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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Heme/Onc

Lymphoma

Hodgkin and Non-Hodgkin lymphoma recognition, staging workup, and inpatient complication management for medical residents.

🔍 Overview

Overview

Lymphoma = malignancy of lymphocytes. Two major categories: Hodgkin lymphoma (HL) -bimodal peak (20s and 60s), Reed-Sternberg cells, excellent prognosis (cure rate > 80%), contiguous nodal spread. Non-Hodgkin lymphoma (NHL) -much more common (90% of lymphomas), heterogeneous group from indolent (follicular) to aggressive (DLBCL, Burkitt). Key teaching point for interns: you are not expected to manage the chemo -you are expected to recognize lymphoma, complete the staging workup, manage inpatient complications (tumor lysis, febrile neutropenia, cord compression, SVC syndrome), and ensure tissue gets to pathology properly.

🧪 Workup

Workup

Excisional lymph node biopsy -gold standard. NOT fine needle aspiration (FNA). FNA disrupts architecture needed for subtyping. Core needle biopsy acceptable if excisional not feasible.
Pathology: hematoxylin/eosin, immunohistochemistry (CD20, CD3, CD15, CD30, Ki-67), flow cytometry, cytogenetics/FISH
PET/CT -staging (Ann Arbor). PET-avid = aggressive. PET-negative nodes in follicular lymphoma may still be involved.
CT chest/abdomen/pelvis -if PET not available
Bone marrow biopsy -required for NHL staging. Optional for HL with PET/CT (PET replaced BMBx in many centers).
Labs: CBC, CMP, LDH (prognostic, correlates with tumor burden), uric acid (TLS risk), hepatitis B (reactivation risk with rituximab), HIV (lymphoma association), ESR (HL prognostic factor), β2-microglobulin (NHL prognostic)
Echocardiography -baseline EF before anthracycline-containing regimens
Fertility counseling -before starting chemo (especially alkylating agents). Sperm banking / oocyte cryopreservation.

🚨 Management

Management

Hodgkin Lymphoma:
- Early stage (I-II) favorable: ABVD × 2-4 cycles ± involved-site radiation. Cure rate > 90%.
- Advanced stage (III-IV): ABVD × 6 cycles or BV-AVD (brentuximab-AVD). [ECHELON-1, 2018]
- PET-adapted: interim PET after 2 cycles guides therapy intensity.
DLBCL (most common aggressive NHL): R-CHOP × 6 cycles (rituximab + cyclophosphamide/doxorubicin/vincristine/prednisone). Cure rate 60-70%. CNS prophylaxis with intrathecal methotrexate for high-risk (testicular, breast, kidney, adrenal involvement). GELA, 2002
Follicular lymphoma (indolent): Watch-and-wait for asymptomatic low tumor burden. Treat when symptomatic: rituximab ± bendamustine or CHOP. Not curable with standard therapy -median survival > 15 years with serial treatments.
Burkitt lymphoma: Medical emergency -fastest growing human tumor. Hyper-CVAD or similar intensive regimen. TLS prophylaxis critical (aggressive IVF + rasburicase).
Intern responsibilities: TLS prevention, infection prophylaxis, transfusion support, recognize treatment complications, ensure adequate IV access (port placement), fertility counseling documentation.

Key Chemotherapy Regimens

Regimen	Components	Used For	Key Toxicities / Pearls
ABVD	Doxorubicin (Adriamycin), Bleomycin, Vinblastine, Dacarbazine	Hodgkin lymphoma (standard first-line)	Bleomycin pulmonary toxicity, monitor PFTs, stop if DLCO drops > 20%. Doxorubicin → cardiomyopathy. q28-day cycles.
BV-AVD	Brentuximab vedotin + Doxorubicin, Vinblastine, Dacarbazine	Advanced HL (replacing ABVD in some centers)	No bleomycin = no pulmonary toxicity. Higher neuropathy risk. Requires G-CSF prophylaxis. ECHELON-1, 2018
R-CHOP	Rituximab + Cyclophosphamide, Doxorubicin (Hydroxydaunorubicin), Vincristine (Oncovin), Prednisone	DLBCL (standard first-line)	q21-day cycles × 6. Rituximab added ~15% survival benefit. GELA, 2002 Vincristine → peripheral neuropathy (cap at 2 mg).
R-EPOCH	Rituximab + Etoposide, Prednisone, Vincristine, Cyclophosphamide, Doxorubicin (dose-adjusted, continuous infusion)	Double-hit/triple-hit DLBCL, primary mediastinal B-cell lymphoma, Burkitt	96-hour continuous infusion, requires central access. More toxic than R-CHOP but better outcomes for high-risk NHL. Dunleavy, 2013
BR	Bendamustine + Rituximab	Indolent NHL (follicular, marginal zone)	Well-tolerated. Less alopecia and neuropathy than R-CHOP. BRIGHT, 2014

