emerg Med. 2018 May;36(5):739-740. doi: 10.1016/j.ajem.2017.09.058. Epub 2017 Oct 4. PMID: 29079377.

Snakes and taste

Q: 24 years old hiker is brought to the ER after a snakebite. The patient is reporting severe symptoms, including a minty taste in his mouth. Which snake is a likely culprit?

Answer: Rattlesnake

Victims complain of a rubbery, minty, or metallic taste if bitten by a particular species of rattlesnake, after 30 to 90 minutes of attack. The most likely is that it is a pit viper. 

Clinical significance: Rattlesnake bite can be poisonous and requires prompt treatment, specifically administration of an anti-venom.

Note: Bites from Australian black snakes can cause a loss of taste and smell (anosmia) as a potential long-term effect. 

#toxicity

#snake-bites

References:

1. https://www.merckmanuals.com/professional/injuries-poisoning/bites-and-stings/snakebites#Symptoms-and-Signs_v1117500  (last accessed July 10, 2025)

2. https://www.medicinenet.com/what_happens_if_you_get_bitten_by_a_rattlesnake/article.htm (last accessed July 10, 2025)

3. Pearn J., McGuire B., McGuire L., Richardson P. The envenomation syndrome caused by the Australian Red-bellied Black Snake Pseudechis porphyriacus. Toxicon. 2000;38:1715–1729. doi: 10.1016/S0041-0101(00)00102-1.

Tinnitus

Q: Which of the following forms of tinnitus raises more concern for underlying significant pathology? - select one

A) pulsatile 

B) non-pulsatile

Answer: A

The objective of this question is to emphasize the importance of thorough history taking and physical examination skills, an art that is rapidly vanishing from clinical practice.

Tinnitus is a perception of sound in proximity to head in the absence of an external source. It is a common presenting symptom from outpatient to ICU. It can be presented in various forms, such as being within one or both ears, within or around the head, or as an outside, distinct noise. It can be a buzzing, ringing, hissing, or any other noise. Two crucial aspects of tinnitus that raise the concern for underlying significant pathology are

• continuous 
• pulsatile 

If the sound of Tinnitus is intermittent and/or non-pulsatile, the likelihood is that it is not related to a serious underlying pathology. Said that all symptoms should be appropriately evaluated, as symptoms sometimes can be more distressing to the patient than the sign! It is important to 'heal' the patient and not to treat the sign!

#neurology

Further reads:

1. Narsinh KH, Hui F, Saloner D, Tu-Chan A, Sharon J, Rauschecker AM, Safoora F, Shah V, Meisel K, Amans MR. Diagnostic Approach to Pulsatile Tinnitus: A Narrative Review. JAMA Otolaryngol Head Neck Surg. 2022 May 1;148(5):476-483. doi: 10.1001/jamaoto.2021.4470. PMID: 35201283.

2. Park KW, Kullar P, Malhotra C, Stankovic KM. Current and Emerging Therapies for Chronic Subjective Tinnitus. J Clin Med. 2023 Oct 16;12(20):6555. doi: 10.3390/jcm12206555. PMID: 37892692; PMCID: PMC10607630.

3. Dalrymple SN, Lewis SH, Philman S. Tinnitus: Diagnosis and Management. Am Fam Physician. 2021 Jun 1;103(11):663-671. PMID: 34060792.

QTc prolongation from a pressor

Q: Which commonly used cardiovascular drip in the ICU may prolong QT interval (and may cause torsades de pointes)?

A: Vasopressin

It may be of only academic interest, as QTc prolongation from vasopressin is not as clinically significant as that from other drugs used in the ICU. However, it may increase the risk by synergistically interacting with other drugs that can cause QTc prolongation or in patients with pre-existing heart disease. In the ICU, the other significant risk factor is electrolyte imbalance. For unknown reasons, this risk is found to be enhanced in patients with intracerebral bleeds.

