When to intubate in GCS?

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.

What is the best initial fluid for sepsis resuscitation?

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.

When to start vasopressors in septic shock?

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.

Why can serum uric acid be normal during acute gout?

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.

How do you distinguish lupus flare from infection in SLE?

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.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

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.

What antibiotics for community-acquired pneumonia?

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.

How to interpret iron studies?

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.

What is the correction rate for hyponatremia?

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.

When to start antibiotics in meningitis?

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.

DOACs vs warfarin in antiphospholipid syndrome?

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.

How to manage scleroderma renal crisis?

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.

What are the 4 pillars of heart failure treatment?

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.

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Nephrology & Electrolytes

Anion Gap

Identifies elevated AG metabolic acidosis. Corrected for albumin.

Sodium (mEq/L)

Chloride (mEq/L)

Bicarbonate (mEq/L)

Albumin (g/dL) (for correction)

FENa / FEUrea

Fractional excretion to differentiate pre-renal from ATN.

Serum Na (mEq/L)

Urine Na (mEq/L)

Serum Cr (mg/dL)

Urine Cr (mg/dL)

Corrected Sodium

Adjusts serum sodium for hyperglycemia-induced osmotic shift.

Measured Sodium (mEq/L)

Glucose (mg/dL)

CrCl (Cockcroft-Gault)

Creatinine clearance for drug dosing. Uses ideal or actual body weight.

Age (years)

Weight (kg)

Serum Creatinine (mg/dL)

Sex

Corrected Calcium

Adjusts calcium for low albumin. Use ionized Ca when available.

Measured Calcium (mg/dL)

Albumin (g/dL)

Winter's Formula

Expected PCO₂ in metabolic acidosis. Detects concurrent respiratory disorder.

Bicarbonate (mEq/L)

Actual PCO₂ (mmHg)

Cardiology

CHA₂DS₂-VASc

Stroke risk in atrial fibrillation. Guides anticoagulation decisions.

Congestive HF (1 pt)

Hypertension (1 pt)

Age ≥ 75 (2 pts)

Diabetes (1 pt)

Stroke/TIA (2 pts)

Vascular disease (1 pt)

Age 65–74 (1 pt)

Sex category female (1 pt)

PREVENT 10-Year ASCVD Risk 2026 GUIDELINE

AHA PREVENT (Predicting Risk of cardiovascular disease EVENTs) equations, Khan et al. Circulation 2024. Adopted by 2026 ACC/AHA Dyslipidemia Guideline -replaces the 2013 Pooled Cohort Equation. Validated ages 30-79, no race input, sex-specific, includes CKD (eGFR), antihypertensive and statin use. Risk categories: low <3% / borderline 3-<5% / intermediate 5-<10% / high ≥10%. Drives 2026 statin and LDL-target decisions in primary prevention.

Age (30-79 years)

Sex

Total cholesterol (mg/dL)

HDL cholesterol (mg/dL)

Systolic BP (mmHg)

eGFR (mL/min/1.73m²)

Diabetes?

Current smoker?

On antihypertensive?

On statin?

ASCVD 10-Year Risk (Pooled Cohort Equation) LEGACY 2013

Legacy 2013 Pooled Cohort Equation (ACC/AHA 2013/2018). Retired by the 2026 ACC/AHA Dyslipidemia Guideline -use the PREVENT calculator above for current 2026 guidance. PCE retained here for cross-reference and patients still being managed on prior thresholds. Validated for ages 40-79 without prior CV event, stroke, or PAD. Inputs: age, sex, race, total cholesterol, HDL, SBP, treated HTN status, DM, smoking. Tends to overestimate risk vs PREVENT, especially in Black patients and the elderly.

Age (40-79 years)

Sex

Race

Total cholesterol (mg/dL)

HDL cholesterol (mg/dL)

Systolic BP (mmHg)

Currently on antihypertensive?

Diabetes?

Current smoker?

Wells Score (PE)

Pretest probability of pulmonary embolism.

Clinical signs DVT (3 pts)

PE most likely dx (3 pts)

HR > 100 (1.5 pts)

Immobilization ≥ 3 days or surgery in past 4 wks (1.5 pts)

Prior DVT/PE (1.5 pts)

Hemoptysis (1 pt)

Malignancy (1 pt)

PERC Rule (PE Rule-Out Criteria)

Use ONLY if pre-test probability is already LOW (gestalt < 15%). All 8 criteria must be negative to rule out PE without a D-dimer.

Age ≥ 50 years

HR ≥ 100 bpm

SpO2 < 95% on room air

Unilateral leg swelling

Hemoptysis

Recent surgery/trauma (≤ 4 wk, requiring hospitalization or GA)

Prior DVT or PE

Estrogen use (OCPs, HRT)

sPESI (Simplified PE Severity Index)

30-day mortality risk in acute PE. Identifies outpatient-eligible patients (score 0) vs those needing admission (score ≥ 1).

