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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High-YieldGI

Inflammatory Bowel Disease

Crohn disease (transmural, skip lesions, any GI segment) vs Ulcerative Colitis (mucosal, continuous, colon only). Distinguish from infectious colitis. Biologics have transformed management.

🔍 Overview

Crohn Disease vs Ulcerative Colitis

Feature	Crohn Disease	Ulcerative Colitis
Location	Mouth to anus (terminal ileum most common)	Colon only -rectum always involved, extends proximally
Depth	Transmural → fistulas, strictures, abscesses	Mucosa/submucosa only
Pattern	Skip lesions, cobblestoning	Continuous, no skip lesions
Histology	Non-caseating granulomas	Crypt abscesses, pseudopolyps
Bloody diarrhea	Less common	Hallmark symptom
Smoking	Worsens disease	Protective (but don't recommend!)
Surgery	Not curative -disease recurs	Total colectomy is curative

Toxic megacolon (colon dilation > 6 cm + systemic toxicity) is a life-threatening complication of both CD and UC. Requires surgical consultation, broad-spectrum antibiotics, and possible colectomy.

Severity Scoring, Truelove and Witts (UC)

Parameter	Mild	Moderate	Severe
Bloody stools/day	< 4	4–6	> 6
Heart rate	Normal	≤ 90	> 90
Temperature	Normal	≤ 37.8°C	> 37.8°C
Hemoglobin	Normal	≥ 10.5 g/dL	< 10.5 g/dL
ESR	≤ 20	20–30	> 30

Clinical Pearl: Truelove and Witts criteria are used at the bedside to determine if a UC flare requires IV steroids (severe) vs outpatient management (mild). A patient meeting severe criteria needs admission for IV methylprednisolone and GI consultation.

Crohn Disease Activity Index (CDAI), Concept

The CDAI is a composite score (0–600+) incorporating stool frequency, abdominal pain severity, general well-being, extraintestinal features, anti-diarrheal use, abdominal mass, hematocrit, and body weight. CDAI < 150 = remission; 150–220 = mild; 220–450 = moderate; > 450 = severe. Primarily used in clinical trials. At the bedside, use clinical judgment: stool frequency, CRP, nutritional status, and presence of complications (fistula, abscess) guide management decisions.

Mnemonic, B Symptoms of IBD Flare Requiring Admission

"FAST", Fever, Anemia, Six+ stools/day, Tachycardia. Any patient meeting these criteria should be admitted for IV steroids and GI consultation. Always rule out C. diff and CMV colitis before escalating immunosuppression.

🚨 Management

Step-Up Therapy

Severity	UC Treatment	Crohn Treatment
Mild	Mesalamine (Asacol/Lialda) PO/PR	Mesalamine (limited evidence) or budesonide
Moderate	Oral steroids → thiopurines or biologics	Budesonide (Entocort) → thiopurines or biologics
Severe	IV steroids → Infliximab (Remicade) or cyclosporine	IV steroids → anti-TNF or vedolizumab
Perianal/Fistulizing	N/A	Anti-TNF (infliximab preferred) + antibiotics + surgical drainage

Acute Severe UC Flare, Inpatient Management Algorithm

Acute Severe UC (Truelove-Witts severe): Admit → IV methylprednisolone 60 mg/day → assess response at Day 3. If no improvement (≥ 8 stools/day or 3–8 stools + CRP > 45): rescue therapy with infliximab or cyclosporine, or colectomy. Do NOT delay surgical consultation. Travis Criteria, 1996

Day 0: Admit. Rule out C. diff (send toxin PCR), CMV colitis (if on immunosuppression, send CMV PCR). IV methylprednisolone 60 mg daily. DVT prophylaxis (UC flares are prothrombotic). NPO if toxic megacolon suspected.
Day 1–3: Monitor stool frequency, CRP, abdominal exam. Flexible sigmoidoscopy (NOT full colonoscopy, perforation risk) to assess severity and rule out CMV.
Day 3 assessment: Responding → transition to oral prednisone 40 mg, plan steroid taper + biologic initiation. NOT responding → infliximab 5 mg/kg (preferred) or IV cyclosporine 2 mg/kg/day. Surgical consultation for colectomy if refractory.
Day 5–7: If rescue therapy failing → subtotal colectomy with end ileostomy is life-saving. Do not delay.

Biologics Comparison Table

Drug	Mechanism	Approved For	Key Pearls
Infliximab (Remicade)	Anti-TNF-alpha (chimeric mAb)	UC + Crohn	Preferred for fistulizing Crohn + acute severe UC. IV infusion. ACT 1/ACT 2, 2005
Adalimumab (Humira)	Anti-TNF-alpha (fully human mAb)	UC + Crohn	SC injection, convenient for outpatient. Less immunogenic than infliximab. CLASSIC I, 2006
Vedolizumab (Entyvio)	Anti-α4β7 integrin (gut-selective)	UC + Crohn	Lower systemic infection risk, does NOT increase TB/opportunistic infection risk. Slower onset (8–14 weeks). Preferred if infection concerns. GEMINI 1, 2013
Ustekinumab (Stelara)	Anti-IL-12/23 (p40 subunit)	Crohn (UC emerging)	IV induction → SC maintenance. Good safety profile. Consider after anti-TNF failure. UNITI-1/UNITI-2, 2016
Tofacitinib (Xeljanz)	JAK inhibitor (small molecule)	UC only	Oral, no infusions. Rapid onset. Risk: VTE, herpes zoster. Avoid in patients with VTE risk factors. OCTAVE, 2017

