Killing me softly
What is the empiric inpatient treatment for non-severe community-acquired pneumonia?
A beta-lactam (e.g., ceftriaxone) plus a macrolide (e.g., azithromycin).
Alternative: Respiratory fluoroquinolone (e.g., levofloxacin or moxifloxacin).
What is the most common inherited cause of cirrhosis?
Hereditary hemochromatosis
Screen with % transferrin saturation (>45%) and ferritin (>600)
Confirm with HFE gene testing (C282Y, H63D mutations)
According to SHA opioid stewardship principles, what’s the first-line strategy in managing inpatient pain?
Always start with non-pharmacological and non-opioid analgesics, scheduled at appropriate doses.
What are the three diagnostic features of DKA?
A:
pH ≤ 7.3
Bicarbonate ≤ 15 mmol/L
Positive ketones (urine or serum)
Glucose typically ≥14 mmol/L
(Anion gap >12 also supportive)
This potion allows someone to assume the appearance of another person.
Polyjuice Potion
What clinical situations should prompt MRSA coverage in a patient with pneumonia?
Severe post-influenza pneumonia, mechanical ventilation/ICU admission, recent antibiotic use, or known prior MRSA colonization.
Empiric options: Vancomycin or Linezolid.
In liver disease, which marker becomes abnormal first and which reflects chronic dysfunction?
Bilirubin rises early in acute liver failure
INR worsens (due to short half-life of clotting factors)
Albumin reflects chronic dysfunction (long half-life)
What are three long-term side effects of opioids?
Long-term side effects:
Opioid-induced hyperalgesia
Hypogonadism / reduced testosterone
Immunosuppression
Mood changes (e.g., depression, anxiety)
Physical dependence or opioid use disorder
Increased sensitivity to pain due to prolonged opioid use.
Management: Opioid taper, rotation (e.g., buprenorphine), NMDA blockers (e.g., ketamine), and non-opioid adjuncts.
What key features distinguish HHS?
A:
Minimal ketones, pH > 7.3, bicarb > 20
Marked hyperglycemia (≥33 mmol/L)
Serum osmolality > 330
Profound dehydration and significantly reduced LOC
Often in older patients with T2DM
What are the 3 unforgivable curses?
Avada Kedavra (Killing Curse)
Crucio (Cruciatus Curse – causes pain)
Imperio (Imperius Curse – mind control)
Name at least three antibiotics that cover Pseudomonas aeruginosa. When should Pseudomonas coverage be included empirically?
Pip-tazo, cefepime, meropenem, ceftazidime, ciprofloxacin, levofloxacin, or aztreonam.
Coverage is needed in patients with prior isolation of Pseudomonas, recent mechanical ventilation, recent hospitalization, or structural lung disease.
What are the top causes of AST/ALT >1000 in a hepatocellular pattern?
Toxin (acetaminophen), ischemic hepatitis, acute viral hepatitis (A, B, E), acute biliary obstruction (early), autoimmune hepatitis.
What is the “10% rule” for calculating opioid PRN doses in patients on scheduled opioids?
PRN opioid doses should be approximately 10% of the patient’s total 24-hour opioid dose (MEDD).
This accounts for tolerance and ensures adequate breakthrough pain control — especially in patients on chronic or high-dose opioids.
What is the main goal of the insulin infusion in DKA management?
To correct the acidosis!
Who impersonated Mad Eye Moody?
Barty Crouch Jr.
A patient with cirrhosis presents with fever and abdominal pain. What diagnostic finding confirms spontaneous bacterial peritonitis, what is the empiric treatment, and what supportive therapy should be added?
SBP diagnosis: PMNs ≥250 cells/mm³ on paracentesis.
Empiric treatment: Ceftriaxone or cefotaxime.
Supportive therapy: Give IV albumin — in practice, almost everyone gets it, but guidelines recommend it especially if:
Creatinine > 88 µmol/L
BUN > 10.7 mmol/L
Bilirubin > 68 µmol/L
Also:
NSBBs (e.g., propranolol) should be temporarily held if the patient has SBP and hypotension.
Post-SBP prophylaxis: Norfloxacin, Septra DS, or Ciprofloxacin.
A patient presents with new-onset ascites. What is your approach to determine the underlying cause?
