pneumonia investigation and management
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"community-acquired pneumonia" AND "guideline"
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pneumonia investigation and management guideline 2024 2025 CURB-65 antibiotics
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Pneumonia: Investigation and Management
1. Initial Clinical Assessment
Confirm the diagnosis clinically first: fever, cough (productive or dry), pleuritic chest pain, dyspnea, tachypnea, and focal chest signs (bronchial breathing, crackles, dullness to percussion) with a compatible new infiltrate on imaging. Distinguish the setting, since it drives both microbiology and treatment:
- Community-acquired pneumonia (CAP) - acquired outside hospital or within 48 hours of admission
- Hospital-acquired pneumonia (HAP) - onset ≥48 hours after admission, not incubating at admission
- Ventilator-associated pneumonia (VAP) - develops ≥48 hours after intubation
- Aspiration pneumonia - in patients with impaired swallow/consciousness
HAP/VAP carry a broader resistant-organism risk (MRSA, Pseudomonas, other gram-negatives) and are associated with higher mortality and morbidity - "substantial evidence links HAP to poorer patient outcomes due to increased mortality, morbidity, including admission to the ICU, need for mechanical ventilation" (Murray & Nadel's Textbook of Respiratory Medicine).
2. Investigations
Severity assessment (determines site of care and test intensity)
- CURB-65 (hospital): Confusion, Urea >7 mmol/L, Respiratory rate ≥30/min, Blood pressure (systolic ≤90 or diastolic ≤60 mmHg), Age ≥65. Score 0-1 = low risk (consider outpatient), 2 = intermediate (consider short admission/ambulatory pathway), ≥3 = high risk (consider inpatient/critical care) - Harrison's Principles of Internal Medicine 22E.
- CRB-65 (primary care, no urea needed) - NICE Pneumonia in adults: diagnosis and management (NG250, 2025).
- Pneumonia Severity Index (PSI) - more granular, RCT-validated, but CURB-65 favored for simplicity - Fishman's Pulmonary Diseases and Disorders.
Baseline tests (all patients)
- Pulse oximetry / ABG if SpO2 low or severe disease, to assess for hypoxemic respiratory failure
- FBC, U&E/creatinine (urea feeds into CURB-65), LFTs, CRP (and/or procalcitonin, useful for antibiotic stewardship/de-escalation)
- Chest X-ray to confirm infiltrate, assess extent (lobar vs multilobar), and look for effusion or cavitation
Microbiological work-up (severity-guided)
- Sputum Gram stain and culture - most useful when a good-quality (purulent) sample is obtained before antibiotics; low yield and poor predictive value otherwise (Murray & Nadel's Textbook of Respiratory Medicine)
- Blood cultures - recommended for hospitalized moderate-to-severe CAP and for HAP; positive in about 10-30% of pneumococcal pneumonia (Goldman-Cecil Medicine)
- Urinary antigen tests for S. pneumoniae and Legionella in moderate/severe cases
- Respiratory viral PCR panel (influenza, RSV, SARS-CoV-2) - increasingly routine, and per 2025 ATS guidance can support withholding antibiotics in otherwise healthy patients with a clear viral cause and no bacterial features
- Endotracheal aspirate (ventilated patients) or bronchoscopic BAL/protected specimen brush in ICU/immunocompromised or non-responding patients
- Pleural fluid sampling (diagnostic +/- therapeutic) if a significant parapneumonic effusion is present, to exclude empyema
- CT chest if complications suspected (abscess, empyema, necrotizing pneumonia) or diagnosis unclear, and CT/US-guided drainage planning for empyema
3. Management
Supportive care
- Oxygen to target saturation (88-92% if at risk of hypercapnic respiratory failure, otherwise 94-98%)
- IV fluids for hypovolemia/sepsis, VTE prophylaxis, analgesia for pleuritic pain, chest physiotherapy/early mobilization in severe or ventilated disease
- Escalate to HDU/ICU for shock, respiratory failure needing ventilatory support, or CURB-65 ≥3-4 with clinical concern
Antibiotics (empirical, then narrow to culture results)
CAP, guided by severity (NICE NG250 2025 / ATS-IDSA 2019 framework):
- Low severity: amoxicillin monotherapy (5 days); doxycycline or clarithromycin if penicillin-allergic
- Moderate severity: amoxicillin + macrolide (clarithromycin) if atypical cover needed, or doxycycline if allergic
- High severity (CURB-65 3-5): broader-spectrum IV beta-lactam (e.g., co-amoxiclav) plus a macrolide; consider adding a systemic corticosteroid for 4-7 days in high-severity CAP per NICE 2025
- Give antibiotics promptly once bacterial pneumonia is suspected, then de-escalate based on microbiology - "empirical antibiotic treatment should be started promptly if bacterial pneumonia is suspected but then narrowed if possible based on microbiologic studies" (Goldman-Cecil Medicine)
- Review IV therapy at 48 hours and step down to oral when clinically stable
- Duration: minimum 5 days if improving and clinically stable (afebrile, eating, stable vitals); 2025 ATS update suggests even shorter courses (3-5 days) may suffice for uncomplicated CAP in select patients
HAP/VAP: empirical regimens must cover MRSA and Pseudomonas in patients at high risk (prior IV antibiotics within 90 days, high local resistance prevalence, septic shock, or ARDS), typically combining an anti-pseudomonal beta-lactam with either vancomycin/linezolid (if MRSA risk) - Murray & Nadel's Textbook of Respiratory Medicine, Table 48.1.
