Review questions Flashcards

Question 1

Q

Bleeding (severe) in
- Dabigatran
- Xaban
- Warfarin
- thrombolytics
- Heparin

Answer

A

Idarucizumab 2.5gram iv infusion 2h apart, consider + PCC also
PCC 50 IU/kg (+ consider novoseven 90mcg/kg)
iv vitamin K 5-10mg + PCC 50 IU/kg
cryoprecipitate (up to 10 units per dose) + transamin x1 dose; monitor fibrinogen
Protamine sulfate slow infusion (more effective for UH); eg for clexane, give at 1:1 dose if last dose clexane within 8h; give half dose if clexane >8h

Question 2

Q

New case - 50/M Malaise and slowing - workup / ddx

Answer

A

Hypothyroid, adrenal insufficiency (& hypoglycemia)
Parkinson’s (incl parkison plus and Wilson’s)
Early dementia (consider CJD, NPH, autoimmune encephalitis)
Malignancy
Anaemia
Heart failure and Lung disease (COPD / ILD)
Drugs (incl hypnotics)
Mood problem

Question 3

Q

Accidental hypothermia

Answer

A

Defined as core temp < 35ºC
Mild hypothermia 32-35 ºC, mod hypothermia 28-32ºC, severe hypothermia <28ºC
Check cortisol and thyroid
check blood gas, CK, toxicology and CTB
Maintain ABC, may need fluid resuscitation and inotropes
consider broad spectrum Abx and empirical hydrocortisone, especially if there is failure to rewarm
Mild hypothermia - External rewarming
Moderate hypothermia - External rewarming of truncal area only
For severe hypothermia, for active external and internal rewarming
- warm IVF 38-42ºC , warm O2 42-46ºC
- endovascular rewarming catheter
Aim rewarm till 35ºC
consider not for rewarming of post-shockable arrest patients with spontaneous mild hypothermia >33ºC

Question 4

Q

AML-M3 management and complications

Answer

A

high LDH, urate +/- DIC
look for hyperleucostasis and tumor lysis
ATRA + arsenic
allopurinol to reduce urate levels (consider rasburicase if high risk)
PCP prophylaxis
aggressive transfusion as required (Plt / FFP / cryoprecipitate)
antibiotics if fever

[] Hyperleukostasis
- WCC >100
- look for end-organ dysfunction - eg chest pain / SOB / hypoxia / MI / acute limb / acute bowel ischemia
- leukopheresis + HU if end-organ symptoms
- HU (+/- cytarabine) if no symptoms
- no transfusion until WCC <100

[] Tumor lysis
- hyperPO4 / urate / K, hypoCa (change >25%)
- aggressive fluid
- rasburicaase for established TLS
- may require dialysis

[] Differentiation syndrome / cytokine storm
(fever, APO, hypotension, AKI)
- Dexamethasone and supportive management

Question 5

Q

Anaphylaxis overview

Answer

A

Presentation
- acute mucocutaneous reaction + respiratory compromise / GI symptom / hypotension and shock
- or exposure to allergen + above symptoms

Management
- 0.5ml 1:1000 im adrenaline, repeat in 5min
- IVF and ABC
- consider iv adrenaline if refractory hypotension
- consider antihistamine (for mucocutaneous symptoms only)
- consider steroid to prevent late phase reaction

Blood x tryptase within 4h + >24h as baseline
Epipen before discharge

Question 6

Q

Conditions that prolong QTc

Answer

A

HyopK, HyopMg, HypoCa
Myocardial ischemia, post-arrest
Hypothermia, raised ICP
congenital long QT
drugs

Drugs:
[] antiarrhythmics
- class IA - quinidine, procainamide
- class IC - flecainide
- class III - amiodarone
[] Psy meds
- antipsychotics (eg haloperidol, quetiapine, olanzapine, amisulpride)
- TCA (eg amitriptyline)
- other antidepressants (eg citalopram, bupropion, venlafaxine)
[] antibiotics
- quinines (hydroxychloroquine)
- quinolones
- macrolides (erythromycin, clarithromycin)
[] antihistamine (eg loratadine)

Question 7

Q

Anticholinergic poisoning and management

Answer

A

Eg with diphenhydramine, atropine / hyoscine, TCA, Artane (benzhexol) and benztropine, oxybutynin

Flushing (red as a beet)
Dry mouth, anhidrosis (dry as a bone)
Hyperthermia (hot as a hare)
Confusion (mad as a hatter)
Mydriasis (blind as a bat)
AROU (full as a flask)
TCA will also have signs of serotonin syndrome and widened QRS

Mx
- phytostigmine (AChE inhibitor) 0.5mg slow iv
(cf also used in MG)
- !! CI in TCA poisoning and asthma

For TCA - GL, AC if within time window; MDAC and urine alkalinization to reverse arrhythmia

Question 8

Q

Assessment of asthma control

Answer

A

Compliance, technique & environment; review diagnosis (eg COPD, EGPA)

GINA assessment
- daytime symptoms >2x per week
- night waking
- SABA reliever >2x per week
- activity limitation

ACT score (asthma control test)

Question 9

Q

Brain death prerequisites, timing of tests and personnel to conduct tests

Answer

A

Diagnosis of severe irremediable brain injury, with diagnosis of that underlying disorder

Exclusion of:
- CNS depressants / drugs
- hypothermia core temp <35’C
- severe metabolic and endocrine disturbances
- arterial hypotension
- locked in syndrome

Done by:
- 1x specialist with skill and knowledge in certifying brain death - ICU, CCM, Neurologist, NS
- 1x specialist, ideally with same qualification, should be at least 6y after registration
- Personnel certifying brain death should not be related to organ removal

Timing of tests
- 1st exam performed after all prerequisite criteria met, at least 4h after reaching GCS 3
- 2nd exam can be performed any time after 1st exam, so that the total period of observation is at least 4 hours
- Need at least 24 hours after an arrest
- Delay for at least 72h after rewarming if therapeutic hypothermia has been used
- time of death = when 2nd exam is completed, or after the confirmatory investigation

Question 10

Q

Brain death tests

Answer

A

Both pupils fixed, >4mm, non-reactive to light
Absence of bilateral corneal reflexes
Absence of vestibulo-ocular reflexes (cold water to ear)
No motor response within trigeminal nerve by pain sensation of any somatic area
Absence of gag reflex
Absence of cough reflex (suction catheter)
Apnea - no resp movements when patient is disconnected from IMV, with oxygenation during the process
(ABG - PaCO2 >8kPa, pH <7.3; suggest PaCO2 rise >2.7 kPa above baseline

Question 11

Q

Carboxyhemoglobin

Answer

A

elevated COHb level in VBG (levels do not correlate with severity), test by co-oximetry
PO2 levels may be normal (but HbO2 is profoundly reduced)
symptoms - headache, nausea, dizziness; chest pain (can have MI), syncope, tachycardia, SOB, confusion and seizures

Mx
- 100% O2 with NRM
- HBOT if LOC, COHb >25%, metabolic acidosis pH <7.25, end-organ ischemia (eg MI, confusion, resp failure)

Question 12

Q

Causes of cerebellar dysfunction

Answer

A

tumor, stroke (localized)
alcohol
B12, thiamine, Wilson’s
inflammatory - MS
paraneoplastic
degeneratie (SCA)

Question 13

Q

Causes of elevated PRL

Answer

A

exclude pregnancy
stress
hypothyroid, ESRF
antipsychotics (eg risperidone)
PRLoma / stalk effect of non-functioning tumors
macroPRL (need polyethylene glycol precipitation)

Question 14

Q

Causes of high AG metabolic acidosis

Answer

A

L - lactic acidosis (metformin, severe shock)
U - Uremia
K - ketoacidosis (DKA, alcoholism, starvation)
E - exogenous (salicylate, ethylene glycol, methanol, paraldehyde)
(Also includes CO, theophylline, cyanide)

Question 15

Q

Causes of hyperCa

Answer

A

High PTH
- 1’ hyperPTH
- 3’ hyperPTH
- consider Lithium and exclude FHH

Suppressed PTH
- Myeloma
- Malignancy - humoral hyperCa of malignancy, bone mets, ectopic vitamin D / PTH production
- Dehydration
- Drugs - Ca supplements, Thiazide
- Granulomatous disease (ectopic vitamin D)