Perform diagnostic paracentesis (prior to starting diuretics or albumin)
Calculate SAAG:
≥11 g/L → portal hypertension (e.g., cirrhosis, CHF, Budd-Chiari)
<11 g/L → TB, cancer, nephrotic, pancreatitis
Check ascitic protein: <25 g/L → cirrhosis, 25 g/L → malignancy, TB, cardiac
Order additional tests: albumin, INR, LFTs, creatinine, ultrasound, and imaging if malignancy suspected
Name 4 symptoms of opioid withdrawal
•Resting Pulse Rate
•Sweating
•Restlessness
•Pupil Size
•Bone and Joint Aches
•Runny Nose or Tearing
•GI Upset
•Tremor
•Yawning
•Anxiety or Irritability
•Gooseflesh Skin
•Change in Temperature
A 79-year-old man recovering from DKA is ready to switch to subcutaneous insulin. He weighs 70 kg, has good oral intake, and no significant renal impairment.
How would you figure out his basal and bolus insulin regimen?
Total Daily Dose (TDD):
0.5 × 70 = 35 units/day
Basal-bolus split:
17–18 units basal (e.g., glargine once daily)
17–18 units bolus, divided into 3 meals → ~6 units lispro or aspart before breakfast, lunch, and dinner
Add correctional insulin with meals based on blood glucose
What magical creature pulls the carriages to Hogwarts that only some students can see?
Bonus - which two students can see?
Thestrals
A 60 year old women with AML was admitted with febrile neutropenia and treated with Meropenem and vancomycin. She is also on Ganciclovir due to a positive blood CMV PCR. 1 week into therapy she has a repeat fever and is found to have candidemia and is started on fluconazole for 2 weeks. She initially improves. She has been neutropenic for the past month, but her neutrophils are now beginning to improve. 1 week later, she becomes febrile again. Bloodwork shows Neutrophils 1.5, ALT 100, ALP 400, Bilirubin 20. What is the cause of her fever?
Hepatosplenic Candidiasis typically occurs in patients with heme malignancy and prolonged neutropenia. Candida gets into the bloodstream and seeds the liver/spleen. Lesions are often not visible while neutropenic, but emerge once the neutrophil count recovers. May be accompanied by an elevated ALP. Suspect in someone who either is not improving on antifungals or improves then worsens again especially after neutrophil recovery. Drug fever could also cause fever and elevated ALP, but overall pattern consistent with hepatosplenic candidiasis
46F with T2DM A1C 6.4%, arthritis, obesity, presenting with fatigue. Her Family MD calls for advice about finding of ferritin 680, TSat 38%, ALT 38, creatinine and CBC normal. Nothing on physical exam to explain fatigue except for poor exercise tolerance due to obesity. What do you advise for next steps?
Screen for MASLD with clinically significant fibrosis by calculating a FIB-4 score, counsel on cardiovascular risk reduction.
Who to screen for clinically significant fibrosis (>F2 fibrosis):
• T2DM, obesity w/ metabolic complications, 1st degree relative with MASH cirrhosis, pts with alcohol use
• Screen with FIB-4 score for everyone if > 1.3, refer for fibroscan. If <1.3, follow with FIB-4 q1-3y depending on CV risk factors
A patient with chronic pain on morphine SR 530 mg BID and hydromorphone IR 24 mg QID is admitted for acute worsening of pain. She reports diffuse pain and has minimal functional improvement.
What is the most likely diagnosis ?
Diagnosis: Opioid-induced hyperalgesia (OIH)
Rotation plan:
Calculate total morphine equivalent daily dose (MEDD)
Morphine SR 530 mg BID = 1060 mg/day
Convert to hydromorphone (divide by ~5) = 212 mg/day
Apply 25–50% dose reduction for incomplete cross-tolerance
Target ~106–160 mg hydromorphone/day
Divide into scheduled doses + PRN (~10% of daily dose)
Consider rotation to buprenorphine using microdosing (Bernese method) if appropriate — safer in OIH
A patient is recovering from DKA, the anion gap has closed, and their bicarbonate and pH have normalized.
How do you safely transition them and how do you prevent recurrence of ketosis?
Calculate total daily insulin dose (TDD), typically 0.4–0.6 units/kg/day
Split the TDD:
- 50% as basal (e.g., glargine once daily)
- 50% as bolus, divided before meals (e.g., lispro or aspart)
Administer the first dose of subcutaneous basal insulin at least 2 hours before stopping IV insulin infusion to maintain insulin coverage and prevent rebound ketosis
Ensure the patient is tolerating oral intake before giving prandial insulin
Continue to monitor glucose and ketones post-transition
Name all the horcruxes
Tom Riddle’s diary
Marvolo Gaunt’s ring
Salazar Slytherin’s locket
Helga Hufflepuff’s cup
Rowena Ravenclaw’s diadem
Harry Potter (unintentional)
Nagini (the snake)
Voldemort himself