Q: Which finding differentiates DKA from HHS?

Presence of ketones. Ketones differentiate DKA from HHS. DKA has ketoacidosis (ketones present, pH 7.3. Both have hyperglycemia (though HHS typically higher >600), dehydration, and can have altered mental status (more common in HHS due to hyperosmolarity).

Q: The target blood glucose range for critically ill patients in the ICU is:

140-180 mg/dL. Current guidelines recommend a target glucose of 140-180 mg/dL for most critically ill patients. Tight glucose control (80-110) was shown to increase hypoglycemia and mortality (NICE-SUGAR trial). Very high glucose (>180) is associated with worse outcomes. Individualize based on patient factors.

Question 1

A Type 1 diabetic presents with glucose 450 mg/dL, pH 7.18, HCO3 10, positive ketones. After IV fluids are started, the NEXT priority is:

Accepted Answer

Check potassium level before insulin. Check potassium BEFORE starting insulin in DKA. Although total body potassium is depleted, serum K may be normal or high due to acidosis shifting K out of cells. Insulin drives K back into cells, potentially causing fatal hypokalemia. Hold insulin if K <3.3 until K is replaced. Replace K when <5.3 and patient is voiding.

Question 2

Which finding differentiates DKA from HHS?

Accepted Answer

Presence of ketones. Ketones differentiate DKA from HHS. DKA has ketoacidosis (ketones present, pH <7.3, anion gap acidosis). HHS has minimal or no ketones and pH usually >7.3. Both have hyperglycemia (though HHS typically higher >600), dehydration, and can have altered mental status (more common in HHS due to hyperosmolarity).

Question 3

A patient in thyroid storm would present with all of the following EXCEPT:

Accepted Answer

Bradycardia. Thyroid storm is a hypermetabolic state with tachycardia (often >140), hyperpyrexia (>104°F), hypertension progressing to hypotension, and altered mental status. Bradycardia is NOT seen in thyroid storm but is characteristic of hypothyroidism/myxedema coma. Treatment includes beta blockers, PTU, iodine (after PTU), and glucocorticoids.

Question 4

A patient with hyponatremia (Na 118), low serum osmolality (<275), and urine osmolality >100 most likely has:

Accepted Answer

SIADH. SIADH presents with: Hyponatremia, low serum osmolality (<275), inappropriately concentrated urine (osmolality >100), high urine sodium (>40). Excess ADH causes water retention and dilutional hyponatremia. DI would show hypernatremia with dilute urine. Treat with fluid restriction, and hypertonic saline if severe.

Question 5

A patient with adrenal insufficiency requires surgery. The appropriate stress-dose steroid is:

Accepted Answer

Hydrocortisone 100 mg IV. Hydrocortisone 100 mg IV bolus is the standard stress-dose steroid for adrenal crisis or surgical stress in patients with adrenal insufficiency. Continue with 50-100 mg every 6-8 hours during the acute stress period. Hydrocortisone has both glucocorticoid and mineralocorticoid activity, which is important in adrenal insufficiency.

Question 6

Diabetes Insipidus is characterized by all EXCEPT:

Accepted Answer

Concentrated urine. DI presents with DILUTE urine (low specific gravity <1.005, low urine osmolality <200), NOT concentrated urine. The patient produces large volumes (5-15 L/day) of dilute urine due to lack of ADH effect, leading to hypernatremia and elevated serum osmolality. Concentrated urine with low output suggests SIADH.

Question 7

The target blood glucose range for critically ill patients in the ICU is:

Accepted Answer

140-180 mg/dL. Current guidelines recommend a target glucose of 140-180 mg/dL for most critically ill patients. Tight glucose control (80-110) was shown to increase hypoglycemia and mortality (NICE-SUGAR trial). Very high glucose (>180) is associated with worse outcomes. Individualize based on patient factors.

Question 8

Myxedema coma is treated with IV thyroid hormone PLUS:

Accepted Answer

Glucocorticoids. Myxedema coma treatment includes IV T4 (and/or T3) PLUS glucocorticoids. Corticosteroids are given because thyroid hormone replacement increases metabolic rate and can precipitate adrenal crisis if underlying adrenal insufficiency exists. Also provide supportive care: passive warming, ventilatory support, and cautious fluid administration.

Question 9

A patient with known Type 2 diabetes presents with glucose 1100 mg/dL, serum osmolality 340, pH 7.38, and minimal ketones. This is most consistent with:

Accepted Answer

Hyperosmolar hyperglycemic state. HHS is characterized by: Type 2 diabetes, severe hyperglycemia (often >600-1000), hyperosmolarity (>320), minimal/no ketones, and pH usually >7.3. The profound hyperglycemia and hyperosmolarity differentiate it from DKA. HHS has higher mortality and more neurological symptoms due to severe dehydration and hyperosmolarity.

Question 10

What should be given BEFORE feeding a severely malnourished patient to prevent Wernicke encephalopathy?

Accepted Answer

Thiamine. Thiamine (Vitamin B1) should be given BEFORE feeding malnourished patients. Carbohydrate metabolism requires thiamine as a cofactor. Refeeding increases carbohydrate metabolism, depleting thiamine stores and potentially causing Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia). Always give thiamine before glucose in at-risk patients.

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