We will have our end rotation quiz with doc redulla on tuseday Topics are Jaundice Pneumonia (RTI) Sepsis UTI Seizure Gastroenteritis
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π©Ί End-Rotation Quiz Study Guide
Topics: Jaundice | Pneumonia | Sepsis | UTI | Seizure | Gastroenteritis
1. JAUNDICE
Definition
Yellowish discoloration of skin, sclera, and mucous membranes due to hyperbilirubinemia (serum bilirubin > 2β3 mg/dL).
Classification & Etiology
| Type | Bilirubin | Causes |
|---|---|---|
| Pre-hepatic | Unconjugated (indirect) β | Hemolysis (G6PD, sickle cell, malaria), ineffective erythropoiesis |
| Hepatic | Both β | Hepatitis (viral, alcoholic, autoimmune), cirrhosis, Wilson's disease |
| Post-hepatic | Conjugated (direct) β | Choledocholithiasis, cholangiocarcinoma, pancreatic head CA, biliary stricture |
Neonatal Jaundice (Physiologic vs. Pathologic)
- Physiologic: Appears day 2β3, peaks day 4β5, resolves by day 14 (term); due to immature hepatic conjugation
- Pathologic: Appears < 24 hrs, bilirubin rises > 5 mg/dL/day, direct bili > 2 mg/dL β think hemolytic disease, sepsis, biliary atresia
Workup
- Total & direct bilirubin, LFTs (ALT, AST, ALP, GGT)
- CBC, peripheral smear, reticulocyte count
- Abdominal ultrasound (biliary obstruction)
- Hepatitis panel if indicated
Management
| Cause | Management |
|---|---|
| Hemolysis | Treat underlying cause |
| Viral hepatitis | Supportive; antivirals for HBV/HCV |
| Obstruction | ERCP, surgery |
| Neonatal (unconjugated) | Phototherapy; exchange transfusion if severe |
| Breastfeeding jaundice | Continue breastfeeding; phototherapy if TSB high |
2. PNEUMONIA (RTI)
Definition
Acute infection of the pulmonary parenchyma β classified as CAP, HAP (β₯48h after admission), or VAP.
Common Pathogens
| Type | Typical | Atypical |
|---|---|---|
| CAP | S. pneumoniae (MC), H. influenzae | Mycoplasma, Chlamydophila, Legionella |
| HAP/VAP | Pseudomonas, S. aureus (MRSA), GNRs | β |
Clinical Features
- Symptoms: Fever, cough (productive), pleuritic chest pain, dyspnea
- Signs: Tachypnea, tachycardia, dullness to percussion, bronchial breath sounds, egophony, crackles
Diagnosis
- CXR: Lobar/segmental consolidation (typical) or bilateral interstitial infiltrates (atypical)
- CBC: Leukocytosis
- Sputum Gram stain & culture
- Blood cultures (moderate-severe)
- Urine antigen (Legionella, S. pneumoniae)
- Severity scoring: CURB-65 (Confusion, Urea >7, RR β₯30, BP <90/60, Age β₯65) β score 0β1: outpatient; 2: inpatient; β₯3: ICU
Management
| Setting | Regimen |
|---|---|
| Outpatient (no comorbid) | Amoxicillin OR Azithromycin/Doxycycline |
| Outpatient (comorbid) | Amox-clavulanate + Macrolide OR Respiratory FQ (Levofloxacin) |
| Inpatient (non-ICU) | Ξ²-lactam + Macrolide OR Respiratory FQ |
| Inpatient (ICU) | Ξ²-lactam + Azithromycin Β± anti-MRSA (if risk) |
| MRSA risk | Add Vancomycin or Linezolid |
3. SEPSIS
Definitions (Sepsis-3, 2016)
| Term | Definition |
|---|---|
| Sepsis | Life-threatening organ dysfunction from dysregulated host response to infection; SOFA score β₯ 2 |
| Septic shock | Sepsis + vasopressor need to maintain MAP β₯ 65 mmHg + lactate > 2 mmol/L despite adequate fluid |
| qSOFA (bedside screen) | RR β₯ 22, AMS, SBP β€ 100 β score β₯ 2 β high risk |
Note: Old SIRS criteria are no longer used for the formal Sepsis-3 definition but remain clinically useful for screening.