Question 16

Q

Causes of hypoCa

Answer

A

Drugs - bisphosphonates, denosumab, cinacalcet
HypoPTH - post-op, hypoMg, congenital (ADH, autoimmune polyglandular type 1 (APECED), DiGeorge)
Low vit D / active vit D (2’ hyperPTH)
(inadequate diet intake and sunlight exposure, liver disease, antiepileptics (25-OHD), low 1a-OHD - CKD, FGF23, hypoPTH and VDDR, end-organ resistance to vit D (VDDR2))
Pancreatitis (saponification of Ca salts by FFA), tumor lysis (sequestered by PO4)
Malabsorption syndromes (eg IBD)
PseudohypoPTH

Question 17

Q

Causes of hypoK

Answer

A

1) Transcellular Shift
- insulin, thyrotoxicosis, refeeding

2) non-renal loss
- diarrhoea (acidosis) and vomiting (alkalosis)
- TTKG <3

3) Renal loss
- Acidosis - Type 1/2 RTA
- Normotensive - Barter, Gitelman

drugs - steroids, liquorice, diuretics
hypoMg
Primary aldosteronism
2’ aldo
RAS, renin secreting tumor
Malignant HT, CHF (renal ischemia)
Suppressed aldo axis
Fluid overload

Question 18

Q

Causes of hypoMg

Answer

A

GI loss (renal FEMg <2.5%)
- PPI
- diarrhoea, malabsorption

Renal wasting
- loop diuretics and thiazide
- alcoholism
- uncontrolled DM
- other drugs - digoxin, amioglycosides, cisplatin

Question 19

Q

Causes of hypopit

Answer

A

Pituitary adenoma with mass effect / Tx (TSS / RT)
Other tumors with mass effect: RCC, craniopharyngioma, lymphoma, germ cell, metastases
Hx of trauma / surgery / RT
Vascular: apoplexy, sheehan (pituitary infarction after postpartum hemorrhage)
Inflammatory: hypophysitis, sarcoidosis, histiocytosis, hemochromatosis
Rare infections incl bacterial / TB / fungal

Question 20

Q

Causes of hypoPO4

Answer

A

1) Transcellular shift - refeeding, resp alkalosis, insulin

2) Non-renal cause
- malabsorption
- vitamin D deficiency
- alcoholism

3) Renal loss (high FEPO4, low TMP/GFR)
- FGF23 mediated - TIO, iv iron, congenital (XLHR)
- non-FGF23 mediated - 1’ hyperPTH, Fanconi, HHRH

Question 21

Q

Causes of pancreatitis

Answer

A

Alcohol, Hypertriglyceridemia
Gallstone
Post-ERCP
HyperCa
IgG4
drugs - DPP4, GLP1RA, azathioprine, 5-ASA, sulphonamide
infections - mumps, Cox, salmonella
idiopathic

Question 22

Q

Causes of Pericarditis and Pericardial effusion

Answer

A

Pericarditis
- Infection - Cox, adenovirus
- TB, fungal
- uremia
- SLE
- isoniazid, hydralazine
- Dressler

Pericardial effusion
- Pericarditis - Cox, adenovirus, TB, fungal, uremia, SLE
- Malignancy
- Hypothyroid

Myocarditis
- Cox, adenovirus, flu
- bacterial - mycoplasma, leptospira, rickettsia
- SLE, Kawasaki
- eosinophilic myocarditis
- clozapine, amphetamine

Question 23

Q

Causes of proteinuria and Ix

Answer

A

Transient (eg orthostatic, exercise)
UTI
Secondary to DM, SLE
Nephritic picture - IgA nephropathy, HSP, membranoproliferative, post-strep GN; ANCA, anti-GBM; SLE
Nephrotic picture - Minimal change, membranous, focal segmental glomerulosclerosis; DM, SLE

Nephrotic:
- ANA dsDNA ENA C3 C4
- A1C
- HBsAg, anti-HCV (membranous)
- malignancy screen

Nephritic
- Similarly screen SLE
- ANCA anti-GBM
- hepatitis and cyroglobulin (membranoproliferative)
- ASOT
- Ig pattern (IgA)

24h urine protein
urine multistix, c/st, cast, dysmorphic cells
KUB for stones
USG and renal Bx

Question 24

Q

Cholinergic crisis

Answer

A

Agents
- insecticide (organophosphate)
- AChE inhibitors - Aricept (Donepezil), Rivastigmine patch, Pyridostigmine in MG

Presentation
- water from orifices - sweating, tearing, rhinorrhoea, salivation, urination, diarrhea, vomiting
- bradycardia, pinpoint pupils
- seizures and bronchoconstriction

Mx
- atropine to reverse toxicity
- consider pralidoxime to prevent aging of AChE
- consult Psy for suicide attempt (if appropriate)

Question 25

Q

Contraindications to lytics

Answer

A

[] Contraindications:
- Hx of ICH, malignant intracranial tumor, AVM / other structural lesion;
- active bleeding
- recent ischemic stroke / significant head trauma in 3m
- intracranial / spinal surgery in 2m
- aortic dissection (beware in inferior MI!)

[] Relative contraindications:
- uncontrolled hypertension
- other major surgery in 3 wks; recent internal bleeding in 2-4 wks; active PUD
- history of ischemic stroke >3m
- prolonged CPR >10min
- on oral anticoagulation (in the past 24h)
- pregnancy

Question 26

Q

Chronic diarrhoea ddx

Answer

A

inflammatory bowel disease
infections including CDT
infections in HIV - Giardiasis, cryptosporidiosis, MAC, CMV
chronic pancreatitis
hyperthyroidism
laxative use, orlistat, other med SE
IBS

Question 27

Q

Common organisms for IE and Abx regime

Answer

A

iv Ampicillin 2g Q4H + Gentamicin 1mg/kg Q8H as initial antibiotic regime
- covers HACEK (Hemophilus and 4 other bacteria), viridans Strep, Strep bovis, MSSA and other enterococci

IVDA
- Staph aureus, may be MSSA or MRSA
- iv ampicillin for MSSA
- iv vancomycin 15-20mg/kg/dose

Prosthetic valves
- also likely to be MSSA or MRSA
- need consider adding Gentamicin and Rifampicin (900mg/day in 3 divided doses) as well

Question 28

Q

Common parki meds and their SE

Answer

A

1) L-dopa
- N/V, constipation if taken before meals
- postural hypotension
- on-off phenomenon
- long-term dyskinesia

2) Peripheral decarboxylase inhibitors
- eg Carbidopa
- add on to L-dopa (included in Sinemet)

3) Dopamine agonists
- non-ergot - ropinirole, rotigotine; ergot - Bct
- N/V, constipation, postural hypotension
- pathological gambling

4) MAO-Bi
- eg Selegiline, rasagiline
- neuroprotective effect in younger patients
- SE insomnia; risk serotonin syndrome

Other meds
- anticholinergics (eg benzhexol) for rest tremor
- Amantadine (NMDA receptor (antagonist) for L dopa dyskinesia

Question 29

Q

Contraindiations to HRT

Answer

A

unexplained vaginal bleeding; CA breast, CA endometrium risk
stroke / TIA, ACS, PE / DVT, thrombophilia
active liver disease
TG >5.6; uncontrolled DM / HT
SLE, migraine with aura
Caution in CV risk, active gallbladder disease,

Question 30

Q

Definition of resistant HT

Answer

A

blood pressure that remains above goal in spite of concurrent use of 3 antihypertensive agents of different classes with good compliance
ideally, one of which should be a diuretic, and all 3 at their maximally tolerated dose
(Remember to check compliance)

Question 31

Q

Diagnosis for Autoimmune neuro conditions
1) GBS
2) Miller Fisher
3) MS
4) NMOSD
5) MG

Answer

A

1) GBS
- LP cytoalbuminologic dissociation (high protein, normal WCC)
- anti-ganglioside Ab
- NCS slow conduction / neuropathy

2) MFS
- LP cystoalbuminologic dissociation
- anti-GQ1B

3) MS
- CSF oligoclonal band
- McDonald criteria - attacks disseminated in time and space

4) NMOSD
- anti-AQP4
- Wingerchuk criteria; not fulfill MS criteria

5) MG
- anti-AChR
- anti-MuSK, anti-LRP4
- Tensilon test (risk bradycardia / asystole) / ice pack test
-fatigability in repetitive nerve stimulation

