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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Palliative Care

Goals of Care & Symptom Management

Palliative care is not hospice. It's about aligning treatment with the patient's values at any stage of illness. Every resident should be able to lead a goals-of-care conversation and manage common symptoms at end of life.

🤝 Goals of Care Conversation

When to Have the Conversation

Any new serious diagnosis (advanced cancer, end-stage organ failure, severe dementia)
Significant clinical deterioration or ICU admission
Repeated hospitalizations for chronic progressive disease
"Would you be surprised if this patient died in the next year?" -if no, initiate GOC discussion.

Framework -REMAP

Step	What to Say
R -Reframe	"I want to step back and talk about the big picture of what's going on."
E -Expect emotion	Pause. Acknowledge. "I can see this is hard to hear." NURSE: Name, Understand, Respect, Support, Explore.
M -Map values	"What matters most to you?" "What does a good day look like?" "Are there things worse than death to you?"
A -Align	"Based on what you've told me -that being independent and not suffering are most important -I'd recommend..."
P -Plan	Concrete next steps. Document. Communicate with team. Revisit as things change.

Code Status Discussion

Avoid: "Do you want us to do everything?" (misleading -implies no CPR = giving up)
Better: "If your heart were to stop, CPR involves chest compressions that often break ribs, a breathing tube, and electric shocks. In someone with your condition, the chance of surviving to leave the hospital is about ___%. Given what you've told me about what matters most to you, I would recommend..."
Make a recommendation. Patients want guidance, not just options.

💊 Symptom Management

Symptom	First-Line	Notes
Pain	Morphine (MS Contin) 2–5 mg IV/SC q2–4h PRN or oxycodone 5–10 mg PO q4h. Scheduled + PRN for constant pain.	Titrate to comfort. No ceiling for opioids in end-of-life care. Add adjuncts: acetaminophen (scheduled), gabapentin (neuropathic), dexamethasone (bone mets, inflammation).
Dyspnea	Morphine (MS Contin) 2–4 mg IV/SC q2–4h PRN. Fan to face. Oxygen if hypoxic.	Opioids are the most effective treatment for dyspnea in palliative care. They reduce the sensation of breathlessness centrally. Low doses are safe and don't hasten death Opioids for Dyspnea Trial, 2003. Anxiolytics (lorazepam 0.5–1 mg) if anxiety-driven.
Nausea / vomiting	Ondansetron (Zofran) 4–8 mg IV q6h or haloperidol 0.5–1 mg IV q6h (good for opioid-induced or chemical causes)	Match anti-emetic to mechanism: chemoreceptor trigger zone → haloperidol/ondansetron. GI dysmotility → metoclopramide. Raised ICP → dexamethasone. Vestibular → meclizine.
Terminal secretions ("death rattle")	Glycopyrrolate 0.2–0.4 mg IV/SC q4h or atropine drops 1% SL q4h	Anticholinergics reduce new secretion production. Suctioning is uncomfortable and often futile. Reposition to lateral. Reassure family -the sound is often more distressing to family than to the patient.
Terminal agitation / delirium	Haloperidol (Haldol) 1–2 mg IV/SC q4h. Add lorazepam 1–2 mg if refractory.	Rule out reversible causes first (urinary retention, constipation, pain, medication). If actively dying and refractory → palliative sedation with midazolam or phenobarbital infusion (requires palliative care consult + family discussion).

🔍 Overview

Overview

Palliative care improves quality of life through symptom management, GOC discussions, and psychosocial support. Appropriate at any illness stage -concurrent with curative treatment. Palliative care ≠ hospice.

🧪 Workup

Workup

ESAS symptom scores (0-10)
Functional status -PPS, ECOG
Prognostication -surprise question, PPI
Advance directives review
Psychosocial/spiritual screening

🚨 Management

Management

Pain: WHO ladder + adjuvants (gabapentin, duloxetine, dexamethasone)
Dyspnea: Morphine 2-5mg SL + fan at face + O₂ if hypoxic
Nausea: Ondansetron, haloperidol, metoclopramide
Delirium: Haloperidol 0.5-2mg. Treat reversible causes.
GOC: REMAP framework

💊 Medications

Medications

Drug	Dose	Route	Notes
Morphine	2-5mg PO/SL q2-4h	PO/SL	Pain + dyspnea
Gabapentin	100-900mg TID	PO	Neuropathic pain
Dexamethasone	4-8mg daily	PO/IV	Bone mets, edema, obstruction
Haloperidol	0.5-2mg q4-6h	PO/IV	Nausea + delirium
Glycopyrrolate	0.2mg SL q4h	SL	Secretions
Lorazepam	0.5-1mg SL q4h	SL	Anxiety, agitation

📋 On Rounds

Pimp Questions

An attending asks you to 'make the patient comfortable' -what specific orders do you write?