#cardiology

#pharmacology

References:

1. Klein GJ. Vasopressin, "torsades de pointes," and QT syndrome. Ann Intern Med. 1980 Sep;93(3):511-2. doi: 10.7326/0003-4819-93-3-511_3. PMID: 7436181.

2. Yap YG, Camm AJ. Drug induced QT prolongation and torsades de pointes. Heart. 2003 Nov;89(11):1363-72. doi: 10.1136/heart.89.11.1363. PMID: 14594906; PMCID: PMC1767957.

3. Faigel DO, Metz DC, Kochman ML. Torsade de pointes complicating the treatment of bleeding esophageal varices: association with neuroleptics, vasopressin, and electrolyte imbalance. Am J Gastroenterol. 1995 May;90(5):822-4. PMID: 7733096.

LFTs in Wilson disease

Q: In acute liver failure (ALF) due to Wilson disease, the ratio of alkaline phosphatase (AP) to total bilirubin (TB) is usually? - select one

A) > 4

B) < 4

      

Answer: B

      

The most crucial thing in Wilson's disease is to rule out other causes of ALF, such as viral hepatitis, alcohol disorder, autoimmune hepatitis, drug-induced liver injury, hereditary hemochromatosis, and alpha-1 antitrypsin deficiency. 

In this regard, a liver function test (LFT) can provide significant clues to establish ALF secondary to Wilson disease. The serum aminotransferases are usually less than 2000 international units/L, and the alkaline phosphatase level is typically normal or below the normal range. In this regard, two of the following ratios can be very helpful.

      

1. AST/ALT ratio of >2 

2. AP/TB ratio < 4

                  

Additionally, low ceruloplasmin is of great significance.

                  

#hepatology

#laboratory-medicine

                  

References:

                  

1. Korman JD, Volenberg I, Balko J, et al. Screening for Wilson disease in acute liver failure: a comparison of currently available diagnostic tests. Hepatology 2008; 48:1167.

                  

2. Alkhouri N, Gonzalez-Peralta RP, Medici V. Wilson disease: a summary of the updated AASLD Practice Guidance. Hepatol Commun. 2023 May 15;7(6):e0150. doi: 10.1097/HC9.0000000000000150. PMID: 37184530; PMCID: PMC10187853.

                  

3. Mazhar A, Piper MS. Updates on Wilson disease. Clin Liver Dis (Hoboken). 2023 Oct 2;22(4):117-121. doi: 10.1097/CLD.0000000000000079. PMID: 37908869; PMCID: PMC10615495.

V2-V3 leads EKG in STEMI

Q: "Younger Males" are supposed to have higher new ST-segment elevation in leads V2 to V3 in ST elevation myocardial infarction (STEMI)  - in comparison to other groups.

A) True

B) False

Answer: A

Although ≥0.1 mV (≥1 mm) new or presumed ST-segment elevation at the J-point in two anatomically contiguous leads (other than V2 to V3) is considered STEMI, the criteria for ST-elevation differ for leads V2 to V3 depends on age and gender:

• ≥0.2 mV (≥2 mm) in males ≥ 40 years
• ≥0.25 mV (≥2.5 mm) in males <40 years
• ≥0.15 mV (≥1.5 mm) in females                                       

                                

#cardiology

                                

                                

Reference:

       

Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction; Katus HA, Lindahl B, Morrow DA, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow RO, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand JP, Menasché P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez-Sendon JL, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S. Third universal definition of myocardial infarction. Circulation. 2012 Oct 16;126(16):2020-35. doi: 10.1161/CIR.0b013e31826e1058. Epub 2012 Aug 24. PMID: 22923432.

Pharmacotherapy and gambling

Q: 58 years old male is admitted to ICU with suicidal ideation after losing most of his assets due to pathological gambling. Besides psychotherapy, which of the following medicines is found to have beneficial effects independent of other factors? - select one

A) Fluvoxamine

B) Haldol

C) Valproic acid

D) Thorazine

E) Methadone

Answer: A

Evidence, though weak, showed that selective serotonin reuptake inhibitors (SSRIs) may be effective in reducing gambling behaviors independent of their effect on mood, depression, or anxiety. The two most studied drugs in this regard are fluvoxamine (choice A) and sertraline. Other SSRIs such as citalopram and fluoxetine are also found to be effective.