Question 32

Q

Diagnosis of AS and Ax-SpA

Answer

A

Modified new york criteria
1) Sacroilitis grade 3-4, AND at least 1 of:
2) (i) LBP >3 months improving with exercise
(ii) Limitation of LS movement in sagittal & frontal planes
(iii) Limitation of chest expansion

Ax-SpA
- sacroilitis / HLA B27 +
- inflammatory back pain / arthritis / dactylitis / enthesitis / uveitis / psoriasis / IBD / FHx / elevated CRP / good response to NSAID

Question 33

Q

Diagnosis of asthma

Answer

A

clinical diagnosis
VARIABLE symptoms of SOB / cough / wheezing
eg by exercise / change in weather / URI; diurnal variation

PFT
- variability of lung function
- post-BD increase in FEV1 >12% and >200ml (not in acute attack)

Others incl - atopy march, daily PEF variability >10%, improvement of parameters after treatment; worse with provocation (eg exercise)

Question 34

Q

Diagnosis of dermatomyositis

Answer

A

Dermatomyositis (DM) - classically with shawl sign, V-sign, gottron’s sign, Gottron’s papules, heliotrope rash
borhan and peter criteria for DM and PM
Elevated CK, Myositis panel (see below)
EMG - show myopathic changes, presence of fibrillation potentials
Skeletal muscle MRI - inflammation, myositis, fibrosis
Muscle biopsy (should not be done on a muscle recently undergone EMG)
Skin biopsy may be considered for amyotrophic cases
Need to workup for underlying malignancy in dermatomyositis cases
Possible associations with ILD, RA, Raynaud; consider overlap syndromes between SLE and SSc
Antisynthetase antibodies - incl anti-Jo1; strong associations with ILD;

Ddx - hypothyroid myopathy, metabolic myopathy, drug-induced myopathy, SLE, etc

Question 35

Q

Diagnosis of DKA, difference from HHS and management

Answer

A

DKA:
- pH ≤7.30, HCO3 ≤15, AG >12
- presence of ketones (urine / beta-hydroxybutyrate)
- +/- RG >14

HHS
- POsm >320 (2xNa + glucose)

Management
- ICU care
- iv insulin (0.1U/kg/h)
- IVF with K+
- NaHCO3 50mmol if pH 6.9-7.0; 100 mmol if pH <6.9
- search for ppt (infection, MI)
- switch to sc insulin after resolution of ketoacidosis and patient can eat

Question 36

Q

Diagnosis of Multiple myeloma

Answer

A

MM - plasma cell proliferation in BM >10% + monoclonal paraprotein production
symptomatic MM - presence of CRAB / osteolytic bone lesion / plasma cell >60% in BM / very high free light chain
CRAB - hyperCa (>2.75), renal impairment (cast nephropathy) (Cr >177), anaemia (Hb <10)

Presentation
- elevated ESR;
- smear - rouleaux formation from paraprotein
- Immunofixation (isolated elevation of particular IgG) (check Ig pattern, free light chain, SPE +/- urine BJ protein)
- hyperCa, anaemia, renal impairment; urine protein; skeletal survey

Management:
- rehydration
- bisphosphonates / Denosumab for symptomatic bone disease / hypercalcemia
- IVIG for infection
- thalidomide; consider palliative chemo

Question 37

Q

Digoxin toxicity
Presentation, risk factors and Management

Answer

A

Presentation
- Digoxin use - reverse tick sign / scooped ST depression
- Digoxin toxicity - frequent PVC (most common) (including bigeminy), high grade AV block, bidirectional VT, AF with CHB / slow regular AF
- loss of appetite, N/V/D, blurred vision, halo, yellow-green discolouration

Risk factors - old age, renal impairment, hypoK

Management
- ABC, cardiac monitor, stop offending agent
- blood for digoxin level, RFT
- consider GL and activated charcoal (within 2h)
- Digifab (see below)
- HD may be necessary
- AVOID BB and TCP (may trigger more severe arrhythmias)
- atropine if bradycardia, lignocaine if tachycardia (0.5mg/kg iv push) and may consider MgSO4 (but most tachyarrhythmias are refractory to treatment if digifab is not given)

Digifab indications
- Digoxin level >10ng/mL, or injection >10mg
- hyperK >5
- brady/tachyarrhythmia not responsive to medical Tx

Question 38

Q

DM drug mechanism

Answer

A

Metformin - biguanide, improves peripheral glucose utilization (liver and muscle)

SU - binds to SU receptor on K-ATP channels, stimulates insulin secretion

TZD - PPAR-gamma inhibitor, alters genetic transcription related to insulin metabolism (to improve insulin sensitivy)

DPP4i - inhibits DPP which is the enzyme that breaks down GLP1 / GIP

GLP1RA - stimulates postprandial insulin secretion, reduces postprandial glucagon secretion, improves satiety and decreases gastric emptying

SGLT2i - inhibits sodium-glucose co-transporter, induces glycosuria and diuresis, reduces intraglomerular pressure, reduces preload, has endothelial modulating effect

Question 39

Q

Drugs that may worsen lupus / drug-induced lupus

Answer

A

hydralazine, methyldopa, diltiazem, procainamide
isoniazid, quinidine, minocycline
chlorpromazine
anti-TNF (esp. infliximab), interferons

Question 40

Q

empirical Abx for skin and soft tissue infection (not NF)

Answer

A

consider cefazolin 1 gram q6h
or ampicillin 2g q4h + cloxacillin 500mg q6h (simple infection; sepsis dose 2g q4h)

Question 41

Q

Pemphigus vs Pemphigoid

Answer

A

Pemphigus
- intra-epidermal lesions (more shallow)
- flaccid blisters
- more mucosal lesions
- associated with malignancy
- anti-desmoglein
- steroid + rituximab

Pemphigoid
- subepidermal lesions (deeper)
- tense blisters wtih urticarial plaques
- dermoepidermal junction Ig deposition
- can treat with super potent topical steroid (clobetasol propionate 0.05% cream)
- also consider systemic steroids, doxycycline, and other immunosuppressants

Pre-Tx and general management
- non-adhesive dressing
- fresh skin biopsy of lesion edge with immunofluorescence staining
- screening - G6PD, HBV / HCV, DM
CXR, Mantoux test / IGRA, TPMT / NUDT for AZA

Question 42

Q

Empirical Abx for CAPD peritonitis

Answer

A

Cefazolin / Vancomycin + Ceftazidime / Amikacin
with nystatin
with fluimucil if use aminoglycosdes
heparin flush into each PDF

Question 43

Q

Empirical Abx for septic arthritis

Answer

A

consider cloxacillin or rocephin as initial Tx
Cloxacillin + Rocephin if more frail / Hx of UTI
Vancomycin + rocephin if known MRSA carrier
doxycycline adjuvant for 7 days if known gonorrhoea arthritis

Question 44

Q

Empirical Abx for treatment of IE

Answer

A

Ampicillin 2g q4h + Gentamicin 1mg/kg Q8H

Prosthetic valve
- cloxacillin 2g q4h + Rifampicin (300mg tds) + Gentamicin 1mg/kg Q8H
- MRSA - switch cloxacillin for Vancomycin 15-20mg/kg/dose

Question 45

Q

Exercise for weight loss

Answer

A

At least 150min moderate intensity aerobic exercise per week
spread over at least 3 days per week
no more than 2 consecutive days of rest

Question 46

Q

Fever + dLFT

Answer

A

Obstructive
- cholangitis, biliary pancreatitis
- liver abscess
- cholecystitis

Hepatitic
- HAV, HEV, HBsAg, anti-HCV
- monospot, CMV
- rickettsia, malaria, dengue
- still’s disease
- DRESS
- fever in cirrhotic patient (includes SBP)
- the obstructive causes above

Question 47

Q

Fever in returning traveler

Answer

A

CBC/dc LRFT RG clotting c/st
CXR, NPS x flu, covid, resp virus
smear for malaria
serology for - dengue, rickettsia, Mpox (lesion)
urine c/st
stool c/st, ova and cyst
consider - coxiella (q fever) serology, psittacosis serology, borrelia (lyme disease) serology
cryptosporidia, giardia, strongyloides and coccidiodomycosis in diarrheoa
others incl - legionella, TB, HAV and HEV, HIV

Question 48

Q

Four key elements of informed consent

Answer

A

Competence (be aware of cognitive function and consciousness)
Voluntariness (free will, independent decision making)
Disclosure of information: pros and cons of choices including alternatives
Understanding and acceptance of information and consequence

Assessing mental competence
1. Patient receive and understand information(s) – capable to comprehend.
2. Patient is asked to paraphrase – in order for the clinician to evaluate his/her understanding of the information, and correct any misconceptions.
3. Capable to analyse the decision(s) to make – seeing both sides of argument and appreciating consequence(s).
4. Patient make his/her own choice(s) with reasoning.
5. Patient has to express his decision(s) by means of communication understandable by others.
6. Capable to retain the information and decision, at least for a short period.

