Acid Base Learner Series: The Anion Gap

The Anion Gap: A balance 

Definition & Clinical Use

The term anion gap (AG) represents the concentration of all the unmeasured anions in the plasma. The negatively charged proteins account for about 10% of plasma anions and make up the majority of the unmeasured anion represented by the anion gap under normal circumstances. The acid anions (eg lactate, acetoacetate, sulphate) produced during a metabolic acidosis are not measured as part of the usual laboratory biochemical profile. The H⁺ produced reacts with bicarbonate anions (buffering) and the CO₂ produced is excreted via the lungs (respiratory compensation). The net effect is a decrease in the concentration of measured anions (ie HCO₃) and an increase in the concentration of unmeasured anions (the acid anions) so the anion gap increases.
AG is calculated from the following formula:

Anion gap = [Na⁺] - [Cl^-] - [HCO₃^-]

Reference range is 8 to 16 mmol/l. An alternative formula which includes K⁺ is sometimes used particularly by Nephrologists. In Renal Units, K⁺ can vary over a wider range and have more effect on the measured Anion Gap. This alternative formula is:

AG = [Na⁺] + [K⁺] - [Cl^-] - [HCO₃^-]

The reference range is slightly higher with this

Acid base balance: A complete explanation for Students, postgraduate Physicians especially Anesthesia Students

Definitions

The definitions of the terms used here to describe acid-base disorders are those suggested by the Ad-Hoc Committee of the New York Academy of Sciences in 1965. Though this is over 35 years ago, the definitions and discussion remain valid today.

Basic Definitions

• Acidosis - an abnormal process or condition which would lower arterial pH if there were no secondary changes in response to the primary aetiological factor.
• Alkalosis - an abnormal process or condition which would raise arterial pH if there were no secondary changes in response to the primary aetiological factor.
• Simple (Acid-Base) Disorders  are those in which there is a single primary aetiological acid-base disorder.
• Mixed (acid-Base) Disorders are those in which two or more primary aetiological disorders are present simultaneously.
• Acidaemia - Arterial pH < 7.36 (ie [H⁺] > 44 nM )
• Alkalaemia - Arterial pH > 7.44 (ie [H⁺] < 36 nM )

An acidaemia of course must be due to an acidosis so is an indicator of the presence of this disorder. In mixed acid-base disorders, there may be co-existing disorders each having opposite effects on the ECF pH so a quick check of the arterial pH is insufficient to fully indicate all primary acid-base disorders. In mixed disorders, it does indicate in general terms the most severe disorder. That is, if the arterial pH is 7.2 (an acidaemia), there must be an acidosis present, and any alkalosis present must be of lesser magnitude. (This idea is the basis of an initial step in the systematic approach to analysis of arterial blood gas results).

The Disorders

The 4 simple acid base disorders are:

• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis.

Respiratory disorders are caused by abnormal processes which tend to alter pH because of a primary change in pCO₂ levels.
Metabolic disorders are caused by abnormal processes which tend to alter pH because of a primary change in [HCO₃^-].

Correct Termin

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Pediatrics Saudi Licensing exam Questions for practice

Pediatrics Saudi Licensing exam Questions

The correct answers -as I hope- is clear by (T) sign. When you notice any wrong answer, tell me with your reference or discussion, please, so we can update to help others.

1. Mother brought her 18 month old infant to ER with history of URTI for the last 2 days with mild respiratory distress. This evening the infant start to have hard barking cough with respiratory distress. O/E: T 38C, RR 40/min, associated with nasal flaring, suprasternal & intercostal recessions. Auscultation to the chest shows equal air entry bilaterally, prolonged expiratory phase, and crackles. What is the most likely diagnosis?
a. Viral Pneumonia
b. Bacterial Pneumonia
c. Bronchiolitis
d. Acute epiglottitis
e. Trachiobronchiolitis ( T )

2. A 3 years old child woke from sleep with croup, the differential diagnosis should include all except:
a. Pneumonia ( T )
b. Tonsillitis
c. Cystic fibrosis
d. Airway foreign body
e. bronchial asthma

3. Regarding treatment of CROUP, All are TRUE EXCEPT:
a. IV fluids
b. Humidified oxygen
c. Sedative ( T )
d. Racemic epinephrine
e. Corticosteroid

4. An 8 months infant came complaining of croup, coryza, air trapping, tachy

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* Saudi Medical Selection Exam (SMSE) previously known as Saudi License Exam (SLE): is intended for
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MRCEM exam. Am i ready ?