Age > 80 years (1 pt)

History of cancer (1 pt)

Chronic cardiopulmonary disease (1 pt)

Heart rate ≥ 110 (1 pt)

SBP < 100 mmHg (1 pt)

SpO2 < 90% (1 pt)

Hestia Criteria (Outpatient PE Eligibility)

11 exclusion criteria for home treatment of acute PE. Any single YES = not an outpatient candidate.

Hemodynamically unstable (SBP < 100, requiring pressors)

Thrombolysis or embolectomy needed

Active bleeding or high bleeding risk

Need > 24h O2 to maintain SpO2 > 90%

PE diagnosed while on anticoagulation

Severe pain requiring IV analgesia > 24h

Medical or social reason for admission > 24h

CrCl < 30 mL/min

Severe liver disease

Pregnancy

History of HIT

MAP (Mean Arterial Pressure)

Estimates average arterial pressure during one cardiac cycle

Systolic BP (mmHg)

Diastolic BP (mmHg)

QTc (Corrected QT Interval)

Bazett formula -corrects QT interval for heart rate

QT Interval (ms)

Heart Rate (bpm)

Pulmonology

CURB-65 (Pneumonia)

Severity scoring for community-acquired pneumonia. Guides disposition.

Confusion (1 pt)

BUN > 19 mg/dL (1 pt)

RR ≥ 30 (1 pt)

BP < 90 systolic or ≤ 60 diastolic (1 pt)

Age ≥ 65 (1 pt)

A-a Gradient

Alveolar–arterial oxygen gradient -evaluates oxygenation defect

FiO₂ (%)

PaO₂ (mmHg)

PaCO₂ (mmHg)

Age (years)

mMRC Dyspnea Scale (COPD)

Modified Medical Research Council Dyspnea Scale. Quantifies functional impairment from breathlessness. Drives the symptom axis of COPD ABE classification (mMRC ≥ 2 = high symptoms → Group B or E).

Which best describes the patient's dyspnea?

CAT (COPD Assessment Test)

8-item symptom questionnaire. Each item scored 0-5; total 0-40. CAT ≥ 10 = high symptom burden (Group B or E in COPD ABE classification). Used alongside mMRC.

Cough (0 never → 5 all the time)

Phlegm (0 none → 5 chest completely full)

Chest tightness (0 none → 5 very tight)

Breathless walking up a hill or one flight of stairs (0 not at all → 5 very breathless)

Activities at home limited (0 not limited → 5 very limited)

Confidence leaving home despite COPD (0 confident → 5 not confident at all)

Sleep (0 sleep soundly → 5 do not sleep soundly)

Energy (0 lots of energy → 5 no energy at all)

ICU / Critical Care

Glasgow Coma Scale (GCS)

Quantify consciousness. Range 3–15. GCS ≤ 8 = intubate for airway protection.

Eye Opening (E)

Verbal Response (V)

Motor Response (M)

NEWS Score

National Early Warning Score -SSC 2026 recommended sepsis screening tool. Scores 7 parameters.

Respiratory Rate

SpO₂ (%)

Supplemental O₂

Temperature (°C)

Systolic BP (mmHg)

Heart Rate

Consciousness

MEWS Score

Modified Early Warning Score -simpler alternative to NEWS. Score ≥5 = urgent clinical review.

Respiratory Rate

Heart Rate

Systolic BP (mmHg)

Temperature (°C)

Consciousness (AVPU)

Neurology

NIHSS (NIH Stroke Scale)

11-item stroke severity scale. Drives thrombectomy eligibility (≥ 6), antiplatelet choice (≤ 3 → DAPT per CHANCE/POINT), and prognosis. Score before tPA, after tPA, and daily.

1a. Level of Consciousness

1b. LOC Questions (age, current month)

1c. LOC Commands (open/close eyes, grip/release)

2. Best Gaze (horizontal eye movement)

3. Visual Fields (confrontation)

4. Facial Palsy

5a. Motor Arm, LEFT (hold at 90° × 10 sec)

5b. Motor Arm, RIGHT

6a. Motor Leg, LEFT (hold at 30° × 5 sec)

6b. Motor Leg, RIGHT

7. Limb Ataxia (finger-nose, heel-shin)

8. Sensory (pinprick)

9. Best Language (naming, reading, describing)

10. Dysarthria ("mama, tip-top, fifty-fifty…")

11. Extinction / Inattention (double simultaneous stimulation)

Pain Management

Opioid Conversion / Oral Morphine Equivalent (OME)

Convert between opioids using total daily OME. Always reduce calculated equivalent by 25–50% for incomplete cross-tolerance when rotating. Methadone is NOT linear, consult palliative care.

Source opioid

Route

Dose per administration (mg, or mcg/hr for patch)

Frequency

Cross-tolerance reduction (standard: 25–50%)

GI / Hepatology

MELD-Na

Model for End-Stage Liver Disease. Transplant priority and 3-month mortality.

Bilirubin (mg/dL)

INR

Creatinine (mg/dL)

Sodium (mEq/L)

On dialysis (2× in past week)?

General

BMI (Body Mass Index)

Weight-based classification for nutritional status

Weight (kg)

Height (cm)

Steroid Converter

Glucocorticoid equivalence -converts between common steroids

Drug

Dose (mg)