AIM exit topic questions Flashcards

Question

Criteria for IE diagnosis

Answer 1

Duke’s criteria Major criteria include - 2x blood culture with typical organism (includes HACEK, Staph aureus, Viridans Strep, Strep bovis, or other enterococci) - Persistently +ve blood cultures drawn more than 12h apart - Single +ve culture for Coxiella burnetii - Positive echo for IE - Oscillating mass suggestive of vegetation, without other explanation - Abscess - New dehiscence of prosthetic valve - New valvular regurgitation Minor criteria include - fever - predisposing condition (heart condition, IVDA) - vascular phenomena - janeway lesions, septic emboli (eg pulmonary infarct, mycotic aneurysm) - immunologic phenomena - osler’s nodes, roth spots, GN, RF - +ve blood culture but not fit major criteria

Answer 2

Cobblestone mucosa, deep linear ulcers, skip lesions, rectal sparing, fistulating disease CDAI - fever, general wellbeing - abd pain, mass - extracolonic - arthritis, uveitis, erythema nodosum - anal complications - fistula and fissure General management - CRP, fecal calprotectin - rule out infection (CDT, CMV, TB) - calcium, ADEK vitamins, iron, B12 Management - steroid to induce remission - Thiopurines to maintain remission (eg AZA) - may consider MTX biologics - anti-TNF - infliximab - ustekinumab, vedolizumab, upadacitinib

Answer 3

Inducers - phenytoin, carbamazepine, oxcarbazepine, topiramate, phenobarbitone - rifampin - mitotane - chronic alcoholism Inhibitors - clarithromycin, ketoconazole - isoniazid - verapamil and diltiazem - Paxlovid

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

NMS - use of dopamine antagonists (eg antipsychotics such as olanzapine, risperidone) or withdrawal of dopamine agonists (eg Bct, L-dopa) - 2 of: fever, rigidity, mental status change, dysautonomia SS - 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 - 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 8

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

Answer 9

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

Answer 10

[] Myopathy (fasciculation, no sensory) - myositis - thyroid / cushing - drug-induced (statin) - congenital conditions [] Neuropathy (sensory) - DM, hypothyroid, uremia - B12, B6 - drugs - isoniazid, platin chemo, alcohol, colchicine - CMT - vasculitis (eg SLE, PAN) - paraproteinemia - GBS (no sensory) [] DDx - MG, MND

Answer 11

1. Competence (be aware of cognitive function and consciousness) 2. Voluntariness (free will, independent decision making) 3. Disclosure of information: pros and cons of choices including alternatives 4. 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.

Answer 12

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

Answer 13

Source HBsAg +ve or unknown Transmission risk 6-30% - HCW vaccinated and anti-Hbs+ => no need Tx - HCW vaccinated but known non-responder (anti-HBs<10) => HBIG within 24h and repeat within 1 month HBV vaccine is offered if anti-Hbs -ve FU check HBsAg + anti-HBc at 24 weeks post exposure

Answer 14

- 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

Answer 15

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

Answer 16

no PEP available check HCV RNA (not anti-HCV Ab) at 6-8 weeks, 24 weeks transmission risk 2%

Answer 17

- 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

Answer 18

(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)

Answer 19

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

Answer 20

- renal failure in a patient with liver failure / cirrhosis - increase in Cr >50% with oliguria - no reversibility after volume expansion and stopping diuretics Exclude - nephrotoxic drugs - shock - GN Precipitants - sepsis including SBP - UGIB - severe alcoholic hepatitis Management - iv albumin 1g/kg/day, then 20-40g/day - Terlipressin 1mg q4h - need to consider TIPS and liver transplant

Answer 21

- Ab against complex between Platelet factor 4 (PF4) and heparin - Type 2 - Plt falls 5-14 days after heparin - Type 1 - Plt falls on 1st day - Usu Plt falls by >50% but not less than 20 - Present with unexplained thrombocytopenia, new thrombosis, skin necrosis at injection site or anaphylactoid reaction for iv heparin - Dx by PF4-heparin ELISA - Tx by discontinuation of heparin; switch to other forms of anticoagulation

Answer 22

Biktarvy within hours of exposure and no later than 72h, total 4 wks Biktarvy - Bictegravir (INSTI) + Emtricitabine (NRTI) + Tenofovir alafenamide (NRTI) check HIV: 6, 12, 24 weeks post exposure Advise not for unsafe sex / blood donation in this period of time