Am i ready for MRCEM?

Ask this question to yourself while standing in front of mirror. If you think you are, here are few sincere tips to help boost your adrenaline.

Do NoT Stay ignorant about the MCEM Postgraduate Examination
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MRCEM stands for Membership of Royal College of Emergency Medicine. The College of Emergency Medicine, United
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Medicine). The College of Emergency Medicine became a College by Royal Charter on 29th February 2008. MRCEM was previously known as Membership of Faculty of Accident and Emergency Medicine (MFAEM). 

The MRCEM examination is set at a standard appropriate with the level of expertise necessary for entry into higher specialist training in Emergency Medicine as well as that for practice at an intermediate level for those not wishing to enter higher training.

The exam assesses the knowledge, skills and behaviors necessary for the
clinical practice of Emergency Medicine in the UK and Irelan

MCEM (Now called as MRCEM) examinations from Royal college of Emergency Medicine

MCEM is one of the certifications available and recommended for doctors training in emergency medicine, within India. The curriculum developed by College of Emergency Medicine-UK for MCEM is of highest standards and also is in line with the curriculum prescribed by International Federation of Emergency Medicine for training in emergency medicine. The MCEM curriculum has evolved through time and continues to get revised to accommodate the best clinical practice and the best collective knowledge possible.

 Completing MCEM enables a doctor to enter UK for higher specialist training in emergency medicine. There is no need to sit the PLAB exams. With MCEM, one will be

How to use resources to Pass MRCP Exam - Key Facts

There are a lot of ways from different sites and many of us will find some of them suitable to us. But i am gonna tell you the best n tricks to get yourself prepared for MRCP esoteric exam.

Here are the tip:

• Do MCQs as much as you can and revise them with Explanation (very imp), don't just keep doing mcq and not to read about explanation, Remember in exams questions will appear from explanation not from questions you did, but if you are lucky enough; you can have some repeat from those that you practiced.

• do BUZZWORD study: What i meant by BUZZWORD or PING-Word study, it means that a hint in the question that will lead you to the answer. FYI Qs in MRCP are not so straight forward so you are gonna face very long stem with multi directional approach from examiners. But they give one hint in the stem that can let us choose the answer. For Example, if a patient gives hx of pneumonia and they also tell you patient is alcoholic, heavy drinker etc then you should probably be thinking about kleibsella, don't you!!!!

• If you don't understand a topic in passmedicine or whatever type mcq you are using then you should go for the OHCM 9th edition or KALRA 4th edition like books instead of reading USMLE STEP 2 CK or MASTER THE BOARDS; we are dealing UK exam here, not US-Board. So don't distract yourself as it will lead to poor performance in exam.

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Difference between MRCP UK n MRCP Ireland

That is one of the commonest question that candidates face while they are approaching to their post graduate studies especially for those who want to do MRCP.

Is there any difference between the value of MRCP uk and ireland? should a person prefer any one of those? which exam u find is more difficult when comparing both?

First of all for the difficulty, many people have many views.

The commonest view about it is that Irish part is more difficult than UK. However,  the Irish questions are much more wonderful than the UK part ( this is for part I ) . UK part, in addition to simple questions; have some questions with options that are very basic  and clinically oriented.

Both exams are not easy if someone goes unprepared.

In UK part they will ask you what's the diagnosis most of the time, but in Irish MRCP you must know diagnosis 1st n then what'd be next step for that diagnosis like investigation or treatment.

Preferences & Value:

Preferences for exam over each other, I think it depends what's your goal. If you want to move to UK, then go for MRCP UK only. However, if someone plan for Ireland then MRCPI should be preferred.
Since worldwide both diplomas are accepted, there shouldn't be much difference in choosing either.

Also read how to get training ST3 post

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• While scrolling down you will reach the end of page showing "OLDER POSTS", click on it to get more past papers under that specefic subject.