Fluoroquinolones (e.g., levofloxacin) are reserved as alternatives due to MHRA/regulatory warnings about disabling and potentially irreversible tendon/CNS/neuropathic side effects.
Follow-up
- Reassess clinical response at 48-72 hours; failure to improve should prompt re-imaging, repeat cultures, and consideration of resistant organisms, empyema, or an alternative diagnosis
- Repeat chest X-ray at around 6 weeks in patients with persistent symptoms, smokers, or those over 50, to exclude an underlying obstructing lesion (e.g., malignancy)
4. Complications to watch for
- Parapneumonic effusion / empyema - most common pulmonary complication, occurring in about 3-5% of cases; bacterial pneumonia with parapneumonic effusion precedes roughly 60% of empyemas (Goldman-Cecil Medicine; Tintinalli's Emergency Medicine)
- Necrotizing pneumonia / lung abscess - particularly with pneumococcal or Klebsiella infection, and S. aureus (Robbins & Cotran Pathologic Basis of Disease)
- Bacteremia with metastatic infection - septic arthritis, meningitis, endocarditis, pericarditis
- ARDS and septic shock in severe cases
- Acute cardiac events (arrhythmia, MI, heart failure decompensation) are recognized complications of CAP, particularly in older adults
Recent evidence note
A 2025 systematic review/meta-analysis (PMID 41062168) examined outcome variability between aspiration and community-acquired pneumonia, and a 2024 network meta-analysis (PMID 38360961) compared initial oral antibiotic choices for adult CAP - both consistent with, rather than contradicting, the severity-stratified approach above. The 2025 French SPILF/SPLF CAP guideline (PMID 40037948) and updated NICE NG250 (2025) also reflect current consensus. Nothing in this recent literature substantially overturns the CURB-65-guided, severity-stratified approach outlined here, though shorter antibiotic durations and selective antibiotic withholding in confirmed viral pneumonia (per ATS 2025) represent an evolving shift toward antimicrobial stewardship.
If you want, I can go deeper into a specific area - e.g., HAP/VAP antibiotic tables, pediatric CAP management, or aspiration pneumonia specifically.
make a chart of investigation and management for asthma,copd,dengue , malaria ,TB , leptospirosis, abcess,
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Investigation and Management Chart: Asthma, COPD, Dengue, Malaria, TB, Leptospirosis, Abscess
| Condition | Key Investigations | Management |
|---|---|---|
| Asthma | - Spirometry - the most useful confirmatory test: obstructive pattern (reduced FEV1/FVC) with reversibility (≥12% and 200 mL improvement in FEV1 post-bronchodilator) - Textbook of Family Medicine 9e - Peak expiratory flow (PEF) - useful for monitoring/self-management, not primary diagnosis - Textbook of Family Medicine 9e - Bronchoprovocation testing (methacholine challenge) if spirometry normal but suspicion high - Harrison's 22E - FeNO (fractional exhaled nitric oxide), allergy skin/IgE testing for atopic triggers - CXR to exclude alternative diagnosis (not routine) | - Stepwise therapy (GINA): as-needed SABA/low-dose ICS-formoterol (mild) → low-dose ICS-LABA maintenance → medium/high-dose ICS-LABA → add-on LAMA, biologics (anti-IgE, anti-IL5, anti-IL4R) for severe eosinophilic/allergic asthma - Acute exacerbation: oxygen to target SpO2 94-98%, nebulized salbutamol +/- ipratropium, systemic corticosteroids (oral prednisolone or IV hydrocortisone), IV magnesium sulfate if severe/life-threatening; escalate to ICU for silent chest, exhaustion, rising CO2 - Trigger avoidance, inhaler technique review, written action plan, vaccination (influenza/pneumococcal) |
| COPD | - Spirometry - mandatory for diagnosis: post-bronchodilator FEV1/FVC <0.70 confirms persistent airflow limitation (GOLD) - Symptom to Diagnosis; Murray & Nadel's - GOLD grading (1-4) by FEV1 % predicted, plus symptom/exacerbation-based ABE grouping - Fishman's Pulmonary Diseases - CXR/CT chest (hyperinflation, bullae, exclude malignancy), ABG if hypoxemic/hypercapnic, alpha-1 antitrypsin level if early-onset/family history, sputum culture during exacerbations, FBC (polycythemia/anemia), pulse oximetry, 6-minute walk/BODE index for prognosis | - Stable disease: smoking cessation (single most effective intervention), bronchodilators (LAMA/LABA), add ICS if frequent exacerbations with eosinophilia, pulmonary rehabilitation, long-term oxygen if PaO2 <55 mmHg, vaccinations - Acute exacerbation: controlled oxygen (avoid hyperoxia in hypercapnic patients), nebulized bronchodilators, oral corticosteroids (5 days), antibiotics if increased purulent sputum, NIV for hypercapnic respiratory failure, escalate to invasive ventilation if NIV fails - Categorized by GOLD grade/exacerbation frequency to guide escalation - Textbook of Family Medicine 9e |