Question 49

Q

Gauging symptoms of COPD

Answer

A

mMRC (Modified Medical Research Council) and CAT (COPD assessment tool)
- mMRC 0-4 - 2 is slower than same age ppl or stop for breath on level walking; 4 is homebound and SOB with dressing
- Group B COPD is mMRC 2+ or CAT >10

Question 50

Q

GCA diagnosis and management

Answer

A

GCA Diagnostic criteria
- age >50
- headache
- high ESR +/- CRP
- temporal artery abnormalities (tenderness to palpitation, decreased pulse amplitude, presence of nodules)
- biopsy suggestive of GCA

Other features
- jaw claudication, sudden visual disturbance (AION)
- unexplained fever, anemia, other constitutional symptoms
- associations with PMR (symmetrical aching of shoulders and proximal muscle with elevated CRP / ESR and normal CK)

Workup
- elevated ESR
- consult eye - AION
- CTB - no lesion
- consult NS - temporal artery bx
- USG doppler temporal artery - halo sign (ddx ANCA vasculitis / severe atherosclerosis)
- high res MRI of cranial arteries if USG inconclusive

Management:
- consider treatment with high dose steroid (prednisolone or iv MP) while awaiting temporal artery biopsy result
- MTX ay be used as adjunctive therapy for large vessel vasculitis
- may consider Tocilizumab in specific cases
- PMR also shows dramatic improvement with steroids

Question 51

Q

General measures for acute poisoning

Answer

A

1) Gastric Lavage if ingested within 1h
- intubation needed if confused
- consent needed; powerful suction needed if alert
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, antipsychotics, TCA, SSRI, Lithium, valproate, paraquat

2) Activated charcoal
- 50-100g po, if ingested within 1-2h
- not for lithium, caustic agents, methanol
- special consideration - NOAC
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, antipsychotics, TCA, SSRI, valproate, paraquat
- contraindicated in ileus / bowel perforation

3) MDAC
- 1g/kg po, followed by 0.5g/kg q4h for 1-2 days
- for theophylline, phenytoin, digoxin, carbamazepine, valproate, salicylate, dapsone, sustained release medications

4) Whole bowel irrigation
- PEG 1-2L/h until clear rectal effluent
- can consider for lithium (cannot use AC)
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, valproate
- CI in ileus / bowel perforation

5) Urinary alkalinisation
- 1-2mmol/kg NaHCO3 iv bolus, then 50mmol 8.4% NaHCO3 in 500ml D5 q4-6h
- in salicylate (if high serum levels), TCA
- also consider for cocaine, phenobarbitone, MTX
- avoid over-alkalinization / hypoK

6) HD / CRRT
- methaol, lithium, salicylate, theophylline
- consider for paracetamol, carbamazepine, phenytoin, valproate, metformin, atenolol

Question 52

Q

Grading of COPD by FEV

Answer

A

GOLD 1 - FEV1 >80%
GOLD2 - FEV1 50-80%
GOLD 3 - FEV1 30-50%
GOLD 4 - FEV1 <30%
(cf diagnosis of COPD - by RATIO of FEV1/FVC <70%)

Question 53

Q

HCM features

Answer

A

FHx (Autosomal dominant)
PE: double apex, double carotid impulse, ESM over LLSB
ECG: precordial leads LVH (V1+V5/6 >35mm) and deep Q over inf / lateral leads
Echo: asymmetric septal hypertrophy, SAM of mitral valve, LVOT gradient >50 = serious (at rest or provoked)
should also do holter to look for ventricular arrhythmias

Question 54

Q

HCM management

Answer

A

Adequate hydration
Avoid competitive sports
Avoid vasodilators (ACEi, nitrates)
Give beta-blockers / nondihydropyridine CCB
Avoid +ve inotropes (incl digoxin)

ICD if ventricular arrhythmias, or if massive LVH / unexplained LOC / apical aneurysm / EF <50% / FHx SCD

Surgical Tx (alcohol septal ablation / surgical myomectomy) if LVOT >50

Genetic counseling and family screening

Question 55

Q

HE precipitants

Answer

A

excessive alcohol / protein intake
constipation / vomiting
infection
GIB
diuretics / large volume paracentesis
vascular occlusion

Question 56

Q

Headache ddx

Answer

A

worst ever / thunderclap - SAH
injury - SDH, artery dissection
vision - GCA, PCOM aneurysm
raised ICP (tumor)
fever / meningitis
chronic tension type headache, migraine, cluster headache, trigeminal headache
Other areas - acute glaucoma, sinusitis, dental pain, cervical spondylosis

Question 57

Q

Hemolytic Anemia Causes

Answer

A

(high retic, high indirect bili / LDH / urate)

DAT -
- TTP / HUS / DIC picture (see Plt +/- clotting)
- Malaria
- Mechanical valves
- PNH
- G6PD deficiency
- Spherocytosis
- Methemoglobinemia

DAT +
- ABOi
- Warm AIHA (40% idiopathic)
Infection (EBV, HIV), Lymphoproliferative (CLL, lymphoma), Autoimmune (SLE), Drugs (quinine, penicillin)
- Cold agglutinin
Infection (Mycoplasma, HIV), Lymphoproliferative (CLL, lymphoma), Autoimmune less common (SLE)

Question 58

Q

Hemoptysis, massive hemoptysis causes and management

Answer

A

Causes
- malignancy
- TB
- pneumonia (eg Klebsiella, MRSA)
- bronchiectasis
- pulmonary embolism, pulmonary artery rupture
- vasculitis (eg Anti-GBM, ANCA associated)

Management
- Protect airway
- Correct coagulopathy
- Antibiotics & transamin
- Bronchoscopy
- Urgent bronchial arterial embolisation
(Risk: Spinal cord infarction )
- Surgical resection

Question 59

Q

prolonged APTT causes

Answer

A

APS
hemophilia (factor 8 and 9)
vWD (esp severe vWD)
heparin contamination
part of mixed picture (warfarin, DIC)

Question 60

Q

HLH

Answer

A

5 or more of:
- fever
- splenomegaly
- bicytopenia / pancytopenia (Hb <9, Plt <100, ANC <1)
- hyperTG or hypofibrinogenemia (TG >3, fibrinogen <1.5)
- hemophagocytosis in BM / spleen / LN
- low or absent NK cell activity
- ferritin >1123 pmol/L (usu favor >2200 for dx)
- serum IL2-R >2400 u/mL

Can be secondary to
- malignancy (eg lymphoma, some solid cancers)
- autoimmune disease (eg Still’s disease)
- infection (EBV, CMV, mycoplasma, salmonella, TB, malaria)

Mx with dexamethasone + etoposide
Need to treat underlying cause

Question 61

Q

Hypertensive emergency definition and management

Answer

A

Bp >180/120 with new end-organ damage

Lower Bp 10-15% in 1st hour
Then to 160/100 in next 6h
Then gradually to 130/80

Consider iv labetalol (20mg over 2min, then repeat every 10min) (CI in asthma)

Nitroprusside - 0.25-0.5mcg/kg/min and then titrate to max 10 mcg/kg/min
(CI in pregnancy and not for use >48h

iv hydralazine 5mg (avoid in dissection)

Question 62

Q

HypoNa workup and approach

Answer

A

1) Confirm not pseudohyopNa
- glucose, hyperTG, paraprotein; check Osmo
(Osmo = (2 x SNa) + Glu + BUN

2) Fluid status
2a) Hypovolemic
- dehydration (GI, consider diuretics)

2b) Hypervolemic
- fluid overload (cirrhosis, nephrotic)

2c) Euvolemic
(i) Rule out adrenal insufficiency, hypothyroid
(ii) Tea and toast diet (UNa >20, UOsm <200)
(iii) Primary polydipsia (very low UOsm)
(iv) Consider inadequate salt intake from tube feed (UNa should be <20, UOsm may be more a dequate)