Other drugs which have been suggested are bupropion, naltrexone, nalmefene, lithium, and topiramate.

All these drugs have a higher effect if combined with psychotherapy.

#psychiatry

References:

1. Hollander E, DeCaria CM, Finkell JN, et al. A randomized double-blind fluvoxamine/placebo crossover trial in pathologic gambling. Biol Psychiatry 2000; 47:813.

2. Saiz-Ruiz J, Blanco C, Ibáñez A, et al. Sertraline treatment of pathological gambling: a pilot study. J Clin Psychiatry 2005; 66:28.

3. Zimmerman M, Breen RB, Posternak MA. An open-label study of citalopram in the treatment of pathological gambling. J Clin Psychiatry 2002; 63:44.

4. Gandara, JJ, Sanz, O, Gilaberte, I. Fluoxetine: open-trial in pathological gambling. 152nd Annual Meeting of the Am Psych Association 1999.

5. Kraus SW, Etuk R, Potenza MN. Current pharmacotherapy for gambling disorder: a systematic review. Expert Opin Pharmacother 2020; 21:287.

6. Kim SW, Grant JE, Adson DE, Shin YC. Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling. Biol Psychiatry 2001; 49:914.

7. Hollander E, Pallanti S, Allen A, et al. Does sustained-release lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders? Am J Psychiatry 2005; 162:137.

preparing for Tumor Necrosis Factor Inhibitors treatment

Q: 39 years old male with history of severe Crohn's disease was admitted to ICU with shock due to ongoing colonic bleeding. The GI service decided to use an anti-TNF agent. Name a few of the underlying conditions that need to be ruled out?

Answer:

• Any active, uncontrolled infection
• Latent (untreated) tuberculosis (TB)
• Demyelinating disease (e.g., multiple sclerosis, optic neuritis)
• New York Heart Association class III/IV heart failure
• Active lymphoma
• Risk of Hepatitis B and C reactivation

Hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), and hepatitis B core antibody (HBcAb) should be checked.

To rule out latent TB, interferon-gamma release assay is preferred.

#pharmacology

References:

1. Chebli JM, Gaburri PD, Chebli LA, da Rocha Ribeiro TC, Pinto AL, Ambrogini Júnior O, Damião AO. A guide to prepare patients with inflammatory bowel diseases for anti-TNF-α therapy. Med Sci Monit. 2014 Mar 26;20:487-98. doi: 10.12659/MSM.890331. PMID: 24667275; PMCID: PMC3972052.

2. Nordgaard-Lassen I, Dahlerup JF, Belard E, Gerstoft J, Kjeldsen J, Kragballe K, Ravn P, Sørensen IJ, Theede K, Tjellesen L; Danish Society for Gastroenterology. Guidelines for screening, prophylaxis and critical information prior to initiating anti-TNF-alpha treatment. Dan Med J. 2012 Jul;59(7):C4480. PMID: 22759856.

3. Gerriets V, Goyal A, Khaddour K. Tumor Necrosis Factor Inhibitors. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482425/

stroke due to cardiac catheterization procedure

Q: Which of the following is NOT considered a risk factor for stroke after cardiac catheterization? - select one

A) Emergency procedure

B) Longer procedure time

C) Radial artery access

D) Greater contrast use

E) Deploying intra-aortic balloon pump

Answer: C

Although relatively less acknowledged, stroke due to the cardiac catheterization procedure is relatively common. Both ischemic and hemorrhagic strokes can occur. Risk factors include:

• Older age 
• Hypertension
• Diabetes mellitus
• History of stroke
• Kidney failure
• Heart failure
• Severe coronary artery atherosclerotic disease
• Coronary artery thrombus
• Carotid artery disease
• Emergent procedure, including acute coronary syndrome
• Longer procedure time
• Greater contrast use
• Retrograde catheterization of the left ventricle in patients with aortic stenosis
• Interventions at bypass grafts
• Use of an intra-aortic balloon pump
• Use of anticoagulation or thrombolytic agents for acute myocardial infarction

Either transfemoral or transradial access has a similar risk of stroke due to the cardiac catheterization procedure.

