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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ChronicRheumatology

Rheumatoid Arthritis

Symmetric inflammatory polyarthritis of the small joints. Early aggressive treatment with DMARDs prevents joint destruction. "Treat to target" -remission or low disease activity. Know the extra-articular manifestations and drug monitoring.

🔍 Overview

Diagnosis

Symmetric polyarthritis of small joints: MCPs, PIPs, wrists, MTPs. Spares DIPs (DIP involvement → think OA or psoriatic).
Morning stiffness > 30 minutes (improves with use -opposite of OA which worsens with use)
Labs: RF (sensitive ~70%, not specific), anti-CCP (most specific ~95%), ESR, CRP elevated. Anti-CCP negative RA exists (seronegative -harder to diagnose).
Imaging: X-ray hands/feet -periarticular osteopenia, joint space narrowing, marginal erosions (late). US or MRI for early synovitis detection.

💊 Treatment

Line	Drug	Monitoring	Key Notes
1ST LINE	Methotrexate (Trexall) 15–25 mg PO/SC weekly	CBC, LFTs, Cr q3 months. CXR at baseline (ILD screening).	Cornerstone of RA treatment. Always give with folic acid 1 mg daily (reduces GI/oral side effects). Teratogenic -contraception required. Avoid in liver disease, heavy EtOH. Hold for surgery (infection risk).
ADD-ON	Hydroxychloroquine (Plaquenil) 200–400 mg daily	Annual eye exam (retinal toxicity after 5 years)	Mild disease or combination therapy. Very safe. Also used in SLE.
ADD-ON	Sulfasalazine 2–3g daily	CBC, LFTs	Triple therapy (MTX + HCQ + SSZ) is as effective as many biologics for moderate RA.
BIOLOGIC	TNF inhibitors (adalimumab, etanercept, infliximab)	Screen for TB (QuantiFERON), Hep B/C, HIV before starting. Annual TB screening.	Add to MTX if inadequate response. Hold for active infection and peri-operatively. Risk: TB reactivation, serious infections, lymphoma (small increase).
BIOLOGIC	IL-6 inhibitor (tocilizumab), JAK inhibitor (tofacitinib, upadacitinib)	CBC, LFTs, lipids. JAKi: screen for VTE risk.	Alternatives if TNFi fails. JAK inhibitors: FDA black box for VTE, MACE, and malignancy in age > 65 ORAL Surveillance, 2022 -use after biologic failure.

Screen for TB before ANY biologic or JAK inhibitor. TNF is critical for granuloma maintenance -TNF inhibition can reactivate latent TB. QuantiFERON-Gold or PPD. If positive → treat latent TB (isoniazid × 9 months or rifampin × 4 months) for ≥ 1 month before starting biologic.

🚨 Management

Management

Goal: Remission or low disease activity within 6 months -treat-to-target TICORA, 2004. Check DAS28 or CDAI q3 months. Adjust until target reached.
First-line: Methotrexate 15-25 mg/week PO or SQ + folic acid 1 mg daily (reduces side effects without reducing efficacy). Start 15 mg, escalate to 25 mg by week 8 if tolerated. SQ has better bioavailability at higher doses.
Bridge therapy: Low-dose prednisone ≤ 10 mg daily while waiting for DMARD effect (4-12 weeks). Taper ASAP -goal is OFF steroids. Depo-medrol intra-articular for 1-2 dominant joints.
If inadequate at 3 months on max MTX: Add biologic DMARD:
- TNF inhibitors (adalimumab, etanercept, infliximab) -most commonly used first-line biologics
- Non-TNF biologics: tocilizumab (IL-6), abatacept (T-cell co-stim), rituximab (anti-CD20, especially if RF/CCP positive)
- JAK inhibitors: tofacitinib, upadacitinib, baricitinib -oral, fast onset. FDA box warning: ↑ VTE, MACE, malignancy in pts > 50 with CV risk factors ORAL Surveillance, 2022
Pre-biologic checklist: QuantiFERON (TB), HBV/HCV serologies, update vaccines (no live vaccines on biologics), CXR
Monitoring on MTX: CBC + CMP q4-8 weeks first 3 months, then q8-12 weeks. Hold MTX if transaminases > 2× ULN. Avoid alcohol. Contraception required (teratogenic -hold 3 months before conception).

📋 On Rounds

An RA patient on methotrexate is admitted with pneumonia. What do you do with the methotrexate?

Hold methotrexate during active infection. MTX is an immunosuppressant -continuing it impairs the patient's ability to fight the infection. Also hold if: surgery planned (increased wound healing complications), new cytopenias (check CBC), or rising LFTs. Resume once infection is treated and patient is clinically improving. Do NOT hold hydroxychloroquine -it has minimal immunosuppression and should be continued through illness.