Question 63

Q

Identification of potential organ donor

Answer

A

a) Definite diagnosis, irreversible CNS damage;
b) Brain death is imminent;
c) Put on mechanical ventilation;
d) GCS 3-5/15;
e) Both pupils fixed to light

Exclusion:
- Uncontrolled infection; Hx of HIV infection / risk factors for HIV, CJD
- Hx of iv drug abuse; case of intoxication
- Malignancy (except certain CIS / localized BCC)
- Uncertain cause of death

Question 64

Q

Interpreting lung function
1) Restrictive + low DLCO
2) Restrictive + high DLCO
3) Obstructive + low DLCO
4) Obstructive + normal / high DLCO

Answer

A

1) Restrictive + low DLCO
ie parenchymal disease
- ILD
- silicosis, pneumoconiosis
- pneumonitis
- lymphangitis carcinomatosis

2) Restrictive + normal DLCO
- volume loss - lobectomy / pneumectomy / collapse
- chest wall - kyphoscoliosis, neuromuscular disease, morbid obesity

3) Obstructive + low DLCO
- emphysema

4) Obstructive + normal DLCO
- asthma (high DLCO)
- bronchiectasis

Answer 65

A

1-1.5mg/kg iv push, can repeat 0.5mg/kg at 5-10min

Answer 66

A

0.5mg/kg iv push +/- repeat another dose
then infuse 1mg/min
only for VT, not for supraventricular arrhythmias

Answer 67

A

Determining line sepsis
- 1 peripheral blood culture + culture of catheter tip
- growth of catheter hub at least 2 hours before growth is detected in peripheral blood
- colony count of microbes from catheter hub is > 3x greater than that of peripheral blood

Management
- removal of catheter (esp for S aureus, Pseudomonas, sepsis, endocarditis, persistent bacteremia, or subcut tunneled catheter)
- systemic Abx
- reinsert new catheter with negative blood cultures for at least 48-72h
- consult MID

Abx choice
- vancomycin for MRSA
- Tazocin for GNB
- if candidemia, consider micafungin, + consult eye + book echo and look for abscess + and remove catheter ASAP with alternate day blood cultures to document clearance

If not feasible to remove catheter
- need to review catheter salvage (consider antibiotic lock treatment) / guidewire exchange
- consult MID

Answer 68

A

Presentation
- N/V/D, bradycardia
- confusion, agitation, coarse tremors
- NDI and hypothyroidism (Li effect) (inhibits thyroid hormone release)

Risk factors
- renal impairment

Management
- rehydration
- HD if Li >5, or Li >4 in renal impairment, or Li >2.5 if frank neurological symptoms
- BZD for seizures

Answer 69

A

Fever with TOCC + (and no prophylaxis eg malarone)
Headache, myalgia, anorexia; hepatosplenomegaly

Severe malaria
- confusion, convulsion, jaundice, bleeding, shock, ARDS
- Lactic acidosis, renal impairment, severe parasitemia (>10%), hypoglycemia,

Check basic bloods, clotting, ABG, lactate
Smear for malaria
Urinalysis (hemoglobinuria)

Management
- monitor GCS, fluid status, hemodynamic stability
- isolation in vector-free room
- severe falciparum - artesunate 2.4mg/kg at 0,12,24h + doxycycline 100mg BD
- uncomplicated falciparum - artequick
- vivax / ovale - chloroquine
- primaquine at the end to eradicate gametocytes

Malarone for malaria prophylaxis

Answer 70

A

Ix
- low haptoglobin, high retic, LDH, urate, bili
- measure ADAMTS13 level & activity (<10%)

Mx
- Plasma exchange + steroid (iv MP 1g/day x 3 days)
- contraindicated to any Plt transfusion
- may consider RTX (check hep B, CXR and Mantoux)

if not ADAMTS13 but Shiga toxin from ETEC –> likely to be HUS; supportive management only

Answer 71

A

1) ITP
- prednisolone 1mg/kg/day (takes wks)
- lifethreatening bleed - IVIG 1g/kg/day x 3 days + iv MP 1 gram/day x 3 days
- may consider iv anti-D, transamin; Plt transfusion (critical bleeding)
- eltrombopag (thrombopoietin mimetics)
- RTX and splenectomy

2) vWD
- DDAVP can raise vWF levels in mild vWD (not useful if absent vWF)
- transfuse vWF concentrate, or recombinant vWF + factor 8
- or consider FFP + factor 8 + additional Plt transfusion for type 2 / 3 vWD
- consider transamin

3) Hemophilia
- Factor transfusion for factor deficiency
- Novoseven to bypass (esp if inhibitors)
90microgram/kg/dose every 2-3h until bleeding stops
- PCC transfusion
- DDAVP may be used for mild hemophilia
- consider transamin

Answer 72

A

ABC
X-match
correct coagulopathy (eg FFP and vit K1)
SBP 90-100, transfusion aim Hb 7-9
Terlipressin 2mg q4h (SE MI, PVD, ischemia)
keep for 5 days
Lactulose
Rocephin
Empirical pantoloc and thiamine
Endoscopic ligation
long-term prophylactic BB and elective banding

Answer 73

A

dysglycemia (FG >5.6)
HDL <1 (M) or <1.3 (F)
TG >1.7
waist circumference >90 (M) or >80 (F)
HT >130/85

Answer 74

A

NKDA, NSND
FHx of DM / HT
Duration of symptoms / History of DM / HT
Current medications and compliance
Any OTC meds that may worsen (eg steroid)
Osmotic symptoms and weight loss
Diet and exercise pattern
Any Hx of chest pain / limb weakness
BP/P, BW, BMI, waist circumference
cushingoid appearance, thyrotoxicosis
Heart murmurs and palpate pulses
Check feet for pulses, wounds, edema (+/- ABI)
Fundoscopy for DMR changes
CBC LRFT FG A1C lipid TFT
check albuminuria
baseline ECG
arrange up-to-date DMCS

Answer 75

A

0.5mcg/kg/min and then titrate to max 10 mcg/kg/min
Not to use in pregnant ladies / use more than 48h

Answer 76

A

use of dopamine antagonists (eg antipsychotics, prokinetics) or withdrawal of dopamine / dopamine agonists (eg parki meds)
Any two of : mental status change, rigidity, fever, or dysautonomia

Management
- withhold antipsychotics / resume PD meds
- aggressive supportive care for severe hyperthermia / rigidity
- monitor for widened QRS and risk of TdP
- benzodiazepine, dantrolene, bromocriptine, amantadine may be used (stepwise approach)
- lorazepam 1-2mg q6h or diazepam 10mg iv q8h
- dantrolene - skeletal muscle relaxant; associated with hepatotoxicity; for severe NMS; iv 2.5 mg/kg, repeat 1 mg/kg every 10min, then consider infusion
- bromocriptine - ergot dopamine agonist; may keep up to 10 days after NMS
- amantadine - NMDA antagonist; alternative to Bct
- ECT may be an option

mean recovery time 7-11 days
rechallenge of antipsychotic may be possible; wait at least 2 weeks, use lower potency agents, avoid lithium and dehydration

Answer 77

A

1) RTA
2) CKD (elevated Cr)
3) Pancreatic / biliary drainage (see Hx)
4) Chronic diarrhea (see history)
5) Carbonic anhydrase inhibitors (Hx)

RTA
HyperK:
- Type 4 - hypoaldosteronism; low aldosteronism level

HypoK:
- Type 1 - distal RTA, fail to secrete acid, associations with Sjogren
High urine AG (which means high urine NH4, which means inappropriately high urine pH >5.2)
- Type 2 - proximal RTA, fail to reabsorb HCO3
Urine pH usually higher
Fanconi also loses amino acid, glucose, PO4, uric acid

Fanconi can be 2’ to:
- Light chain gammopathies; amyloidosis
- carbonic anhydrase inhibitors (eg acetazolamide, topiramate)
- other nephrotoxic drugs - tenofovir, aminoglycosides, oxaliplatin; heavy metal poisoning (lead, mercury, copper)
- can be idiopathic
- can be familial (AR transmission), or associations with glycogen storage disease, wilson’s disease, tyrosinemia etc