SOFA Score Components
- PaOβ/FiOβ ratio (respiratory)
- Platelets (coagulation)
- Bilirubin (hepatic)
- MAP/vasopressors (cardiovascular)
- Glasgow Coma Scale (CNS)
- Creatinine/urine output (renal)
Common Sources
Lungs > Abdomen > Urinary tract > Skin/soft tissue > CNS
Hour-1 Bundle (Surviving Sepsis Campaign)
- Measure lactate; re-measure if > 2 mmol/L
- Blood cultures (Γ2, before antibiotics)
- Broad-spectrum IV antibiotics within 1 hour
- IV crystalloid 30 mL/kg for hypotension or lactate β₯ 4
- Vasopressors (Norepinephrine 1st line) if hypotensive during/after fluids to maintain MAP β₯ 65
Empiric Antibiotics
- Unknown source: Pip-tazo OR Meropenem Β± Vancomycin (MRSA risk)
- Urinary source: Ceftriaxone
- Abdominal source: Pip-tazo or Carbapenem
4. UTI
Classification
| Type | Definition |
|---|---|
| Uncomplicated | Lower UTI (cystitis) in healthy, non-pregnant women |
| Complicated | UTI with structural/functional abnormality, male, pregnant, immunocompromised, indwelling catheter, pyelonephritis |
| Asymptomatic bacteriuria | Bacteria in urine without symptoms β treat only in pregnancy and pre-urologic procedures |
Clinical Features
| Cystitis | Pyelonephritis |
|---|---|
| Dysuria, frequency, urgency | + Fever, chills, flank/CVA tenderness |
| Suprapubic discomfort | Nausea, vomiting |
| No systemic features | Systemic illness |
Diagnosis
- Urinalysis: Pyuria (WBC β₯ 5/hpf), bacteriuria, nitrites (+), leukocyte esterase (+)
- Urine culture & sensitivity: Gold standard (β₯ 10β΅ CFU/mL, or β₯ 10Β³ in symptomatic)
- Common organisms: E. coli (MC ~80%), Klebsiella, Proteus, Staphylococcus saprophyticus (young women)
Management
| Type | Drug of Choice | Duration |
|---|---|---|
| Uncomplicated cystitis | Nitrofurantoin OR TMP-SMX | 5β7 days |
| Uncomplicated cystitis (alt) | Fosfomycin (single dose) | 1 day |
| Complicated/pyelonephritis (outpt) | Ciprofloxacin or Levofloxacin | 7 days (FQ) |
| Pyelonephritis (inpt) | IV Ceftriaxone or FQ, then step-down | 14 days total |
| Catheter-associated | Remove/replace catheter + antibiotics | Per culture |
5. SEIZURE
Definition
Transient neurological event from abnormal, excessive, or synchronous neuronal activity.
Classification (ILAE 2017)
- Focal (aware vs. impaired awareness) β may secondarily generalize
- Generalized: Tonic-clonic, absence, myoclonic, atonic, tonic, clonic
- Unknown onset
First Seizure Workup
- Blood glucose (hypoglycemia!), electrolytes (Na, Ca, Mg), BUN/Cr
- CBC, toxicology screen
- EEG (essential for classification)
- MRI brain (preferred over CT; CT if acute bleed suspected)
- LP if CNS infection suspected
Status Epilepticus (SE)
Seizure lasting β₯ 5 minutes OR β₯ 2 seizures without return to baseline.