Mnemonic, ABVD side effects: A driamycin = cardiotoxicity (echo before each cycle) · B leomycin = pulmonary fibrosis (PFTs) · V inblastine = myelosuppression · D acarbazine = severe nausea (give strong antiemetics)

💊 Medications

Medications

Drug	Dose/Regimen	Route	Notes
R-CHOP	Rituximab + Cyclo/Doxo/Vincristine/Pred	IV	Standard for DLBCL. q21 days × 6 cycles. GELA, 2002
ABVD	Doxorubicin/Bleomycin/Vinblastine/Dacarbazine	IV	Standard for Hodgkin. q28 days. Monitor PFTs (bleomycin).
Rituximab	375 mg/m²	IV	Anti-CD20. Infusion reactions common (premedicate). Screen HBV (reactivation risk -give entecavir prophylaxis if HBsAg+ or anti-HBc+).
Brentuximab vedotin	1.2 mg/kg q2wk	IV	Anti-CD30 ADC. HL + some NHL. Peripheral neuropathy. ECHELON-1, 2018
TMP-SMX	1 DS tab Mon/Wed/Fri	PO	PCP prophylaxis during and 6 months after R-CHOP/ABVD.
Acyclovir	400 mg BID	PO	VZV prophylaxis during chemo.
Entecavir	0.5 mg daily	PO	HBV prophylaxis if anti-HBc positive + receiving rituximab.

🏥 Rounds

Pimp Questions

❓ Why should you NOT do FNA for suspected lymphoma?

FNA provides individual cells but destroys the lymph node architecture needed for subtyping. Lymphoma diagnosis requires: architecture assessment (follicular vs diffuse), immunohistochemistry panel (CD20, CD3, CD15, CD30, Ki-67), and often FISH/cytogenetics. An excisional biopsy (or at minimum core needle biopsy) provides all of this. FNA can suggest lymphoma but cannot subtype it.

❓ What are B symptoms and why do they matter?

B symptoms: (1) Fever > 38°C, (2) drenching night sweats, (3) weight loss > 10% in 6 months. They indicate higher disease burden and worse prognosis. In Hodgkin lymphoma, B symptoms upstage the disease (Stage IIB is treated like advanced stage). Pruritus and alcohol-induced pain are associated symptoms but not technically B symptoms.

❓ Why must you screen for hepatitis B before starting rituximab?

Rituximab (anti-CD20) depletes B cells → HBV reactivation risk. Even patients with resolved infection (HBsAg−, anti-HBc+) can reactivate. Reactivation can cause fulminant hepatic failure. Screen ALL patients with HBsAg, anti-HBs, anti-HBc. If anti-HBc positive → start entecavir prophylaxis and monitor HBV DNA monthly. Continue prophylaxis 12 months after last rituximab dose.

❓ What is the difference between Hodgkin and Non-Hodgkin lymphoma?

Hodgkin: Reed-Sternberg cells (CD15+/CD30+), bimodal age (20s, 60s), contiguous spread (node to adjacent node), excellent prognosis (> 80% cure), mediastinal mass common. NHL: much more common (90%), diverse subtypes, non-contiguous spread, prognosis varies (follicular = indolent/incurable vs DLBCL = aggressive/curable vs Burkitt = ultra-aggressive).

❓ When do you "watch and wait" vs treat lymphoma?

Watch and wait is appropriate for asymptomatic follicular lymphoma with low tumor burden. Criteria for treatment: B symptoms, cytopenias from marrow involvement, bulky disease (> 7 cm), organ compression, rapid growth, or patient preference. Treating asymptomatic follicular lymphoma does not improve survival. For ALL aggressive lymphomas (DLBCL, Burkitt, HL with B symptoms), treatment should start promptly.

❓ What fertility counseling is needed before starting lymphoma chemotherapy?

Alkylating agents (cyclophosphamide, procarbazine) and radiation cause gonadal toxicity. Men: sperm banking before first cycle. Women: oocyte/embryo cryopreservation (requires 2 weeks for ovarian stimulation -discuss urgency with oncology). ABVD has lower gonadal toxicity than BEACOPP. Document the fertility discussion -it is a quality measure and medicolegal requirement.

❓ What is tumor lysis syndrome (TLS) and how do you prevent it in lymphoma patients?

TLS occurs when rapid tumor cell death releases intracellular contents: hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia. Can cause acute kidney injury, cardiac arrhythmias, seizures, and death. Highest risk: Burkitt lymphoma (fastest-growing human tumor), DLBCL with high tumor burden, high LDH, bulky disease. Prevention: (1) Aggressive IV hydration (200-250 mL/hr). (2) Allopurinol (prevents new uric acid formation) for intermediate risk. (3) Rasburicase (breaks down existing uric acid) for high risk,do NOT give to G6PD-deficient patients (hemolysis). (4) Monitor K, phos, Ca, uric acid, creatinine q6-8h for 48-72h after starting chemo. Avoid alkalinizing urine (promotes calcium phosphate precipitation).

