Question 1

When to intubate in GCS?

Accepted Answer

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

Question 2

What is the best initial fluid for sepsis resuscitation?

Accepted Answer

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

Question 3

When to start vasopressors in septic shock?

Accepted Answer

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Question 4

Why can serum uric acid be normal during acute gout?

Accepted Answer

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

Question 5

How do you distinguish lupus flare from infection in SLE?

Accepted Answer

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

Question 6

What is the difference between DKA and HHS?

Accepted Answer

DKA features acidosis (pH < 7.3), elevated anion gap, and ketones -typically in Type 1 DM. HHS features severe hyperglycemia (often > 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

Question 7

When to give tPA in acute ischemic stroke?

Accepted Answer

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

Question 8

What antibiotics for community-acquired pneumonia?

Accepted Answer

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

Question 9

How to interpret iron studies?

Accepted Answer

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

Question 10

What is the correction rate for hyponatremia?

Accepted Answer

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

Question 11

When to start antibiotics in meningitis?

Accepted Answer

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

Question 12

DOACs vs warfarin in antiphospholipid syndrome?

Accepted Answer

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

Question 13

How to manage scleroderma renal crisis?

Accepted Answer

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

Question 14

What are the 4 pillars of heart failure treatment?

Accepted Answer

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

Scenario	Recommendation
Patient eating normally	Full basal-bolus-correction: 50% basal (glargine QHS) + 50% nutritional (lispro AC meals) + correction scale
NPO	Continue basal (reduce 20–50% if concerned). Hold nutritional. Correction-only sliding scale q6h. Never hold basal completely in Type 1.
Tube feeds (continuous)	Basal (glargine) + correction q6h. Or NPH q12h + correction. Or 70/30 insulin q12h.
On steroids	↑ TDD by 20–40%. Steroids cause afternoon/evening hyperglycemia → increase lunch and dinner nutritional doses more than basal.
Transitioning from drip	24h drip total × 80% = TDD. Split 50/50. Give SubQ basal 2–4h BEFORE stopping drip (overlap for glargine onset).
Correction factor	1800 ÷ TDD = how many mg/dL 1 unit drops glucose. Example: TDD 60 → CF = 30 → 1 unit drops BG by 30 mg/dL.

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