Answer 23

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

Answer 24

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)

Answer 25

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

Answer 26

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 27

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 28

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 29

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 30

1) Primary spontaneous PTX - < 2cm and asymptomatic - may observe and give O2 - >2cm or symptomatic - chest drain insertion / needle aspiration 2) Secondary spontaneous PTX - <1cm and asymptomtic - may observe and give O2 - 1-2cm with minimal symptoms - chest drain insertion / needle aspiration - >2cm or symptomatic - chest drain insertion 3) Consider pleurodesis - recurrent / bilateral / tension / secondary PTX - prolonged air leak - professions at risk (pilots, drivers)

Answer 31

- 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 32

* Cyanosis with normal oxygen saturation * - Fe2+ oxidized to Fe3+, so it cannot bind O2 - Test the metHb with co-oximetry (arterial blood with special wavelength detection) Inciting agents - lidocaine, dapsone, quinines, maxolon - nitrites / sodium nitrate used as preservative, or contaminated water with the nitrates - Dyes / antifreeze / solvents, paraquat (herbicide) Presentation - cyanosis, dyspnea, headache; shock, severe respiratory depression, or neurologic deterioration Mx - stop offending drug - methylene blue (CI in G6PD); ascorbic acid; if symptomatic and high methemoglobin levels (>20%) - exchange transfusion - hyperbaric oxygen

Answer 33

- 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 34

- 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 35

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) - 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 36

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 37

By PSG - PSG >15 predominantly obstructive events per hour (ie AHI >15; or - Clinical symptoms + AHI >5 - AHI 15-30 is moderate and >30 is severe OO screening - desaturation index as a quantitative criteria - desat SpO2 >4% from baseline, to SpO2 <90%, greater than 5 events per hour

Answer 38

- 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 39

- 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 40

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 41

GALAW CHOBBS Glucose Age LDH AST WCC Calcium Hematocrit change Oxygen BUN change Base excess change Sequestered fluid

Answer 42

1) NOAC - activated charcoal, local hemostasis - PCC 50 IU/kg if last dose <24h FFP if PCC not available - Idarucizumab 2.5 gram iv x 2 doses for Dabigatran Andexanet alfa not available in HK for Xaban - Novoseven may be considered 2) Warfarin - omit dose +/- 2.5mg oral vit K if no bleeding - iv vit K1 5-10mg + PCC 50 IU/kg if INR elevated with significant bleeding 3) TPA (antifibrinolytic) - cryoprecipitate (up to 10 units per dose) + 1 dose transamin - alternative may give fibrinogen concentrate - aim reach normal fibrinogen levels 4) Heparin - protamine sulfate slow iv infusion (more effective for UH) - eg for Clexane - 1:1 dose if given <8h; give half dose protamine if >8h

Answer 43

- 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 44

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 45

>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 46

- 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 47

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 48

- 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 49

1) MTX - teratogenic; hepatotoxicity; lung fibrosis; oral ulcers 2) AZA - BM suppression, hepatotoxicity, pancreatitis, drug interaction with allopurinol 3) SSZ - CI in G6PD, pancreatitis 4) HCQ - macular damage, corneal deposit 5) LEF - leucopenia, N/V/D, hepatotoxicity; stop 2y before conception 6) MMF - myelosuppression, diarrhoea, teratogenic 7) CsA - gum hypertrophy, hypertrichosis, nephrotoxicity, HT, tremors and seizures; drug interaction with diltiazem 8) FK - DM, neurotoxicity

Answer 50

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 51

[] cord pathology (sensory also) - traumatic / PID / malignant vertebral collapse - transverse myelitis (MS / NMO / SLE) - subacute combined degeneration of cord [] others - parasagittal tumor, HSP

Answer 52

- 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 53

- 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 54

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 55

** Always think TTP if low Plt + Anemia or AKI ** (May also have hemolysis picture) 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 56