❓ What is the Deauville score and how is it used in lymphoma management?

The Deauville score (1-5) is used to interpret interim and end-of-treatment PET/CT in lymphoma. It compares FDG uptake in residual lesions to reference structures: 1 = no uptake. 2 = uptake ≤ mediastinum. 3 = uptake > mediastinum but ≤ liver. 4 = uptake moderately > liver. 5 = markedly > liver or new lesions. Deauville 1-3 = complete metabolic response (good). Deauville 4-5 = residual disease (may need treatment change). In Hodgkin lymphoma, interim PET (after 2 cycles) guides therapy: Deauville 1-3 may allow de-escalation (drop bleomycin); Deauville 4-5 may require escalation to BEACOPP or BV-AVD. RATHL, 2016

Clinical Examples

📋 Case 1, Classic Hodgkin Lymphoma with Mediastinal Mass

Patient: 24F presents with 2 months of dry cough, dyspnea on exertion, and a 15 lb weight loss. She also reports drenching night sweats requiring changing her sheets nightly. No fevers.

Exam: Non-tender left supraclavicular lymphadenopathy (2.5 cm, rubbery). No hepatosplenomegaly.

Labs: WBC 11K, Hgb 10.8, ESR 55, LDH 280 (mildly elevated). HIV negative.

Imaging: CXR: large anterior mediastinal mass. CT chest: 12 cm mediastinal mass with bilateral hilar lymphadenopathy. PET/CT: intensely FDG-avid mediastinal, bilateral hilar, and left supraclavicular nodes. No disease below diaphragm.

Biopsy: Excisional biopsy of supraclavicular node: Reed-Sternberg cells in background of mixed inflammatory infiltrate. IHC: CD15+, CD30+, CD20−. Consistent with nodular sclerosis classical Hodgkin lymphoma.

Staging: Stage IIB (bilateral hilar = still same side of diaphragm, B symptoms present). Despite being stage II, B symptoms → treated as advanced stage.

Management:

Pre-chemo: Echo (EF 62%), PFTs (baseline DLCO normal), HBV screen negative, fertility counseling → oocyte cryopreservation.
ABVD × 6 cycles. Interim PET after cycle 2: Deauville 2 (complete metabolic response).
Bleomycin dropped after cycle 2 per PET-adapted approach. RATHL, 2016
End-of-treatment PET: Deauville 1. Complete remission.

Teaching Point: Nodular sclerosis is the most common HL subtype, classically presenting in young women with a mediastinal mass. B symptoms upstage IIA to advanced-stage treatment protocols. PET-adapted therapy allows de-escalation to reduce bleomycin toxicity.

📋 Case 2, Diffuse Large B-Cell Lymphoma (DLBCL)

Patient: 67M presents with 3 weeks of rapidly enlarging right neck mass, fatigue, and unintentional 12 lb weight loss. No night sweats or fevers.

Exam: 5 cm firm, non-tender right cervical mass. Left axillary lymphadenopathy (3 cm). Spleen palpable 2 cm below costal margin.

Labs: WBC 6K, Hgb 11.2, LDH 580 (elevated, correlates with tumor burden), uric acid 9.2. HBsAg negative, anti-HBc positive.

Imaging: PET/CT: FDG-avid bilateral cervical, axillary, retroperitoneal nodes + splenic involvement. No bone marrow uptake on PET.

Biopsy: Core needle biopsy: diffuse proliferation of large CD20+ B cells, Ki-67 > 80%. BCL2+ by IHC. FISH: no MYC rearrangement (rules out double-hit). Diagnosis: DLBCL, GCB subtype.

Staging: Stage IIIA (nodes both sides of diaphragm + spleen, no B symptoms).

Management:

Anti-HBc positive → start entecavir prophylaxis before rituximab (HBV reactivation risk).
Echo baseline (EF 58%). TLS risk: intermediate → allopurinol + aggressive hydration.
R-CHOP × 6 cycles (q21 days). GELA, 2002
IPI score calculated (age > 60, elevated LDH, stage III = IPI 3, high-intermediate risk).
End-of-treatment PET: Deauville 2. Complete remission. Surveillance CT q6 months × 2 years.

Teaching Point: DLBCL is the most common aggressive NHL. R-CHOP is curative in 60-70%. Always check anti-HBc before rituximab, even resolved HBV can reactivate fatally. LDH correlates with tumor burden and is prognostic (part of IPI score).