Answer 78

A

obstructive - FEV1/FVC <70%
restrictive - FEV1/FVC >70%, and FVC <80%

Answer 79

A

Yamaguchi Criteria
[] Major (at least 2)
- fever 39’C for at least 1 week
- arthralgia / arthritis for at least 2 weeks
- non-puritic salmon colored rash on trunk / extremities
- WCC >10 (ANC >10)

[] Minor
- Sore throat
- lymphadenopathy
- Hepato/splenomegaly
- dLFT
- Negative ANA and RF

Need to exclude
- infections (HIV, TB, IE, parvovirus, yersinia, brucella)
- malignancies (eg lymphoma, MPN, solid cancers)
- other rheumatological diseases
- drug rash

Management
- NSAID
- Anakinra, or prednisolone if Anakinra is not available
(anakinra - anti-IL1R)

Answer 80

A

Bisphosphonate - binds to hydroxyapatite of bone and induces osteoclast apoptosis

Dmab - inhibits RANKL; need RANKL-RANK complex to activate osteoclast

TPT - PTH analogue, short term use stimulates osteoblast more than osteoclast

Rmab - sclerostin inhibitor; Sclerostin inhibits Wnt signalling which is needed for osteoblast differentiation

Raloxifene - SERM, agonist in bone to prevent bone loss; antagonist at endometrium and breast

Answer 81

A

Vomiting; HypoK, hyopMg
seizures
tachyarrhythmias, hypotension
check theophylline level; cardiac mon
GI decontamination with AC, MDAC / GL
correct hypoK, hypoMg
Give IVF and phenylephrine if hypotension (or noradrenaline)
Give diltiazem, esmolol if tachyarrhythmias (note COPD)
Give BZD to manage seizure; consider keppra; ** CI phenytoin
consider HD if Ileus (ie cannot MDAC), or
theophylline >80 in acute or >60 in chronic cases, or >40 in elderly with severe symptoms, or if unstable

Answer 82

A

check panadol level at 4 h, repeat testing if extended release formulations
King’s college - pH <7.3, or INR >6.5 & Cr >300 & HE grade III/IV
MELD >15

Mx
- AC if within 1 hour; may be inadequate for extended release
- NAC if panadol level above treatment line; may consider direct Tx if ingestion >8h while waiting for results
- NAC
loading 150 mg/kg in 200 ml D5 over 1h,
then 50 mg/kg in 500ml D5 over 4h,
then 100 mg/kg in 1000 ml D5 over 16h
- vit K1, laxatives, empirical Rocephin
- consult Psy for suicide attempt (if appropriate)

Answer 83

A

1) PAH - idiopathic, related autoimmune (eg connective tissue disease)
2) PH due to LH disease (valvular heart, HFrEF, HFpEF, congenital malformations)
3) Lung disease
4) Pulmonary arterial obstruction (chronic PE)
5) Unknown / multifactorial mechanism (eg sarcoidosis, hematological disorder, complex congenital heart)

Answer 84

A

HT crisis, PET
Acute / chronic kidney disease
TTP / HUS
Vasculitis (includes SLE, PAN)
Immunomodulatory drugs, chemotherapy drugs (includes anti-VEGF incl Bevacizumab, Platin chemo, CyA / RTX / MTX / FK)
iodine contrast (cerebral angiography)
severe sepsis

Answer 85

A

volume repletion (NS 1-1.5L/h if anuric), then 1D1S to maintain u/o 200ml/h
continue fluid until CK <5000
add NaHCO3 50 mmol/L to every other bag of IVF to keep urine pH >6.5;
Stop if ABG pH >7.5, or HCO3 >30 or hypoCa
dialysis for AKI
Ca replacement should be avoided unless symptomatic

Answer 86

A

female; premature or early menopause
older age
Hx of fragility fracture; family Hx of osteoporosis or fragility fracture
lower BW (<45kg)
low Ca2+ intake, sedentary lifestyle, lack of sun exposure and vitamin D deficiency (aim >75nmol/L)
smoking, excessive alcohol (>3 drinks per day)
Vitamin D deficiency, hypercalciuria
Endocrine: DM; hyperparathyroidism; hypogonadism (common); Hypercortisolism, Acromegaly, GH deficiency, Hyperthyroidism;
Malabsorption syndromes (eg IBD, gastric resection, celiac disease)
Chronic liver disease / cholestatic liver disease (eg PBC)
Drugs: Alcohol; anti-epileptics, aromatase inhibitors (eg letrozole); TZD; glucocorticoids; +/- PPI
Rheumat: AS, RA
Hemat: Thalassemia, multiple myeloma
COPD
Misc - pregnancy, AN, bariatric surgery, HIV, chronic psychological stress

Answer 87

A

> 150mg/kg - potentially toxic

hyperthermia, diaphoresis, tachycardia, tachypnea
confusion, agitation/coma
can have cerebral edema, and APO, hypotension in severe cases
primary respiratory alkalosis and metabolic acidosis (usually predominantly acidotic in late stage)

Mx
- GL, AC, MDAC can be used depending on formulation
- urine alkalinization if high levels of salicylate (>2.9mmol/L)
- HD if fail urine alkalinisation or ESRF or very high salicylate level (>7.3 mmol/L)

Answer 88

A

1) Fever
- febrile non-hemolytic transfusion reaction - temp rise <1.5’C and stable; (give panadol and restart infusion at slower rate)
- ABOi - hemolysis, hematuria, hypotension
- Anaphylaxis - bronchospasm, rash; give iv piriton, iv hydrocortisone; consider im adrenaline 0.5ml 1:1000
- Septic - Abx
- cultures, broad spectrum Abx, return blood to bank; gram stain of blood product

2) Hypotension
- ABOi
- Anaphylaxis
- Septic
+/- TACO

3) Desaturation
- TACO
- TRALI - usu 6h after transfusion; esp plasma containing product
- Anaphylaxis - bronchospasm
+/- ABOi, Septic

Answer 89

A

diagnostic tap - WCC >500, PMN >250
not for large volume paracentesis
stop beta-blockers
iv rocephin 2g q24h (5-10 days)
iv albumin 1.5g/kg/day on D1, 1g/kg/day on D3
consider long-term prophylaxis if recurrent SBP (eg ciprofloxacin 500mg daily)

Answer 90

A

Localized scleroderma - eg morphea

Limited systemic sclerosis - CREST
- calcinosis, raynaud’s, esophageal dysmotility, sclerodactyly, telangiectasia
- associations with PAH
- anti-centromere

Diffuse systemic sclerosis
- diffuse skin involvement
- anti-Scl70, also associated with ILD
- renal crisis (may also have MAHA), joint involvement, myositis

Management
- Cold avoidance, hand warmers
- Raynaud - calcium channel blockers (eg nifedipine), PDE5i (eg sildenafil), topical nitrates
- avoid steroid (renal crisis)
- PAH - CCB, prostacyclin agonist (eg iloprost), PDE5i, endothelin receptor antagonist (eg bosentan)
- renal crisis - ACEi and bp control
- ILD - consider nintedanib

Answer 91

A

Phenytoin (Dilantin) - purple glove syndrome, arrhythmias (cardiac monitoring)
Long-term SE of CYP inducer, Hirsutism, Enlarged gums, Nystagmus, Yellowing skin, Teratogen, Osteopenia, Inhibit folate, Neuropathy
Valproate (Epilim) - hepatotoxicity (idiosyncratic), thrombocytopenia; Monitor hyperammonemia and LFT regularly
Long-term SE of Vomiting, Alopecia, Liver toxicity, Pancytopenia, Retention of fat, Oedema, Anorexia, Tremor, Enzyme inhibitor
Levetiracetam (Keppra) - Renal dose adjustment needed; GI upset
Increased SE of behavioral changes (less so for Brivaracetam)
Carbamazepine (Tegretol) - HLAB1502 risk of SJS; CYP inducer; other SE of neurotoxicity, INO / diplopia, teratogenicity, SIADH; avoid in absence seizures; mandatory to check HLAB1502 before starting (not mandatory to check for Oxcarbazepine (Trileptal) and phenytoin, but also suggest not to start if HLAB1502 +ve)

Answer 92

A

Use of serotoninergic agents + 1 of:
i) spontaneous clonus
ii) inducible clonus / ocular clonus with agitation / diaphoresis
iii) ocular / inducible clonus with fever and hypertonia
iv) tremor and hyperreflexia
- other features also include agitation, confusion, tachycardia, tachypnea, dry mucous membranes, ataxia, autonomic dysfunction