#procedures

#cardiology

References:

1. Feng YQ, He XY, Song FE, Chen JY. Association between Contrast Media Volume and 1-Year Clinical Outcomes in Patients Undergoing Coronary Angiography. Chin Med J (Engl). 2018 Oct 20;131(20):2424-2432. doi: 10.4103/0366-6999.243563. PMID: 30334527; PMCID: PMC6202589.

2. Korn-Lubetzki I, Farkash R, Pachino RM, Almagor Y, Tzivoni D, Meerkin D. Incidence and risk factors of cerebrovascular events following cardiac catheterization. J Am Heart Assoc. 2013 Nov 14;2(6):e000413. doi: 10.1161/JAHA.113.000413. PMID: 24231658; PMCID: PMC3886771.

3. Tanaka A, Node K. Prediction of Stroke After Cardiac Catheterization: No Reason, No Stroke. J Atheroscler Thromb. 2018 Mar 1;25(3):221-223. doi: 10.5551/jat.ED086. Epub 2017 Sep 20. PMID: 28931783; PMCID: PMC5868507.

Young's Syndrome

Q: What is Young's syndrome?

Answer:

Young's syndrome is usually a triad of 

• bronchiectasis
• sinusitis, and 
• obstructive azoospermia 

WITHOUT any evidence of Cystic Fibrosis (CF). 

Previously, it was attributed to childhood exposure to mercury. Now, its etiology is linked to genetically occurring primary ciliary dyskinesia (PCD). 

#pulmonary

#genetics

References:

1. Hendry WF, A'Hern RP, Cole PJ. Was Young's syndrome caused by exposure to mercury in childhood? BMJ 1993; 307:1579.

2. Ito M, Morimoto K, Ohashi M, Wakabayashi K, Miyabayashi A, Yamada H, Hijikata M, Keicho N. Primary Ciliary Dyskinesia Due to Compound Heterozygous Variants in CFAP221 with Obstructive Azoospermia: Young's Syndrome May Be a Phenotype of Primary Ciliary Dyskinesia. Intern Med. 2025 Feb 1;64(3):423-428. doi: 10.2169/internalmedicine.3978-24. Epub 2024 Jul 4. PMID: 38960684; PMCID: PMC11867755.

Unusual complications of infectious mononucleosis

Q: Describe atypical complications associated with infectious mononucleosis (IM).

Answer: 

Although most of the patients with IM recover in a week or two with supportive care, and are left with fatigue for another few weeks, a few patients may end up having potentially acute and sub-acute fatal complications such as:

• Airway obstruction
• Splenic rupture 
• Hemophagocytic lymphohistiocytosis (HLH) 
• Fulminant liver failure
• Severe hemolytic or aplastic anemia

#ID

References:

1. Lloyd AM, Reilly BK. Infectious Mononucleosis and Upper Airway Obstruction: Intracapsular Tonsillectomy and Adenoidectomy With Microdebrider for Prompt Relief. Ear Nose Throat J. 2021 Dec;100(10_suppl):958S-960S. doi: 10.1177/0145561320930046. Epub 2020 Jun 8. PMID: 32511006.

2. Bartlett A, Williams R, Hilton M. Splenic rupture in infectious mononucleosis: A systematic review of published case reports. Injury 2016; 47:531.

3. Huang R, Wu D, Wang L, Liu P, Zhu X, Huang L, Chen M, Lv X. A predictive model for Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis. Front Immunol. 2024 Dec 5;15:1503118. doi: 10.3389/fimmu.2024.1503118. PMID: 39703509; PMCID: PMC11655318.

