Medical Expertise domain

Question 1

Adrenal insufficiency - features

Answer 1

Fatigue
GI symptoms

Hyponatraemia
Hypotension - refractory
Hypoglycaemia

Hyperkalaemia

Question 2

Adrenal insufficiency - treatment

Answer 2

Maintenance

• hydrocortisone 20mg mane, 10mg nocte
• fludrocortisone 50-100mcg daily
• double for stress dosing

CRISIS
- dexamethasone 4mg IV bolus
OR
- hydrocortisone 100mg IV bolus

Normal saline 2-3L in the first instance
switch to D5NS if hypoglycaemic
Treat precipitating illness

Question 3

HHS features

Answer 3

Hyperglycaemia
Hyperosmolarity
Dehydration
Decreased mental function - frank coma
Extremely hypotonic urine

May have seizures, stroke syndromes, movement disorders

Associations with gram negative infections, GI bleeding, chronic renal disease, arterial and venous thrombosis

Question 4

HHS - Labs

Answer 4

Marked hyperglycaemia (>30)

Hyperosmolarity (>320mosm/L)

Elevated Cr/Urea ratio

Low corrected Na+
(corrected = glucose/3.5 + measured Na)

Acidosis mild or absent

Ketones usually <3mmol/L

DIC

Question 5

HHS - management

Answer 5

1. FLUID RESUS
   - often large volumes - care with overload comorbidities, sodium load, dilutional effect on glucose
2. INSULIN
   - usually not required, but consider if glucose not falling or need to lower ketones
3. POTASSIUM
   - replace if K < 5.5, unless patient anuric
4. TREAT PRECIPITATING CAUSE
5. CONSIDER LMWH for thromboembolic prevention

6. DISPOSITION
ICU if 
- osmolality >350
- Na+ >160
- venous/arterial pH <7.1
- K <3.5 or >6 on admission
- GCS <12
- creatinine >200
- hypothermia
- ongoing hypotension
- concomitant heart failure

Question 6

DIC bloods

Answer 6

anaemia

prolonged APTT, INR, PT

thrombocytopaenia

low fibrinogen

high D dimer

fragmented RBCs on blood film

Question 7

Thyroid storm management

Answer 7

1. Propranolol 60-80mg PO q4h or 0.5mg IV aliquots, max 10mg
   (or esmolol 50-100mcg/kg/min IVI)
2. Propylthiouracil 500-1000mg load, then 250mg q4h
3. Lugol’s iodine 5-7 drops PO tds
4. Hydrocortisone 300mg IV then 100mg tds (or dexamethasone 204mg IV qid)
5. consider empiric ABx
6. supportive measures
   - volume resuscitation and replace glycogen stores
   - cooling
   - anxiolysis (diazepam)

Question 8

Hypoglycaemia in kids

• definition
• action

Answer 8

<3.3mmol/L
urgent action at <2.6

10% dextrose 2mL/kg (or food if conscious)

Question 9

DKA in kids - definition

Answer 9

BSL > 11

Ketones 0.6mmol/L+ OR 2+ on urine

pH <7.25

HCO3 < 15

Question 10

DKA in kids - management pillars

Answer 10

1. Treat glucose
2. Treat precipitating cause
3. Treat complications
4. Treat hyperketonaemia
5. Treat electrolyte imbalance
6. Treat dehydration

Question 11

DKA in kids - management specifics

Answer 11

FLUID
[(Maintenance + Deficits) - fluid bolus already given]/48
–> start an hour before insulin

INSULIN
0.1 units/kg/hr actrapid infusion

POTASSIUM
K <3.5 requires supplementation prior to starting insulin
Max rate of replacement = 0.3mmol/kg/hr

SODIUM
correct for BSL
Measured Na + (Glucose-5.5)/3

Question 12

DKA Adults definition

Answer 12

Ketones >1.5
pH <7.35
HCO3 <15

BGL may be normal or elevated

Question 13

DKA Adults ICU disposition

Answer 13

If any of

pH <7.1
altered LOC
K <3
Na <125
Severe dehydration/altered BP
pregnancy

Question 14

Tumour lysis syndrome bloods

Answer 14

Hyperkalaemia
Hyperphosphataemia
Hyperuricaemia
High LDH
High creatinine and urea (renal impairment)

Hypocalcaemia
Low HCO3 (metabolic acidosis)

+/- high lactate

Question 15

Hyperkalaemia treatment

Answer 15

CALCIUM
10mL of 10% calcium gluconate

INSULIN/DEXTROSE
10U actrapid + 50mL 50% glucose

SALBUTAMOL
500mcg IV or 20mg nebulised

INCREASED ELIMINATION
diuretics eg frusemide
dialysis
resonium (15-30g PR/PO)

Question 16

Centor criteria for antibiotics in sore throat

Answer 16

1 point for each of

• history of fever
• anterior cervical adenopathy
• tonsillar exudates
• absence of cough

<2 points = no antibiotic or throat culture necessary