Management
- Discontinue serotoninergic agents
- GL, AC if within time window
- Supportive; hydration, cooling (panadol not useful)
- Benzodiazepine (for agitation, neuromuscular abnormalities, ↑ BP and heart rate)
- Cyproheptadine (H1 antagonist) if not respond to Benzo
- not to give beta-blockers (unopposed vasoconstriction of alpha)
- Often resolves within 24-36 hrs with supportive treatment
——————————————–
- SSRI - citalopram, fluoxetine; sertraline
- SNRI - venlafaxine, duloxetine
- TCA - amitriptyline, imipramine
- MAOi - selegiline, rasagiline (MAOBi); other inhibitors incl methylene blue, linezolid
- Stimulants - Amphetamines, mirtazapine (remeron) (increase serotonin production)
- Others - Tramadol, fentanyl, codeine, dextromethorphan, trazodone, bupropion, ondansetron, Triptans, lamotrigine

Answer 93

A

70g/week for women
140g/week for men
(ie <1 and <2 standard drinks/day respectively, 1 standard drink being 10g)

Answer 94

A

SPIKES
S: setting up the interview: arrange for some privacy; involve significant others, sit down,
making connection with patients, manage time constraints and interruptions

P: assessing patient’s perception e.g. what is your understanding of the reasons we did chest
tap?

I: obtaining patient’s INVITATION. How would you like me to give the information about the
test result?, Would you like me to give you all the information or sketch out the results and
spend more time discussing the treatment plan?

K: giving Knowledge to patient: unfortunately I ‘ve got some bad news to tell you

E: addressing patient’s EMOTION with EMPATHIC responses

S: Strategy and Summary

Answer 95

A

ABC, airway protection
check h’stix
iv ativan 4mg stat (over 2min), or iv diazepam 5mg stat, or im midazolam 10mg stat

ASM
- levetiracetam 20mg/kg loading (eg 1000mg), then 1500mg Q12H, with renal dose adjustment
- valproate 20mg/kg loading (eg 1200mg), then 600mg Q8H
- phenytoin 15mg/kg loading, max 1 gram, then 100mg q8h

Other agents
- lacosamide
- midazolam and propofol infusion
- ketamine

Ix cause of seizure (eg CTB / LP) and monitor with EEG

Answer 96

A

assess hemodynamic stability; any s/s heart failure; monitor cardiac rhythm
assess any frank contraindications (eg active major bleeding)
Aspirin ASAP loading 160-320 mg chewed / crushed, non-enteric coated formulations
CBC/dc LRFT clotting TnI CE (consider A1C and lipids also)
then Ticagrelor 180mg loading (or Clopidogrel 600mg loading)
for PPCI patients, give 50-70 IU/kg heparin up to max dose 5000 IU heparin, then adjust according to ACT
for TNK patients, if age <75, Enoxaparin 30 mg iv bolus, followed in 15 min by 1mg/kg sc Q12H (renal dose Q24H); give up to 8d till PCI
beware NOT for nitrates if suspect RV infarction (reducing preload will lead to shock)
NOT for beta-blockers if in fluid overload

Answer 97

A

Overview / indications
- Post-arrest (out of hospital arrest) ROSC patients with initial rhythm VF or pulseless VT, with significant brain injury (eg suspicions of cerebral edema)
(though may also be beneficial for patients with nonshockable rhythm / in-hospital arrests)
- Intubated with treatment initiation within 6h of arrest, at coma at time of cooling and able to maintain SBP >90mmHg with/without inotropes
- Exclude patients with recent major surgery, with sepsis, coma from other non-cardiac causes (eg drug intoxication), and other bleeding tendencies
- May achieve lower mortality and improved neurological outcome

Process
- temperature to be maintained 32-34 ºC
- surface cooling with ice packs (not directly in contact with skin) and cooling blanket
- internal cooling with intravascular heat exchange device, infusion of 500-1000ml cold saline at 4ºC given as a bolus (risks pulmonary edema)
- not for rewarming of hemodynamically stable patients who develop spontaneous mild hypothermia (>33ºC ) after resuscitation from cardiac arrest
- duration of cooling should be 12-24h
- prefer MAP >80 mmHg with help of vasopressors (eg noradrenaline); maintain SpO2 >94%
- NOT for nutrition during initiation, maintenance or rewarming phases of therapy
- monitor any bradyarrhythmias
- neuromuscular blocking agents and sedation if shivering (EEG monitoring needed to review any masked seizures)

Passive rewarming
- start at 24h after the initiation of cooling
- aim 0.3-0.5 ºC per hour, will take around 8-12 hours total
- set water temperature in cooling device to 35ºC
- maintain paralytic agent and sedation until temperature reaches 36’C
- monitor for hypotension secondary to vasodilation

Answer 98

A

** Always think TTP if low Plt + Anemia or AKI **
(May also have hemolysis picture)

Rule out platelet clumps

Production
- usu as part of pancytopenia picture (eg MF, AML, aplastic anemia)

Destruction
- ITP (primary vs secondary to APS / SLE, malignancy, infection eg HIV / CMV)
- MAHA - HUS / TTP, HIT; DIC
- SLE
- malaria, rickettsia, dengue
- hypersplenism (destruction and sequestration)
- drugs - heparin, amiodarone, digoxin

Answer 99

A

PTU blocks thyroid hormone synthesis (inhibits organification of iodine) + blocks peripheral T4 → T3 conversion
Iodine blocks thyroid hormone release (Wolff Chaikoff); escape 10-14d
(at least one hour after thionamide given to prevent the iodine from being used as substrate for new hormone synthesis)
Inderal slows heart rate, reduces oxygen demand of myocardium; reduced catecholamine binding to beta-adrenergic receptors; minor effect to inhibit peripheral T4 → T3 deiodination and conversion
Steroid for any (relative) adrenal insufficiency, blocks peripheral T4 → T3 conversion
fluid resuscitation and acetaminophen for fever
NSAIDs are contraindicated as they will increase peripheral deiodination to T3
Salicylates are contraindicated as they will compete for T4 carrier proteins leading to transient increase T4
Lithium carbonate can inhibit proteolysis of colloid and limit the release of pre-formed thyroid hormone into the bloodstream
cholestyramine binds thyroid hormones in the gut during enterohepatic circulation, prevents reuptake

Answer 100

A

iv calcium gluconate 3g over 2min
iv glucagon 2.5mg over 1 min
iv insulin 1U/kg + dextrose
lipid emulsion and methylene blue if refractory shock
atropine for bradycardia, inotropes incl NA
D50 0.5g/kg bolus through central line;
im glucagon 5mg x1; sc octreotide 0.5mg if refractory hypoglycemia
Levocarnitine iv or po 100 mg/kg (max 6g), then half dose q8h - if encephalopathy, hepatotoxicity, hyperNH3 or massive overdose or Valproate levels >3120 umol/L
May also consider naloxone and HD
None…
Ethanol infusion, or Fomepizole
Folinic acid for methanol; Thiamine 100mg, pyridoxine 50mg q6h for EG
may consider HD
Hydroxycobalamin; or Na nitrite + Na thiosulphate
See cholinergic;
Atropine 0.6mg iv (anticholinergic), repeat and double dose every 5min until clinical improvement
Consider pralidoxime in organophosphate poisoning (AChE reactivating agent)
immunosuppression with iv MP and CYC (at HKPIC), and charcoal hemoperfusion
WBI and GL may be contraindicated
Beta-blockers for bronchospasm and IMV for ARDS
Antivenom and tetanus vaccine

Answer 101

A

Digifab - digoxin >10 ng/mL, digoxin ingested 10mg, hyperK >5, refractory arrhythmia
None… HD if Lithium levels high
NAC - if panadol level above treatment line
iv vit K1, laxatives, empirical rocephin; consider transplant
None… GL, AC, MDAC, urine alkalinization, HD
Atropine 0.6mg iv (anticholinergic), repeat and double dose every 5min until clinical improvement
Consider pralidoxime in organophosphate poisoning (AChE reactivating agent)
Phytostigmine iv (AChE inhibitor); CI in asthma
Naloxone, 0.4mg iv if drug naive, 0.1mg iv if chronic user
give once every min up to 2 mg total
Flumazenil, iv 0.2mg, give every 30s, up to 1-2mg in total
reverse respiratory depression
None… Urine alkalinization for wide QRS;
For Serotonin syndrome
- give BZD (eg ativan 2mg q6h)
- cyproheptadine (12mg then 2mg every 2h)
CI flumazenil and phytostigmine
Benztropine 1mg iv for dystonia
For NMS
- regular BZD (eg ativan 2mg q6h)
- dantrolene (iv 2.5mg/kg, repeat 1mg/kg, then consider infusion)
- consider bromocriptine (2.5mg tds)