Treatment ladder:
| Stage | Drug | Dose |
|---|---|---|
| 1st line (0β5 min) | Lorazepam IV OR Diazepam IV/PR | Lorazepam 0.1 mg/kg IV |
| 2nd line (5β20 min) | Phenytoin/Fosphenytoin IV OR Valproate IV OR Levetiracetam IV | Fosphenytoin 20 PE/kg |
| 3rd line (refractory) | Phenobarbital IV β Midazolam/Propofol/Pentobarbital infusion (ICU) | β |
Common Causes (Mnemonic: VITAMINS)
Vascular (stroke), Infection (meningitis, encephalitis), Trauma, Anoxia, Metabolic (hypoglycemia, hyponatremia), Idiopathic/epilepsy, Neoplasm, Substances (drugs, alcohol withdrawal)
Antiepileptic Drug Selection
| Seizure Type | Drug |
|---|---|
| Focal | Carbamazepine, Lamotrigine, Levetiracetam |
| Generalized tonic-clonic | Valproate, Levetiracetam, Lamotrigine |
| Absence | Ethosuximide, Valproate |
| Myoclonic | Valproate, Levetiracetam |
6. GASTROENTERITIS
Definition
Inflammation of the stomach and intestines, typically manifesting as diarrhea Β± vomiting Β± abdominal cramps, usually infectious.
Etiology
| Category | Pathogen | Key Feature |
|---|---|---|
| Viral (MC overall) | Norovirus (MC adult), Rotavirus (MC pediatric) | Watery diarrhea, self-limited |
| Bacterial toxin | S. aureus, B. cereus | Vomiting within 1β6 hrs of ingestion |
| Bacterial invasive | Salmonella, Shigella, Campylobacter, EHEC (E. coli O157:H7) | Bloody diarrhea, fever |
| Protozoal | Giardia, Cryptosporidium, E. histolytica | Chronic/travelers' diarrhea |
Clinical Features
- Acute watery diarrhea, nausea/vomiting, crampy abdominal pain, fever
- Alarm signs: Bloody stool, high fever, dehydration, prolonged course (>7 days), elderly/immunocompromised
Dehydration Assessment (Especially Pediatric)
| Degree | Features |
|---|---|
| Mild (<5%) | Mildly dry mucosa, normal turgor |
| Moderate (5β10%) | Sunken eyes/fontanelle, decreased turgor, oliguria |
| Severe (>10%) | Lethargy, mottling, poor perfusion, no urine output |
Management
| Step | Action |
|---|---|
| Rehydration (priority) | Oral rehydration salts (ORS) first-line for mild-moderate; IV fluids (NS or LR) for severe |
| Diet | Early refeeding; BRAT diet is outdated but acceptable |
| Antibiotics | Usually NOT indicated for viral/mild bacterial; USE for: Shigella (Azithromycin), severe Salmonella, C. difficile (Metronidazole/Vancomycin PO), E. histolytica (Metronidazole) |
| Antiemetics | Ondansetron (preferred) |
| Antimotility | Loperamide β avoid in bloody diarrhea or suspected invasive infection |
| Probiotics | Adjunctive; shorten duration slightly |
Complications
- Dehydration β shock
- HUS (Hemolytic Uremic Syndrome) β EHEC O157:H7 β microangiopathic hemolytic anemia, thrombocytopenia, AKI; do NOT give antibiotics (worsens HUS risk)
- Reactive arthritis (post-Salmonella/Shigella/Campylobacter)
Quick High-Yield Summary Table
| Topic | Key Diagnosis Tool | First-line Treatment |
|---|---|---|
| Jaundice | Bili fractionation + U/S | Depends on cause; phototherapy (neonatal) |
| Pneumonia | CXR + CURB-65 | Amoxicillin / Ξ²-lactam + macrolide |
| Sepsis | qSOFA / SOFA | Hour-1 bundle: cultures β abx β fluids β vasopressors |
| UTI | Urinalysis + U-CS | Nitrofurantoin (cystitis); Ceftriaxone/FQ (pyelo) |
| Seizure | EEG + MRI | Lorazepam β Fosphenytoin β Phenobarbital (SE) |
| Gastroenteritis | Clinical + stool culture if indicated | ORS + early feeding; selective antibiotics |
Good luck on Tuesday! If you want me to go deeper on any specific topic, generate practice questions, or make a condensed cheat sheet, just ask.
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