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.

RoundsRx

Dashboard

Overview

Recent

Rotations

Quick Reference

Antibiotic Guide Analgesia Guide Sedation Guide Bowel Regimen Electrolyte Replacement Pain Management & Conversions Drug Interactions Anticoag Reversal IV Fluid Guide Inotropes Guide Vasopressors Insulin Guide Code Blue & Rapid Response Procedures Guide ECG Interpretation Lab Interpretation Radiology Quick Ref GCS Pocket Card Admission Orders & I-PASS Landmark Trials

Tools

💎 Clinical Pearls 🧠 Pimp Me Quiz 🧮 Clinical Calculators 📰 What's New 🎓 Intern Survival Guide ✅ Rounding Checklists 🩺 Procedure Guides ⚡ Electrolyte Replacement 💧 IV Fluids Guide 🩸 Transfusion Guide 💓 ECG Pattern Guide 🧪 Lab Interpretation Guide 📱 QR Poster 🔗 Resources 🎙️ Channels & Podcasts 🎮 Medical Games 🏛️ Famous Cases 🎬 Media Library

ℹ️ About

Available offline

High-YieldRheumatology

PMR & Giant Cell Arteritis

PMR: bilateral shoulder/hip girdle pain and stiffness in elderly. ESR/CRP markedly elevated. Dramatic response to low-dose prednisone. GCA: temporal headache, jaw claudication, vision loss. Emergent steroids -do not wait for biopsy.

🔍 Overview

PMR vs GCA

Feature	PMR	GCA
Age	> 50 (mean ~72)	> 50 (mean ~72)
Symptoms	Bilateral shoulder/hip girdle pain, morning stiffness > 45 min	New temporal headache, jaw claudication, scalp tenderness, visual changes
Feared complication	15–20% develop GCA	Permanent vision loss (anterior ischemic optic neuropathy)
ESR/CRP	↑↑ (ESR often > 40–50)	↑↑↑ (ESR often > 50–100)
Diagnosis	Clinical + ↑ inflammatory markers + response to steroids	Temporal artery biopsy (gold standard). Temporal artery US.
Treatment	Prednisone (Deltasone) 12.5–25 mg daily	Prednisone (Deltasone) 60 mg daily (or 1g IV methylpred × 3 days if vision threatened)

If GCA is suspected with visual symptoms → start high-dose steroids IMMEDIATELY. Do NOT wait for biopsy. Vision loss is irreversible. Biopsy can be done within 1–2 weeks of starting steroids without affecting results.

PMR vs GCA Comparison

Feature	PMR	GCA
Age	> 50 (mean ~72), women > men	> 50 (mean ~72), women > men
Symptoms	Bilateral shoulder/hip girdle pain, morning stiffness > 45 min, difficulty rising from chair	New temporal headache, jaw claudication, scalp tenderness, vision changes, fever
ESR/CRP	↑↑ (ESR often > 40–50)	↑↑↑ (ESR often > 50–100)
Treatment dose	Low-dose: Prednisone 15–20 mg daily	High-dose: Prednisone 60 mg daily (or IV methylpred 1g × 3d if vision loss)
Biopsy needed?	No -clinical diagnosis + response to steroids	Yes -temporal artery biopsy is gold standard (but do NOT delay treatment)
Duration of treatment	12–18 months taper (relapse common)	1–2 years taper; tocilizumab as steroid-sparing agent

GCA Red Flags -Act Immediately:
• Jaw claudication (most specific symptom for GCA)
• Sudden vision loss (anterior ischemic optic neuropathy -irreversible)
• New headache in patient > 50 years old
• Temporal artery tenderness or nodularity on palpation
• Scalp tenderness (pain when combing hair)

Mnemonic -TEMPORAL for GCA Features:
Temporal headache · ESR elevated (> 50) · Monocular vision loss · Polymyalgia overlap (15–20%) · Older age (> 50) · Response to steroids (dramatic) · Artery biopsy (skip lesions -may need bilateral) · Large vessel involvement (aortitis, subclavian)

🚨 Management

PMR Treatment

Prednisone (Deltasone) 12.5–25 mg daily -dramatic response within 24–72h (if no response, reconsider diagnosis)
Taper over 12–18 months (very slow -relapse is common)
Calcium + Vitamin D + DEXA (steroid-induced osteoporosis prevention)

GCA Treatment

Prednisone (Deltasone) 60 mg daily -immediate start
If vision threatened: Methylprednisolone (Solu-Medrol) 1g IV daily × 3 days, then oral prednisone
Slow taper over 1–2 years
Tocilizumab (Actemra) -IL-6 inhibitor, steroid-sparing agent (GiACTA trial)
Low-dose aspirin -reduces ischemic complications (visual, stroke)

Steroid Taper Guide

Condition	Starting Dose	Taper Schedule
PMR	Prednisone 15–20 mg daily	↓ 2.5 mg every 2–4 weeks to 10 mg, then ↓ 1 mg/month. Total duration 12–18 months. Relapse common -increase dose if flare and re-taper slowly.
GCA (no vision loss)	Prednisone 60 mg daily	↓ 10 mg every 2 weeks to 20 mg, then ↓ 2.5 mg every 2–4 weeks to 10 mg, then ↓ 1 mg/month. Total 1–2 years.
GCA (with vision loss)	IV Methylprednisolone 1g daily × 3 days, then prednisone 60 mg	Same taper as GCA above after completing IV pulse. Add tocilizumab early for steroid-sparing.