This is a practical question that catches many interns off guard. A complete comfort care order set includes: (1) Pain: morphine 2–5 mg IV/SC q2h PRN (or current opioid equivalent). Scheduled if constant pain. (2) Dyspnea: morphine 2–4 mg IV/SC q2h PRN (opioids are first-line for dyspnea). (3) Anxiety/agitation: lorazepam 0.5–1 mg IV/SC q4h PRN. (4) Secretions (death rattle): glycopyrrolate 0.2 mg IV/SC q4h PRN or atropine 1% drops SL q4h.

How do you know when to give morphine for dyspnea vs when it will hasten death?

This is one of the most common misconceptions in medicine. Appropriately dosed opioids for dyspnea do NOT hasten death. This was definitively shown by Abernethy et al. (2003): low-dose morphine significantly improved dyspnea without affecting respiratory rate, oxygen saturation, or survival.

What is the REMAP framework for goals of care conversations?

R eframe -Set the stage: "I want to make sure we're on the same page about what's happening." Clarify medical reality without jargon. E xpect emotion -Pause. Let silence work. Acknowledge: "I can see this is really hard." Don't fill silence with medical facts.

How do you manage terminal dyspnea?

Dyspnea is the symptom patients and families fear most in the terminal phase. Management: (1) Morphine is first-line -2-5 mg PO/SL/SQ q2-4h PRN. Reduces central perception of breathlessness without clinically significant respiratory depression at appropriate doses Opioids for Dyspnea Trial, 2003. (2) Fan directed at face -stimulates V2 branch of trigeminal nerve → reduces sensation of air hunger. Evidence-based and free

Clinical Examples

📋 Case 1, Transitioning to Comfort Measures

Patient: 78M with metastatic pancreatic cancer, ECOG 4, declining PO intake × 2 weeks. Family ambivalent about hospice. Current: morphine PCA, ondansetron, IV fluids.

Key findings: PPS 20%. Recurrent SBO from peritoneal carcinomatosis. No further oncologic options. Patient previously expressed "no machines" but no formal advance directive.

Management:

Goals of care conversation using REMAP framework with patient and family
Transition PCA to SQ morphine infusion 2 mg/hr for comfort
D/C IV fluids (contributes to secretions and edema at end of life)
Add glycopyrrolate 0.2 mg SQ q4h PRN for secretions
Hospice referral, inpatient hospice given symptom burden

Teaching point: IV fluids at end of life often worsen symptoms (secretions, edema, dyspnea). Discontinuing is not "giving up", it is symptom management.

📋 Case 2, Refractory Cancer Pain

Patient: 62F with metastatic breast cancer to bone. Pain 9/10 despite oxycodone 40 mg q4h. Somnolent but still reporting severe pain. Cr 2.4 (new).

Key findings: Opioid neurotoxicity (myoclonus, somnolence with persistent pain). Renal failure accumulating active metabolites. Current opioid dose equivalent: 360 MME/day.

Management:

Opioid rotation to hydromorphone (no active renal metabolites), reduce by 25-50% for cross-tolerance
Dexamethasone 4 mg IV q6h for bone pain and peritumoral edema
Radiation oncology consult for palliative XRT to painful metastases
Add gabapentin 100 mg TID (renal dose) for neuropathic component
IV hydration to address prerenal AKI

Teaching point: Opioid rotation is indicated when dose escalation causes toxicity without adequate analgesia. Hydromorphone and fentanyl are preferred in renal failure.

📋 Case 3, Terminal Dyspnea Management

Patient: 85M with end-stage IPF, on 15L high-flow, SpO₂ 78%. DNR/DNI. Progressive dyspnea with visible distress. Family at bedside.