Answer 102

A

1) GBS
- FVC monitoring
- IVIG / plasmapheresis

2) MS
- steroid
- plasmapheresis
- contraindicated for anti-TNF
- Natalizumab, Fingolimod

3) NMOSD
- pulse steroid
- IVIG / plasmapheresis
- contraindicated for anti-TNF
- long-term immunomodulatory meds

4) MG
- FVC monitoring
- pyridostigmine
- IVIG / plasmapheresis
- risk of worsening if steroid used
- long-term immunomodulatory meds
- thymoma excision

Answer 103

A

iv septrin (higher dose) 21 days; may consider oral for mild cases
Suggest steroid in severe case
or clindamycin + primaquine
or pentamidine (iv only, SE of hyper/hypoglycemia, arrhythmias)

Answer 104

A

antiphospholipid antibodies (LA, anti-β2-glycoprotein Ab, ACL)
protein C / protein S / antithrombin III deficiency, Factor V Leiden deficiency
MPN - ET, PCV
OCP / HRT, steroid
malignancy
nephrotic syndrome
immobilization

Answer 105

A

quit smoking
pulmonary rehab
vaccination (influenza, covid, pneumococcal, shingrex, pertussis)
LTOT

Answer 106

A

Production problem
- B12 / folate deficiency
- BM suppressing drugs (eg azathioprine, MMF), including chemotherapy (HU, cytarabine)
- Aplastic anaemia following post-viral infection (eg parvovirus, hepatitis)
- PNH
- MDS
- BM infiltration from hematological malignancy

Destruction
- hypersplenism
- autoimmune disease

Check
- CBC/dc LRFT CaPO4 urate LDH clotting smear (hemat malignancy)
- B12, folate
- parvovirus serology
- PNH will have hemolysis picture (high bili / LDH / urate / retic, with low haptoglobin), confirmed by flow cytometry
- autoimmune markers
- check for splenomegaly
- BME

Answer 107

A

Formal legal document regarding refusal of life-sustaining therapies (CPR, ventilation, artificial nutrition)
Mentally competent patient (rule out delirium and mood problem)
2 witnesses, one must be doctor; neither can be beneficiaries
Applicable only when patient has lost capacity to make decisions and is terminally ill, or irreversible coma
Requires the original printed document to work
Can be revoked anytime if patient still mentally competent
Cannot be made by proxy
Cannot invalidate the AD by family members / doctors when patient loses capacity

Answer 108

A

Conflicts between family members / between family and healthcare providers, that may lead to inappropriate accommodation or failure to get appropriate medical Tx for patient
When patient refuses to their proposed care (eg placement)
When patient is suffering abuse / neglect / exploitation, and their interests are not being protected sufficiently

Powers of Guardian
- decide placement
- bring patient to a specific place and use reasonable force for the purpose
- require the patient to attend to attend their appointments / training
- consent to medical or dental treatment if the person concerned is incapable of doing so
- to allow access of care to be given to HCW
- to mobilize from the person’s private funds (max HK$17,000 per month currently) for the maintenance of the person (any greater funds → apply at high court)

Answer 109

A

Minor risk
- eg dental extraction, cataract, joint injections, pleural tapping, endoscopy without biopsy
- withhold 12-24h before procedure, resume 6h post-procedure if hemostasis achieved

Low risk
- eg chest drain / pleural biopsy, endoscopy Bx, tumor ablation, PPM
- withhold 24h before procedure (48h if Dabigatran with CKD), resume 24h postprocedure if hemostasis achieved

High risk
- eg LP, endoscopy with polypectomy; major ORT / eye / cardiac surgery
- withhold 48h (96h if dabigatran with CKD), resume 48h post-procedure if hemostasis achieved

Warfarin
- withhold 5 days before procedure
- therapeutic clexane bridging at 1mg/kg q12h when INR <2, last dose clexane >24h before procedure
- resume clexane 12-24h post-procedure (or 48-72h if high bleeding risk)

Answer 110

A

FHx of HT / secondary HT
current drug regime and drug compliance
Snoring
Paroxysmal symptoms of headache / dizziness
weight changes
Cushingoid
Palpate pulses, radiofemoral delay
ballotable kidneys, renal bruit
CBC LRFT RG A1C lipid
urine for proteinuria
CXR / ECG
overnight oximetry
renin/aldosterone, ODST, 24h urine metanephrines
USG kidneys / MRA renal arteries

Answer 111

A

give VARICELLA vaccine within 5 days
(eligible if not pregnant and not immunocompromised)
VZIG is available for patients not eligible for Varicella vaccine and at high risk of severe VZV infection (eg immunocompromised patients, pregnant women)

Answer 112

A

Target
- age >50 (esp >60y)
- immunocompromised adult patients
- usually wait 1y after an episode of zoster

Shingrex - recombinant vaccine
- 2 doses im
- CI - Hx of GBS, CVID, MS, pregnancy, patients on potent immunosuppressants (esp elderly)

(Note this is different from chickenpox vaccine)

Answer 113

A

1) Gastric Lavage if ingested within 1h
- intubation needed if confused
- consent needed; powerful suction needed if alert
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, antipsychotics, TCA, SSRI, Lithium, valproate, paraquat

2) Activated charcoal
- 50-100g po, if ingested within 1-2h
- not for lithium, caustic agents, methanol
- special consideration - NOAC
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, antipsychotics, TCA, SSRI, valproate, paraquat
- contraindicated in ileus / bowel perforation

3) MDAC
- 1g/kg po, followed by 0.5g/kg q4h for 1-2 days
- for theophylline, phenytoin, digoxin, carbamazepine, valproate, salicylate, dapsone, sustained release medications

4) Whole bowel irrigation
- PEG 1-2L/h until clear rectal effluent
- can consider for lithium (cannot use AC)
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, valproate
- CI in ileus / bowel perforation

5) Urinary alkalinisation
- 1-2mmol/kg NaHCO3 iv bolus, then 50mmol 8.4% NaHCO3 in 500ml D5 q4-6h
- in salicylate (if high serum levels), TCA
- also consider for cocaine, phenobarbitone, MTX
- avoid over-alkalinization / hypoK

6) HD / CRRT
- methaol, lithium, salicylate, theophylline
- consider for paracetamol, carbamazepine, phenytoin, valproate, metformin, atenolol

Answer 114

A

Statin - HMG CoA reductase inhibitor; rate limiting enzyme in cholesterol synthesis

Bempedoic acid - ATP Citrate lyase; upstream enzyme in cholesterol synthesis

Ezetrol - Niemann pick C1 like 1 protein; reduces absorption of cholesterol from intestines

PCSK9i - inhitbits the enzyme that degrades LDL-R, thus promoting LDL uptake into cells

Cholestyramine - bile acid sequestrant, limits reabsorption of bile salts (bound to LDL-C)

Fenofibrate - PPAR-a agonist, downregulates apoC3 (which is an LPL inhibitor) and thus increases VLDL catabolism

Answer 115

A

Heat exhaustion - depleted salt and water
Heat stroke - over-heating body; hot and dry; significant CNS features, metabolic acidosis and respiratory alkalosis

Check ABG, CK, lactate, urine myoglobin and toxicology
Remove clothing, fanning, cooling blankets
can stop cooling measures when temp 38-39’C is reached
Oral fluid and salt replacement if possible (25g NaCl in 5L water)
BZD if seizures
avoid all alpha-agonists (vasoconstriction impairs cooling)

Answer 116

A

inhibits oxidative phosphorylation
widespread tissue hypoxia
tachycardia, tachypnea, confusion, seizures, arrest
lactic acidosis
reduced arterio-venous O2 gradient
high blood cyanide level

Early antidote if significant acidosis, reduce AVO2 gradient
- hydrocobalamin
- or sodium nitrite + sodium thiosulphate

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