Choosing a Biologic: Anti-TNF is first-line for most moderate-severe IBD and fistulizing Crohn. Vedolizumab preferred if TB/infection risk is high (gut-selective mechanism). Ustekinumab for anti-TNF failures. Tofacitinib is oral and fast-acting but limited to UC with VTE monitoring required.

Extraintestinal Manifestations

MSK: Peripheral arthritis (follows disease activity), sacroiliitis/ankylosing spondylitis (independent)
Skin: Erythema nodosum (follows activity), pyoderma gangrenosum (independent)
Eyes: Uveitis, episcleritis
Hepatobiliary: Primary sclerosing cholangitis (strong UC association)

🧪 Workup

Colonoscopy with biopsies -gold standard for diagnosis
CT enterography/MR enterography -small bowel involvement (Crohn)
Stool studies -C. diff, cultures, O&P (rule out infectious mimics)
CRP, ESR -inflammation markers
Fecal calprotectin -non-invasive marker of intestinal inflammation
CBC (anemia), albumin, iron studies
pANCA (UC ~70%) vs ASCA (Crohn ~60%)

💊 Medications

Drug	Dose	Class	Key Notes
Mesalamine (Asacol)	2.4–4.8 g/day PO	5-ASA	UC first-line mild disease. Minimal role in Crohn.
Budesonide (Entocort)	9 mg daily × 8 wk taper	Steroid	Ileal/right colon Crohn. Less systemic effects than prednisone.
Azathioprine (Imuran)	2–2.5 mg/kg/day	Thiopurine	Steroid-sparing. Check TPMT before starting. Risk: lymphoma, pancreatitis.
Infliximab (Remicade)	5 mg/kg IV wk 0,2,6 then q8wk	Anti-TNF	Moderate-severe IBD. Screen for TB/Hep B before starting.
Vedolizumab (Entyvio)	300 mg IV q8wk	Anti-integrin	Gut-selective. Lower infection risk than anti-TNF.
Ustekinumab (Stelara)	Induction IV → 90 mg SC q8wk	Anti-IL12/23	Moderate-severe Crohn. Growing UC evidence.

📋 On Rounds

Pimp Questions

How do you distinguish Crohn from UC on colonoscopy?

Crohn: Skip lesions (patchy inflammation), cobblestone mucosa, aphthous ulcers, deep linear ulcers, strictures. Can involve terminal ileum. Histology: non-caseating granulomas (found in ~30%). UC: Continuous inflammation starting at rectum extending proximally, loss of vascular pattern, pseudopolyps, friability. Histology: crypt abscesses, crypt architectural distortion.

What must you screen for before starting anti-TNF therapy?

(1) Tuberculosis -QuantiFERON Gold or PPD (anti-TNF reactivates latent TB). (2) Hepatitis B -HBsAg, anti-HBc, anti-HBs (risk of fulminant reactivation). (3) Hepatitis C. (4) Age-appropriate cancer screening. (5) Vaccination status (give live vaccines BEFORE starting, not after).

What is PSC and which IBD is it associated with?

Primary Sclerosing Cholangitis -progressive fibrosis and stricturing of intra/extrahepatic bile ducts. Strongly associated with UC (~70-80% of PSC patients have UC). Diagnosed by MRCP (beading of bile ducts). Increases risk of cholangiocarcinoma. UC + PSC patients have even higher colorectal cancer risk.

A UC patient on azathioprine presents with a flare. What infection must you rule out before escalating immunosuppression?

You must rule out C. difficile (send stool toxin PCR) and CMV colitis (send CMV PCR and request CMV immunohistochemistry on biopsy). Both mimic IBD flares and will worsen with increased immunosuppression. C. diff is extremely common in IBD patients (even without prior antibiotics). CMV colitis occurs in immunosuppressed patients and requires IV ganciclovir, not steroids. Always test before escalating therapy.

Why is vedolizumab considered safer than anti-TNF agents in terms of infection risk?

Vedolizumab targets the α4β7 integrin, which is selectively expressed on gut-homing lymphocytes. This blocks lymphocyte trafficking to the GI tract specifically, without systemic immunosuppression. Unlike anti-TNF agents, vedolizumab does not increase the risk of TB reactivation, opportunistic infections, or systemic infections. Preferred in patients with prior serious infections, latent TB concerns, or elderly patients.

What are the criteria for toxic megacolon and how do you manage it?

Toxic megacolon = radiographic colonic dilation > 6 cm (transverse colon) or cecum > 9 cm PLUS systemic toxicity (fever > 38.6, HR > 120, WBC > 10.5K, or altered mental status). Management: (1) NPO + NG decompression. (2) IV fluids + electrolyte correction. (3) IV broad-spectrum antibiotics. (4) IV methylprednisolone.