Why do you check hepatitis B and TB before starting a biologic in RA?

Biologics (TNF inhibitors like adalimumab, infliximab; IL-6 inhibitors like tocilizumab; B-cell depleting agents like rituximab) cause profound immunosuppression that can reactivate latent infections. Hepatitis B: TNF inhibitors can cause fatal HBV reactivation (fulminant hepatitis) -check HBsAg, anti-HBs, anti-HBc. If HBsAg+ or anti-HBc+ → start antiviral prophylaxis (entecavir or tenofovir) before starting biologic.

What is the treat-to-target approach in RA?

Goal: remission or low disease activity within 6 months. Start methotrexate (first-line DMARD, 15-25 mg/week + folic acid 1 mg daily). Reassess at 3 months: if not at target → add or switch therapy. Options: (1) Add biologic (TNFi: adalimumab, etanercept; or non-TNF: tocilizumab, abatacept, rituximab), (2) Add JAK inhibitor (tofacitinib, upadacitinib -oral, convenient, but risk of VTE/MACE at higher doses).

What monitoring is needed for a patient on methotrexate for RA?

Before starting: CBC, CMP (LFTs, Cr), hepatitis B/C serologies, chest X-ray (baseline for pulmonary toxicity), pregnancy test (teratogenic -Category X). Ongoing monitoring (every 2-3 months initially, then q3-6 months when stable): CBC (pancytopenia -bone marrow suppression), LFTs (hepatotoxicity -hold if AST/ALT > 2× ULN), Cr (renal clearance -dose reduce if CrCl declining).

What is the most specific antibody for RA?

Anti-CCP (anti-citrullinated peptide) -~95% specific. Can be positive years before symptoms. High titer predicts more aggressive, erosive disease. RF is sensitive (~80%) but not specific.

A patient with RA on methotrexate for 3 months still has active disease. What's next?

Add a biologic DMARD (TNF inhibitor like adalimumab, or non-TNF like tocilizumab/abatacept). Per treat-to-target guidelines, if target not met at 3 months → escalate. If still not met at 6 months → switch class.

Why are DOACs inferior to warfarin in antiphospholipid syndrome?

The TRAPS trial [2018] was stopped early because rivaroxaban had significantly more arterial thrombotic events than warfarin in triple-positive APS. ASTRO-APS confirmed. The mechanism: DOACs don't adequately block the thrombin generation pathway in APS.

Which RA medication is safe in pregnancy?

Sulfasalazine and hydroxychloroquine are safe. Certolizumab (Fc-free anti-TNF) has minimal placental transfer. Methotrexate is category X -stop 3 months before conception. Leflunomide has a very long half-life -needs cholestyramine washout.

Clinical Examples

📋 Case 1, Methotrexate Pneumonitis

Patient: 56-year-old woman with seropositive RA on methotrexate 20 mg/week × 2 years, presenting with 1 week of progressive dyspnea, dry cough, and low-grade fever. No sick contacts.

Key findings: CT chest: bilateral ground-glass opacities. PFTs: restrictive pattern with reduced DLCO. BAL: lymphocyte predominance, cultures negative. Mild eosinophilia.

Management:

Stop methotrexate immediately, methotrexate pneumonitis (hypersensitivity, not dose-dependent)
Prednisone 1 mg/kg daily with taper over 4-6 weeks
Rule out PJP, RA-ILD, and infection
Do NOT rechallenge with MTX, switch to leflunomide or biologic

Teaching point: MTX pneumonitis can occur at any time. It is a hypersensitivity reaction, not dose-related. Acute onset and temporal relationship to MTX distinguishes it from RA-ILD. Never rechallenge.

📋 Case 2, Biologic Initiation with Latent TB

Patient: 48-year-old man with RA, inadequate response to methotrexate 25 mg/week × 6 months (DAS28 = 5.1). Rheumatology recommends adalimumab. Pre-biologic screening: QuantiFERON POSITIVE. CXR normal.

Key findings: Latent TB identified. No active disease. HBsAg negative, anti-HBc negative.

Management:

Start latent TB treatment: isoniazid 300 mg daily + pyridoxine × 9 months
Delay biologic by ≥ 1 month after starting TB treatment
Continue methotrexate; bridge with low-dose prednisone if needed
Monitor LFTs on INH + MTX (both hepatotoxic)

Teaching point: TNF-alpha maintains granuloma integrity. TNF inhibitors → granuloma breakdown → disseminated TB. Always screen with QuantiFERON before ANY biologic.

📋 Case 3, RA Flare During Active Infection

Patient: 63-year-old woman on adalimumab + methotrexate admitted with cellulitis. Also has active RA flare with 6 swollen joints.