1. 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 2. D50 0.5g/kg bolus through central line; im glucagon 5mg x1; sc octreotide 0.5mg if refractory hypoglycemia 3. 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 4. None... 5. Ethanol infusion, or Fomepizole Folinic acid for methanol; Thiamine 100mg, pyridoxine 50mg q6h for EG may consider HD 6. Hydroxycobalamin; or Na nitrite + Na thiosulphate 7. See cholinergic; Atropine 0.6mg iv (anticholinergic), repeat and double dose every 5min until clinical improvement Consider pralidoxime in organophosphate poisoning (AChE reactivating agent) 8. immunosuppression with iv MP and CYC (at HKPIC), and charcoal hemoperfusion 9. WBI and GL may be contraindicated 10. Beta-blockers for bronchospasm and IMV for ARDS 11. Antivenom and tetanus vaccine

Answer 57

1. Digifab - digoxin >10 ng/mL, digoxin ingested 10mg, hyperK >5, refractory arrhythmia 2. None... HD if Lithium levels high 3. NAC - if panadol level above treatment line iv vit K1, laxatives, empirical rocephin; consider transplant 4. None... GL, AC, MDAC, urine alkalinization, HD 5. Atropine 0.6mg iv (anticholinergic), repeat and double dose every 5min until clinical improvement Consider pralidoxime in organophosphate poisoning (AChE reactivating agent) 6. Phytostigmine iv (AChE inhibitor); CI in asthma 7. Naloxone, 0.4mg iv if drug naive, 0.1mg iv if chronic user give once every min up to 2 mg total 8. Flumazenil, iv 0.2mg, give every 30s, up to 1-2mg in total reverse respiratory depression 9. 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 10. 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 58

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 59

Topical - emollients - steroid - coal tar - vitamin D analogues - salicylic acid Phototherapy Systemic treatment - retinoids - MTX, CYC - anti-TNF

Answer 60

Continuous inflammation extending proximally from rectum; clear demarcation between healthy and affected mucosa Truelove and Witt criteria (she hasn't ever finished pooping) - Stool frequency - Hb - ESR / CRP - Fever - Pulse General management - CRP, fecal calprotectin - rule out infection (CDT, CMV, TB) - calcium, ADEL vitamins, iron, B12 Management - topical treatment for distal disease - mesalazine / steroid enema - systemic- SSZ, 5-ASA, steroid, thiopurines (eg AZA) Rescue therapy - anti-TNF (eg infliximab) - vedolizumab - CsA, FK

Answer 61

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

Answer 62

- Air may be introduced during surgery, trauma, vascular intervention, diving, barotrauma from mechanical ventilation - ABC stabilization and give high flow O2 - Consider trendelenburg position for venous embolism; otherwise remain in supine position for arterial air embolism - HBOT is given if patient is hemodynamically unstable, or with neurological deficits or end-organ damage or other

Answer 63

Production problem - B12 / folate deficiency - BM suppressing drugs (eg colchicine, 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 64

- 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 65

- characterized by a range of neurologic symptoms that affect patients on hemodialysis - first started on dialysis or when patients have missed multiple consecutive dialysis treatments Risk factors: - newly initiated HD, baseline high urea (eg 60) - Advanced age, pre-existing neurological disease or other conditions associated with cerebral edema Symptoms - headache, nausea, blurred vision - May have confusion, seizures and coma Exclude - acute stroke / ICH - predisposing drugs - air embolism - CNS infection / tumor Management - Prevention - lowering dialysis blood flow and shortening dialysis session length - Usually spontaneously recovers within 24h - May consider trial of hypertonic saline / mannitol in severe DDS

Answer 66

suspicious signs - abnormal injury locations (eg face bruise) - low mood of elderly, withdrawn - sudden financial transactions - abuser answering on behalf of patient What to do - ensure safety of elder* - document injuries, clinical photo - inform MSW and geri specialist; need to report to central information system on elder abuse cases and review in multidisciplinary case conference - report to police if serious threat to elder - emergency guardianship if abuser refuses patient to be taken care of

Answer 67

- 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 68

- 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 - USG kidneys / MRA renal artery - renin/aldosterone, ODST, 24h urine metanephrines

Answer 69

- 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 70

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 71

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 72

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 73

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 (consider SBP also) - the obstructive causes above

Answer 74

- 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

Answer 75

- 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 76

- 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

Answer 77

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 78

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 a-glucosidase inhitibor - blocks polylsaccharide conversion to monosaccharide and thus reduce intestinal absorption

Answer 79

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 80

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)

Answer 81

- 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

Answer 82

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 83

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 84

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)

AIM exit topic questions Flashcards

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