What is the role of TPMT testing before starting azathioprine?

TPMT (thiopurine methyltransferase) metabolizes azathioprine/6-MP. ~10% are heterozygous (intermediate activity) and 0.3% are homozygous deficient. Deficient patients accumulate toxic 6-thioguanine nucleotides causing severe myelosuppression. Check TPMT genotype/phenotype before the first dose. Homozygous deficient = absolute contraindication. Heterozygous = start at 50% dose with close CBC monitoring.

When should you consider surgery for Crohn disease?

Surgery in Crohn is not curative (recurs in ~50% within 5 years), reserved for complications: (1) Obstruction/stricture unresponsive to medical therapy. (2) Abscess not drainable percutaneously. (3) Fistula refractory to anti-TNF + surgical drainage. (4) Perforation. (5) Dysplasia/cancer on surveillance. Post-surgical prophylaxis with metronidazole or anti-TNF reduces recurrence. POCER, 2015

How does UC increase colorectal cancer risk and what is the surveillance strategy?

UC-associated CRC follows the inflammation-dysplasia-carcinoma sequence. Risk factors: duration > 8 years, pancolitis, concurrent PSC, family history, persistent inflammation. Surveillance: colonoscopy at 8 years after onset, then every 1-3 years with chromoendoscopy + random biopsies. PSC patients: annual colonoscopy from diagnosis. 5-ASA may be chemoprotective.

Clinical Examples

📋 Case 1, Acute Severe UC Flare

Patient: 34F with known UC (pancolitis, on mesalamine) presents with 3 days of worsening bloody diarrhea (10-12/day), cramping, fever 38.9°C, HR 112.

Labs: WBC 14.2, Hgb 9.8, CRP 62, albumin 2.4, K 3.1. C. diff PCR negative.

Assessment: Meets Truelove-Witts severe criteria. KUB: no toxic megacolon.

Management:

Admit. IV methylprednisolone 60 mg/day. DVT prophylaxis. Correct K.
Flexible sigmoidoscopy day 1-2 for severity + CMV biopsy.
Day 3: 8+ stools/day, CRP 55 → Travis criteria met for steroid failure.
Rescue therapy: infliximab 5 mg/kg. Surgical consultation placed.
Responded by day 5. Oral prednisone taper + infliximab maintenance initiated.

Teaching Point: Day-3 reassessment with Travis criteria is critical. Delayed rescue therapy increases colectomy and mortality risk.

📋 Case 2, Crohn with Perianal Fistula

Patient: 26M with ileal Crohn (on azathioprine), 2 weeks of perianal pain, swelling, purulent drainage. 4-5 loose stools/day, 8 lb weight loss.

Exam: External fistula at 5 o'clock with purulent discharge. Fluctuant area = undrained abscess.

Imaging: MRI pelvis: complex perianal fistula + intersphincteric abscess (2.3 cm).

Management:

Step 1: EUA with abscess I&D + seton placement.
Step 2: Cipro 500 BID + metronidazole 500 TID (bridge to biologic).
Step 3: Infliximab initiated (preferred for fistulizing Crohn). ACCENT II, 2004
Azathioprine continued (combination reduces immunogenicity). Seton removed at 3 months.

Teaching Point: Always drain abscess BEFORE biologics. Combined medical-surgical approach is standard for fistulizing Crohn.

📋 Case 3, Toxic Megacolon

Patient: 58F with UC on IV steroids for 4 days. Overnight: abdominal distention, absent bowel sounds, fever 39.4°C, HR 128, BP 92/58, AMS.

Labs: WBC 22K, lactate 3.8, K 2.9, Hgb 7.4.

Imaging: KUB: transverse colon 8.5 cm. No free air.

Assessment: Toxic megacolon, dilation > 6 cm + systemic toxicity.

Management:

NPO, NG tube, aggressive IVF, correct K. IV pip-tazo. Continue IV steroids.
Avoid: opioids, anticholinergics, loperamide, colonoscopy.
Emergent surgical consult. Serial abdominal exams + KUB q12h.
No improvement 24h → subtotal colectomy with end ileostomy.

Teaching Point: Mortality 20-30% with perforation. Do NOT delay surgery. Intern role: serial exams, trend WBC/lactate, escalate immediately.

⚡ Summary

Crohn vs UC

Crohn: transmural, skip lesions, granulomas, fistulas. UC: mucosal, continuous from rectum, crypt abscesses.

Mild UC

Mesalamine (5-ASA) PO/PR. Mild Crohn: budesonide.

Moderate-Severe

Steroids bridge → biologics (anti-TNF, vedolizumab, ustekinumab). Thiopurines steroid-sparing.

Before Biologics

Screen TB (QFT), Hep B, vaccinations. Give live vaccines before starting.

Complications

Toxic megacolon, fistulas/abscesses (Crohn), strictures, colon cancer (surveillance at 8yr).

EIMs

Arthritis, erythema nodosum, pyoderma gangrenosum, uveitis, PSC (UC association).