Key findings: WBC 14,000, CRP 12. Blood cultures negative. Cellulitis without abscess.

Management:

Hold adalimumab AND methotrexate during active infection
Continue hydroxychloroquine, minimal immunosuppression, safe during illness
Treat cellulitis: IV cefazolin → oral cephalexin
For RA flare: prednisone 20 mg × 5 days (acceptable during infection at moderate doses)
Resume biologics only after infection fully resolved

Teaching point: Holding biologics during infection is mandatory. HCQ is the one DMARD safe to continue through most infections. Do not restart biologics too early, ensure complete clinical resolution.

📣 Sample Presentation

One-Liner

"Mrs. Patterson is a 42-year-old with seropositive RA on methotrexate 20 mg weekly who presents with 3 weeks of worsening bilateral hand and wrist swelling and morning stiffness >2 hours. CRP 4.8, ESR 62. Active flare."

Key Points to Cover on Rounds

RA flare on methotrexate monotherapy. DAS28 score indicates high disease activity. Treatment: prednisone 20 mg PO burst × 5 days for acute symptom control. Rheumatology consulted -plan to add biologic (adalimumab or tocilizumab). Pre-biologic workup: QuantiFERON (TB), HBsAg, anti-HBs, anti-HBc (hepatitis B reactivation risk), hepatitis C, CBC, LFTs. Immunizations: flu, pneumococcal, COVID -updated before starting biologic. Plan: taper prednisone, initiate biologic when screening complete, repeat CRP in 4 weeks.

Monitoring Parameters -Discharge Planning Checklist

Parameter	Frequency	Target / Action
Vitals	q4h floor, q1–2h ICU	HR, BP, RR, SpO₂, Temp -notify for significant deviations
Labs (BMP, CBC)	Daily AM or as indicated	Trend Cr, K⁺, WBC, Hgb -adjust treatment based on trajectory
Disease-specific markers	Per clinical context	See Overview and Management tabs for condition-specific targets
I&Os	Strict if volume-sensitive	UOP ≥ 0.5 mL/kg/hr. Net fluid balance guides diuresis or resuscitation.
Telemetry	Continuous if indicated	Arrhythmia detection. Discontinue when no longer indicated (reduces alarm fatigue).
Clinical response	Each assessment	Symptom improvement, functional status, appetite, mental status -the exam matters more than labs

Don't just order labs -act on them. Every lab should have a clear clinical question. If you wouldn't change management based on the result, don't order it.

Monitoring

DAS28 or CDAI score q3 months -standardized disease activity tracking. Adjust treatment to target.
CBC, CMP (LFTs, Cr) q8-12 weeks on MTX -hepatotoxicity, cytopenias, renal function
ESR + CRP q3-6 months -inflammatory marker trending
X-rays hands/feet annually first 3 years -structural damage progression
Lipids -check at baseline and periodically on tocilizumab and JAK inhibitors
Infection vigilance -on biologics/JAKi: annual flu + pneumococcal vaccines (inactivated only). Low threshold for workup of fever.
Cervical spine X-ray -if surgery planned (atlantoaxial subluxation risk in severe RA)
CV risk assessment -RA is an independent CV risk factor. Multiply Framingham score by 1.5.

🧪 Workup

Workup

RF (rheumatoid factor) -sensitive (~80%) but not specific. Also positive in Sjögren's, HCV, endocarditis, elderly.
Anti-CCP (anti-citrullinated peptide) -most specific for RA (~95%). Can be positive years before symptoms. High titer = more aggressive/erosive disease.
ESR + CRP -baseline disease activity markers. CRP more responsive to treatment changes.
CBC, BMP, LFTs -baseline before starting DMARDs. Anemia of chronic disease common.
Hepatitis B/C serologies -before methotrexate or biologics (reactivation risk)
QuantiFERON/PPD -latent TB screening before biologics (especially TNF inhibitors)
X-rays of hands/feet -baseline. Periarticular osteopenia, joint space narrowing, marginal erosions. Erosions within first 2 years in 70% untreated.
Musculoskeletal ultrasound -synovitis, erosions earlier than X-ray. Increasingly used for subclinical inflammation.
Joint distribution -symmetric small joint polyarthritis (MCPs, PIPs, wrists, MTPs). Spares DIPs (DIP involvement = think OA or psoriatic arthritis).