Key findings: Terminal respiratory failure. No reversible cause. Patient previously documented desire for comfort-focused care. PPS 10%.

Management:

Morphine 2 mg IV q15min PRN for dyspnea (titrate to comfort, not respiratory rate)
Fan directed at face, stimulates trigeminal V2 branch, reduces air hunger
Lorazepam 0.5 mg SL q4h PRN for anxiety component
Continue supplemental O₂ for comfort (not to target SpO₂)
Proactive family communication: normalize Cheyne-Stokes breathing, explain death rattle

Teaching point: Morphine for dyspnea does not hasten death at appropriate doses. The principle of double effect permits symptom management even if it theoretically shortens life.

📣 Sample Presentation

One-Liner

"Mr. Washington is a 82-year-old with advanced dementia (FAST 7c), recurrent aspiration pneumonia × 3 admissions this year, and worsening functional status. Family requesting "everything" but primary team is concerned about escalating interventions."

Key Points to Cover on Rounds

Goals of care conversation needed. Current trajectory: advanced dementia with recurrent aspiration -antibiotics are treating the symptom, not the underlying cause. REMAP framework used: R (reframe: "his dementia is causing the pneumonias -antibiotics can't fix that"), E (expect emotion -family is grieving), M (map values: "what would he say if he could tell us?"), A (align), P (plan). Family shared that he previously said he "never wanted to be a burden." After discussion, family chose: comfort-focused care, treat symptoms (dyspnea with morphine 2 mg SL q2h PRN), no more antibiotics for aspiration, no intubation, no ICU. Hospice referral initiated. Palliative care following.

⚡ Summary

Summary

REMAP

Reframe → Expect emotion → Map values → Align → Plan. The gold standard framework for goals of care conversations.

Code Status ≠ GOC

Goals of care is about values and what matters. Code status is one small part. Don't lead with "do you want CPR?" -map values first.

Dyspnea

Morphine (first-line), fan at face, O₂ for hypoxic patients, benzodiazepines for anxiety component. Positioning. Discontinue SpO₂ alarms in comfort care.

Pain

WHO ladder: non-opioid → weak opioid → strong opioid. Adjuvants for neuropathic: gabapentin, duloxetine. Dexamethasone for bone pain, bowel obstruction, cerebral edema.

Prognostication

PPS, ECOG, disease-specific models. Clinicians overestimate survival by 3-5×. Use objective tools. Communicate uncertainty honestly.

When to Consult

Refractory symptoms, complex goals of care, family conflict, transition to hospice, existential/spiritual distress, withdrawal of life-sustaining treatment.

📄 One Pager

Palliative Care · One Pager

Palliative Care

REMAP framework for goals of care. Code status ≠ GOC. Morphine for dyspnea. Fan at face. Consult for refractory symptoms, complex GOC, family conflict.

🧪 REMAP Framework

Reframe (medical reality without jargon). Expect emotion (pause, acknowledge). Map values ("what matters most?"). Align (recommendation based on values). Plan (concrete next steps).

🚨 Symptom Management

Pain: WHO ladder (non-opioid → weak → strong opioid) + adjuvants (gabapentin, duloxetine). Dyspnea: morphine (first-line) + fan at face + O₂ if hypoxic. Nausea: ondansetron, haloperidol. Delirium: haloperidol, lorazepam.

💊 When to Consult

Refractory symptoms despite standard management. Complex goals of care conversations. Family conflict. Transition to hospice. Withdrawal of life-sustaining treatment. Existential/spiritual distress.

💊 Key Drugs

Morphine2-5 mg PO/SL q2-4h PRN (dyspnea + pain)

Gabapentin100-900 mg TID (neuropathic)

Dexamethasone4-8 mg daily (brain mets, obstruction)

Haloperidol0.5-2 mg q4-6h (nausea/delirium)

⚠️ Pitfalls

Jumping to code status without mapping values first
Withholding morphine for dyspnea (effective and safe at appropriate doses)
Not considering palliative care consult until patient is dying
O₂ for non-hypoxic dyspnea (fan at face is equally effective Fan for Dyspnea Trial, 2010)