Subject wise approach:

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5. FCPS PART 1 OPHTHALMOLOGY PAST PAPER

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7. FCPS Part 1 Surgery Past Paper Pool

Entry to ST3 Post (Specialty Training)? after Doing MRCP only?How about MRCP Ireland, MMed Singapore?

Entry to ST3 requirements:

There are 3 methods by which someone seeking ST3 training post in UK.

1. Gaining Complete MRCP Diploma
2. Alternative training pathway examinations
3. EAA Eligibility

Gaining Complete MRCP Diploma

There are three parts to the MRCP(UK) examination - Part 1, Part 2 (written), and Part 2 (clinical examination) - commonly referred to as 'Part 1', 'Part 2' and 'PACES'.


Alternative training pathway examinations

Others will also accept training pathways for ST3 position if someone has done alternate training in other specialisties. These Include audiovestibular medicine , clinical genetics , clinical neurophysiology , dermatology , haematology ,palliative medicine , rehabilitation medicine and sport & exercise medicine .
These specialties are also accepted for the ST3.

EAA Eligibility

Under the EAA  EU-Directive 2005 Act  can also be eligible to get the post provided the information accordingly. See the link of the Act.


Questions arise how about the MRCP Ireland and MMed of singapore????

Are they accepted???

Here is the answers to these questions


MRCP Ireland

According to the JOINT ROYAL COLLEGE OF PHYSICIANS OF TRAINING BOARD;
MRCP Ireland will not be accepted as a direct substitute for the MRCP(UK) in ST3 recruitment. However, candidates who are EEA nationals, whose training to date has been undertaken under the Irish 'Basic Specialty Training' system, and who have gained the MRCP(Ireland) examination, are likely to be eligible under the EEA eligibility rule described above (assuming all other criteria are also met).

MMed Singapore 

MMed Singapore qualification contain the full MRCP(UK) diploma, and hence will continue to be accepted as 'alternative' to MRCP(UK)

Saudi Licensing Exam prep---Mock Exam 9 with answers

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Q1. Most common medical problems faced in primary health care is:

a. Coryza

b. UTI

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d. Diabetes

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b. Quality of patient care

c. Honesty

d. Patient relationship

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b. Criminal neglect

c. Malfeasance

d. Nonfeasance

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a. Human behavior must be well understood

b. Information should be from cultural background

c. Doctors are the only health educators

d. Methods include pictures and videos

Saudi Licensing Exam prep---- Mock Exam 8 with answers

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Q1. Patient with hypercholesterolemia, he should avoid:

a. Organ meat

b. Avocado

c. Chicken

d. White egg

Q2. A mother brought her 10 y/o obese boy to the family practice clinic, what is your advice:

a. Same dietary habits only exercise

b. Fat free diet

c. Multifactorial intervention

Q3. Attack rate for school children that developed pink eye, first day 10 out of 50, second day 30 out of 50:

a. 20

b. 40

c. 60

d. 80

Q4. Treatment of contacts is applied in all of the following except:

a. Bilharziasis

b. Malaria

c. Hook worm

d. Filariasis

Q5. A patient is taking bupropion to quit smoking what is SE

a. Arrythmia

b. Seizure

c. Xerostomia

d. Headache

Q6. 10 people developed nausea,

Saudi Licensing exam Exam Prep- Mock Exam 7 with answers and explantion

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Q1. As doctor if you see patient and you face difficulty to get accurate information from him the best tactic to do it is:

a. Ask direct question (close-ended)

b. Ask open question

c. Control way of discussion

d. Use medical terms

Q2. Endemic means:

a. Spread of disease in incidence all the time

b. It cause by virulent pathologic organism

c. Spread of disease from country to country by carrier

d. Rapid spread of disease

e. There is very low incidence

Q3. Patient diagnosed with DM type 2 and he is in your office to discuss with him the plane to reduce his weight, you will told him to:

a. Decrease calorie intake in daytime

b. Decrease calorie and increase fat

c. Decrease by 500 kcal/kg per week

d. Decrease 800 per day

Q4. In PHC, from 50 children 10 got the disease on the 1st week, another 30 on the subsequent 2 weeks, what is the inci