💊 Medications

Medications

Drug	Dose	Route	Notes
Conventional DMARDs
Methotrexate	15-25 mg/week	PO/SQ	First-line DMARD -anchor drug. Start with folic acid 1 mg daily (reduces GI + oral ulcer side effects). SQ better absorbed at doses > 15 mg. Monitor: CBC, LFTs, Cr q8-12 weeks. Teratogenic (category X) -stop 3 months before conception.
Leflunomide	20 mg daily	PO	Alternative to MTX if intolerant. Pyrimidine synthesis inhibitor. Very long half-life (14 days). Cholestyramine washout if toxicity or pregnancy planned.
Sulfasalazine	1-1.5g BID	PO	Mild RA or combination therapy. Safe in pregnancy (one of few DMARDs). Check G6PD.
Hydroxychloroquine	200-400 mg daily	PO	Mild RA, often combined with MTX. Annual retinal screening after 5 years.
Biologic DMARDs -add if inadequate response to MTX at 3 months
Adalimumab	40 mg SQ q2 weeks	SQ	TNF inhibitor. Most prescribed biologic. Screen TB/HBV before starting. Risk: serious infections, reactivation TB, lymphoma (rare).
Etanercept	50 mg SQ weekly	SQ	TNF inhibitor (receptor fusion protein). Less TB reactivation risk than monoclonal anti-TNFs. Does NOT work for IBD (unlike other TNFis).
Tocilizumab	162 mg SQ weekly or 8 mg/kg IV monthly	SQ/IV	Anti-IL-6 receptor. Suppresses CRP (can mask infection). Monitor lipids (LDL ↑), neutrophils, LFTs. Risk of GI perforation.
Abatacept	125 mg SQ weekly	SQ	T-cell costimulation blocker (CTLA-4 Ig). Generally well tolerated. Good safety profile in elderly.
Rituximab	1000 mg IV × 2 doses (day 1 + day 15)	IV	Anti-CD20 (B-cell depletion). Usually reserved for refractory RA after TNFi failure. Screen HBV. Monitor immunoglobulins.
JAK Inhibitors -oral targeted synthetic DMARDs
Tofacitinib	5 mg BID	PO	JAK1/3 inhibitor. FDA boxed warning: increased CV events + malignancy vs TNFi in patients ≥ 50 with CV risk ORAL Surveillance, 2022. Use after TNFi failure.
Upadacitinib	15 mg daily	PO	Selective JAK1 inhibitor. Superior to adalimumab in SELECT-COMPARE. Same FDA boxed warning class. VTE risk.

Treat-to-target: reassess disease activity (DAS28, CDAI) every 3 months. If target not met at 3 months → escalate. If target not met at 6 months → switch class. Goal: remission or low disease activity.

⚡ Summary

Summary

Diagnosis

≥ 6 points on ACR/EULAR 2010 criteria. Joint involvement + serology (RF, anti-CCP) + acute phase (CRP, ESR) + duration ≥ 6 weeks.

First-Line DMARD

Methotrexate 15-25 mg/week + folic acid 1 mg daily. Monitor: CBC, LFTs, Cr every 2-3 months.

Treat-to-Target

Goal: remission or low disease activity within 6 months. Reassess q3 months. If not at target → add biologic or JAK inhibitor.

Biologics

TNFi (adalimumab, etanercept), IL-6 (tocilizumab), T-cell (abatacept), B-cell (rituximab), JAKi (tofacitinib, upadacitinib).

Pre-Biologic Screen

QuantiFERON (TB), HBV/HCV serologies, CBC, LFTs, CXR. Update vaccines before starting. Annual flu + pneumococcal.

Don't Miss

Atlantoaxial instability (subluxation) -flexion/extension C-spine X-ray before intubation. Increased CV risk. Screen for ILD.

📄 One Pager

Rheumatology · One Pager

Rheumatoid Arthritis -Quick Reference Card

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RHEUMATOID ARTHRITIS -AT A GLANCE

📋 Diagnosis: ACR/EULAR 2010 criteria (≥ 6 points). Symmetric small joint polyarthritis + RF/anti-CCP + elevated ESR/CRP + duration ≥ 6 weeks. Spares DIPs.
🧪 Workup: RF, anti-CCP (most specific ~95%), ESR, CRP, CBC, BMP, LFTs, HBV/HCV serologies, QuantiFERON (before biologics), hand/foot X-rays.
⚡ First-Line: Methotrexate 15-25 mg/week + folic acid 1 mg daily. Reassess q3 months. If not at target → add biologic.
💊 Biologics: TNFi (adalimumab, etanercept) · IL-6 (tocilizumab) · T-cell (abatacept) · B-cell (rituximab) · JAKi (tofacitinib, upadacitinib, after TNFi failure).
📈 Monitor: DAS28/CDAI q3 months. CBC + LFTs + Cr q8-12 weeks on MTX. Annual retinal exam on HCQ. QuantiFERON before biologics.
⚠️ Don't Miss: Atlantoaxial instability (C-spine X-ray before intubation). Increased CV risk. Screen for ILD. MTX is category X.