🧪 Workup

ESR, CRP -both markedly elevated
CBC -normocytic anemia common, ↑ platelets
Temporal artery biopsy -GCA gold standard. Get ≥ 1 cm sample. Skip lesions mean negative biopsy doesn't exclude GCA.
Temporal artery US -"halo sign" (hypoechoic wall thickening). Increasingly used as first-line in Europe.
CK -normal in PMR (elevated CK → consider myositis instead)
RF, anti-CCP -negative (rule out RA, which can mimic PMR)

💊 Medications

Drug	Dose	Indication
Prednisone (Deltasone)	12.5–25 mg (PMR) / 60 mg (GCA)	First-line both conditions
Methylprednisolone (Solu-Medrol)	1g IV × 3 days	GCA with threatened vision loss
Tocilizumab (Actemra)	162 mg SC weekly	GCA steroid-sparing (GiACTA trial)
Methotrexate (Trexall)	7.5–15 mg weekly	Steroid-sparing in relapsing PMR (limited evidence)
Aspirin	81 mg daily	GCA -reduces ischemic events

📋 On Rounds

Pimp Questions

Should you wait for biopsy results before starting steroids in suspected GCA with vision symptoms?

Absolutely not. Vision loss from GCA (anterior ischemic optic neuropathy) is irreversible. Start high-dose steroids immediately -IV methylprednisolone 1g daily if vision is threatened. Temporal artery biopsy remains diagnostic for up to 2 weeks after starting steroids, so there is no reason to delay treatment. The risk of permanent blindness far outweighs the risk of a short course of steroids if the diagnosis turns out to be wrong.

📋 Case 1, Classic PMR Presentation

Patient: 72F presents with 3 weeks of bilateral shoulder and hip girdle pain, worse in the morning. Morning stiffness lasting 2 hours. Cannot lift arms above head or rise from a chair without assistance. No headache or vision changes.

Labs: ESR 88 mm/hr (↑↑), CRP 45 mg/L (↑↑), CK normal, RF negative, anti-CCP negative.

Management:

Start Prednisone (Deltasone) 15 mg daily
Dramatic response within 24–48 hours -patient can raise arms and rise from chair by day 2
This dramatic response essentially confirms the diagnosis
Begin slow taper: ↓ 2.5 mg every 2–4 weeks to 10 mg, then ↓ 1 mg/month
Start calcium 1000 mg + vitamin D 800 IU daily, order DEXA scan (steroid osteoporosis prevention)
Monitor ESR/CRP q2–4 weeks during taper; counsel patient that relapse is common
Screen for GCA symptoms at every visit: headache, jaw claudication, vision changes

Key lesson: PMR responds dramatically to low-dose prednisone. If no improvement in 24–72h, reconsider the diagnosis. Normal CK rules out myositis; negative RF/anti-CCP rules out RA.

📋 Case 2, GCA with Jaw Claudication

Patient: 68M with 2 weeks of new-onset severe right temporal headache, jaw pain when chewing (jaw claudication), and scalp tenderness. No vision changes. Temporal artery is tender and nodular on palpation.

Labs: ESR 102 mm/hr (↑↑↑), CRP 68 mg/L, platelets 450k, normocytic anemia (Hgb 11.2).

Management:

Start Prednisone (Deltasone) 60 mg daily IMMEDIATELY -do not wait for biopsy
Schedule temporal artery biopsy within 1–2 weeks (steroids do not affect biopsy results for up to 2 weeks)
Start aspirin 81 mg daily (reduces ischemic complications)
Biopsy result: Granulomatous inflammation with giant cells, fragmented internal elastic lamina → confirms GCA
Plan: Taper prednisone (↓ 10 mg q2 weeks to 20 mg, then slow). Consider Tocilizumab (Actemra) for steroid-sparing.
Ophthalmology follow-up -monitor for visual complications

Key lesson: Jaw claudication is the most specific symptom for GCA. Start high-dose steroids immediately. Biopsy confirms but should never delay treatment.

📋 Case 3, PMR Patient with Sudden Vision Loss

Patient: 75F with known PMR on prednisone 10 mg (tapering), presents with sudden painless monocular vision loss in the left eye lasting 20 minutes, now resolved. Reports new left temporal headache × 3 days.

Exam: Left temporal artery tender, diminished pulse. Visual acuity 20/20 right, 20/200 left with afferent pupillary defect.

Labs: ESR 75 (rising from 30 on prior visit), CRP 38.

This is an ophthalmologic emergency:

IV Methylprednisolone 1g NOW -do not wait for any testing. Repeat daily × 3 days.
This is amaurosis fugax (transient ischemic visual loss) → impending permanent vision loss
Urgent ophthalmology consult within hours
After 3 days IV pulse → transition to prednisone 60 mg daily with slow taper
Add Tocilizumab (Actemra) 162 mg SC weekly as steroid-sparing agent
Temporal artery biopsy within 1–2 weeks
Key: 15–20% of PMR patients develop GCA -always screen for GCA symptoms during follow-up

Key lesson: PMR can evolve into GCA. Any new headache, jaw claudication, or vision changes in a PMR patient = emergent GCA workup. Vision loss from GCA is irreversible -IV methylprednisolone must be given immediately.

⚡ Summary

PMR

Age > 50, bilateral shoulder/hip pain, morning stiffness, ↑ ESR/CRP. Prednisone 12.5-25mg. Dramatic response.

GCA

Temporal headache, jaw claudication, vision loss. Prednisone 60mg. IV methylpred if vision threatened.

Vision Loss

Anterior ischemic optic neuropathy. IRREVERSIBLE. Start steroids BEFORE biopsy. Do not wait.

Biopsy

Temporal artery biopsy is gold standard. Skip lesions → can be negative. Treat empirically if high suspicion.

Tocilizumab

IL-6 inhibitor (Actemra). Steroid-sparing in GCA (GiACTA trial). SC weekly.

PMR → GCA

15-20% of PMR patients develop GCA. Monitor for headache, visual symptoms, jaw claudication.