📋 Case 3, Follicular Lymphoma

Patient: 55F found to have bilateral inguinal lymphadenopathy on routine physical exam. Completely asymptomatic. No B symptoms, no fatigue, no cytopenias.

Exam: Bilateral inguinal nodes (2-3 cm), rubbery, non-tender. No other palpable lymphadenopathy. No hepatosplenomegaly.

Labs: CBC normal. LDH normal. β2-microglobulin mildly elevated (3.1).

Imaging: PET/CT: mildly FDG-avid bilateral inguinal and external iliac nodes (SUVmax 4). Small mesenteric nodes. No bulky disease.

Biopsy: Excisional inguinal node biopsy: follicular architecture with small cleaved cells. CD20+, CD10+, BCL2+. Ki-67 15%. Grade 1-2. Diagnosis: follicular lymphoma, grade 1-2.

Staging: Stage IIIA (nodes both sides of diaphragm, no symptoms).

Management:

Low tumor burden (GELF criteria not met: no node > 7 cm, no B symptoms, no cytopenias, no organ compression).
Watch and wait, no treatment initiated. Active surveillance with exam + labs q3 months, CT q6 months.
Patient counseled: follicular lymphoma is not curable with standard therapy, but median survival is > 15-20 years with serial treatments. Early treatment does NOT improve overall survival.
Criteria to initiate treatment: development of B symptoms, cytopenias, bulky disease (> 7 cm), rapid growth, organ compression, or patient preference.
When treatment needed: options include rituximab monotherapy, BR (bendamustine-rituximab), or R-CHOP.

Teaching Point: Follicular lymphoma is the classic "watch and wait" lymphoma. Asymptomatic patients with low tumor burden should NOT be treated. This is one of the hardest conversations in oncology, telling a patient they have cancer but you are not going to treat it. Treatment does not improve OS in asymptomatic disease, and each line of therapy has toxicity.

Monitoring

CBC before each cycle -delay if ANC < 1000 or platelets < 100K
Interim PET/CT -after 2 cycles (HL) or 3-4 cycles (NHL). Complete metabolic response = Deauville 1-3.
Echo q3 months during anthracycline therapy (doxorubicin cardiotoxicity)
PFTs during bleomycin therapy -stop if DLCO drops > 20% from baseline
HBV DNA monthly if on rituximab with HBV risk (reactivation can be fatal)
LDH + uric acid before each cycle -rising LDH suggests progression; high uric acid = TLS risk
Post-treatment surveillance: CT q6 months × 2 years, then annually × 5 years. PET only if suspected relapse (not for routine surveillance).

Sample Presentation

Mr. Rodriguez is a 28-year-old man presenting with 6 weeks of painless left cervical lymphadenopathy (3 cm), night sweats, 10 lb weight loss, and pruritus. No fevers. No cough. Exam: firm, rubbery, non-tender left cervical and left supraclavicular nodes. No hepatosplenomegaly. Labs: WBC 9K, Hgb 11.8, LDH 320 (elevated), ESR 45. CXR: mediastinal widening.

Key Points: Young male with B symptoms (weight loss > 10%, night sweats) + painless lymphadenopathy + mediastinal mass = classic Hodgkin lymphoma until proven otherwise. Next step: excisional lymph node biopsy (NOT FNA). Expect Reed-Sternberg cells (CD15+/CD30+). Staging with PET/CT. ABVD × 2-6 cycles based on stage. Cure rate > 80%.

📋 Summary

Summary

Hodgkin

Reed-Sternberg cells. Bimodal. ABVD. Cure > 80%. B symptoms upstage.

DLBCL

Most common aggressive NHL. R-CHOP × 6. Cure 60-70%. CNS prophylaxis if high-risk.

Follicular

Indolent. Watch-and-wait if asymptomatic. Not curable but median survival > 15y.

Workup

Excisional biopsy (never FNA). PET/CT staging. BMBx. LDH, HBV, HIV, echo, PFTs.

Intern Job

TLS prevention. Infection prophylaxis. Transfusion. Recognize complications. Fertility counseling.

Pearl

Screen HBV before rituximab. Don't FNA a node. B symptoms matter. Fertility talk before chemo.

📄 One Pager

One-Pager

Lymphoma

Hodgkin vs Non-Hodgkin

Key Regimens

HL: ABVD (or BV-AVD). DLBCL: R-CHOP. Follicular: rituximab ± bendamustine. Burkitt: intensive regimen + TLS prophylaxis (rasburicase).

Before Starting Chemo

Echo (baseline EF). PFTs (if bleomycin). HBV screen (rituximab reactivation risk). HIV. Fertility counseling. Port placement. TLS risk assessment.

Trials

GELA 2002 (R-CHOP for DLBCL) · ECHELON-1 2018 (BV-AVD for HL) · RELEVANCE (rituximab + lenalidomide for follicular)