4. Seog WJ, Steinberg J, Ghafary I, Clores M, Aroniadis O. Severe Acute Liver Injury From Hemophagocytic Lymphohistiocytosis Related to Disseminated Herpes Simplex Virus Type 1 in a Young Immunocompetent Man. ACG Case Rep J. 2025 Jan 4;12(1):e01581. doi: 10.14309/crj.0000000000001581. PMID: 39764152; PMCID: PMC11703433.

Preferred rectal benzo in convulsive status epilepticus

Q: Which of the following medicines is preferred as per rectal administration in convulsive status epilepticus? - select one

A) Lorazepam 

B) Midazolam 

C) Diazepam 

D) Chlordiazepoxide

E) Flurazepam

Answer: C

The objective of treatment in convulsive status epilepticus is to administer the first line of drug, i.e., benzodiazepines, as soon as possible (ASAP!)

IF an Intravenous line cannot be established quickly, other routes should be considered. As a rule of thumb,

• Lorazepam (choice A) is preferred for the intravenous (IV) route
• Midazolam (choice B) is preferred for intramuscular (IM), intranasal, or buccal route, and
• Diazepam (choice C) is preferred for rectal administration

It is prudent to order other intravenous nonbenzodiazepine antiseizures such as levetiracetam, fosphenytoin, valproate, lacosamide, or phenobarbital simultaneously as per the clinical judgement of the physician.

Chlordiazepoxide (choice D) is preferred to prevent the recurrence of seizures.

Flurazepam (choice E), one of the earliest 'benzos' and less used now, is good as an anti-anxiety or as a sleep medicine.

#Neurology

References:

1. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016; 16:48.

2. Prasad M, Krishnan PR, Sequeira R, Al-Roomi K. Anticonvulsant therapy for status epilepticus. Cochrane Database Syst Rev 2014; :CD003723.

3. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012; 366:591.

4. Alldredge BK, Gelb AM, Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001; 345:631.

5. Kellinghaus C, Rossetti AO, Trinka E, et al. Factors predicting cessation of status epilepticus in clinical practice: Data from a prospective observational registry (SENSE). Ann Neurol 2019; 85:421.

EGPA and steroids

Q: What is the caveat in interpreting peripheral blood eosinophilia in patients with suspected Eosinophilic granulomatosis with polyangiitis (EGPA or Churg-Strauss syndrome)?

Answer: Glucocorticoids

EGPA is a vasculitis of the small and medium-sized arteries, described 75 years ago by Churg and Strauss. Common symptoms are asthma, nasal and sinus symptoms, and peripheral neuropathy. It can involve many body organs and progress slowly, and it is usually diagnosed in the fifth decade of life. As it gets worse, the patient develops pulmonary opacities, cardiomyopathy, renal insufficiency, and gastrointestinal (GI) symptoms. 

Peripheral blood eosinophilia is the most characteristic finding with absolute blood eosinophil counts ≥1000 cells/microL (or greater than 10 percent of the total leukocyte count). This blood workup finding should raise suspicion for EGPA. 

Many patients have been administered glucocorticoids to control their chronic symptoms from EGPA. Glucocorticoids may reduce or fluctuate eosinophil counts and falsely rule out EGPA. 

#rheumatology

References:

1. CHURG J, STRAUSS L. Allergic granulomatosis, allergic angiitis, and periarteritis nodosa. Am J Pathol 1951; 27:277.

2. Cottin V, Bel E, Bottero P, et al. Revisiting the systemic vasculitis in eosinophilic granulomatosis with polyangiitis (Churg-Strauss): A study of 157 patients by the Groupe d'Etudes et de Recherche sur les Maladies Orphelines Pulmonaires and the European Respiratory Society Taskforce on eosinophilic granulomatosis with polyangiitis (Churg-Strauss). Autoimmun Rev 2017; 16:1.

3. Grayson PC, Ponte C, Suppiah R, et al. 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology Classification Criteria for Eosinophilic Granulomatosis with Polyangiitis. Ann Rheum Dis 2022; 81:309.