| Dengue | - NS1 antigen - detectable early (first 1-7 days), highly specific - Goldman-Cecil Medicine; Park's Textbook of PSM - IgM/IgG serology (ELISA) - IgM rises after day 3-5; if early sample IgM-negative, test RNA/NS1 - Brenner & Rector's The Kidney - RT-PCR for dengue RNA for early confirmation/serotyping - FBC (thrombocytopenia, rising hematocrit/hemoconcentration - key warning sign), LFTs, tourniquet test (capillary fragility), serial hematocrit and platelet monitoring, USG/CXR for pleural effusion/ascites in severe dengue | - No specific antiviral - supportive care is mainstay - Fluid management guided by hematocrit trend (careful judicious IV fluids in severe/warning-sign cases; oral fluids for uncomplicated cases) - Avoid NSAIDs/aspirin (bleeding risk) - use paracetamol for fever/pain - Close monitoring for warning signs (abdominal pain, persistent vomiting, mucosal bleeding, lethargy, rapid hematocrit rise with falling platelets) heralding progression to severe dengue/dengue shock syndrome - Severe dengue: managed in center experienced with careful fluid resuscitation +/- blood products; reduces mortality substantially - Goldman-Cecil Medicine |
| Malaria | - Thick and thin blood film (Giemsa stain) - gold standard; thick film for detection, thin film for species ID and parasitemia % - Tietz Textbook of Laboratory Medicine - Rapid diagnostic tests (RDT) - antigen-based (HRP-2, pLDH), useful when microscopy unavailable - Harrison's 22E - Repeat films if initial negative but clinical suspicion high (P. falciparum smear may be falsely negative early) - Tintinalli's Emergency Medicine - Parasitemia % (>20% mature-form parasitemia predicts poor prognosis), FBC, glucose, renal/liver function, lactate for severity | - Uncomplicated P. falciparum: artemisinin-based combination therapy (ACT) e.g., artemether-lumefantrine - Uncomplicated non-falciparum (P. vivax/ovale): chloroquine (if sensitive) + primaquine/tafenoquine for radical cure of liver-stage hypnozoites (check G6PD first) - Severe/complicated malaria: IV artesunate is first-line; do not delay treatment awaiting confirmation - Tintinalli's Emergency Medicine - Supportive care for complications: correct hypoglycemia, manage seizures, dialysis for renal failure, exchange transfusion considered in extreme hyperparasitemia - Chemoprophylaxis and vector control for prevention |
| Tuberculosis | - Sputum smear microscopy (acid-fast bacilli / Ziehl-Neelsen) - three specimens recommended - Goldman-Cecil Medicine - GeneXpert MTB/RIF (molecular PCR) - rapid detection plus rifampin resistance - Tietz Textbook of Laboratory Medicine - Mycobacterial culture (liquid/solid media) - gold standard, also needed for full drug-susceptibility testing - CXR (cavitation, upper lobe infiltrates, hilar lymphadenopathy), CT chest for extrapulmonary/complicated disease - TST (Mantoux) or IGRA for latent TB infection screening - Red Book 2021 - HIV testing (co-testing recommended in all TB patients) | - Active TB: standard 6-month regimen - 2 months intensive phase (isoniazid, rifampin, pyrazinamide, ethambutol = RIPE) followed by 4 months continuation (isoniazid + rifampin); directly observed therapy (DOT) recommended - Drug-resistant TB (MDR/RR-TB): longer regimens with second-line agents (e.g., bedaquiline-based) per WHO guidance - Latent TB: isoniazid preventive therapy (6-9 months) or shorter rifapentine-based regimens in appropriate contacts - Contact tracing, airborne isolation for smear-positive pulmonary disease, notify public health authorities, monitor LFTs (hepatotoxicity) and visual acuity (ethambutol) |
| Leptospirosis | - Serology is the primary diagnostic method (MAT - microscopic agglutination test is reference standard; ELISA IgM for rapid screening) - Sherris & Ryan's Medical Microbiology - Note: serologic tests can have poor sensitivity in the first week of illness - Jawetz Melnick & Adelberg's - Blood culture (first week/leptospiremic phase) or urine culture (second week/leptospiruric phase) can confirm diagnosis - Sleisenger & Fordtran's - PCR for early detection, FBC, renal function (creatinine - renal impairment common), LFTs (jaundice in Weil's disease), CK (myositis), CXR if pulmonary hemorrhage suspected | - Mild disease: oral doxycycline 100 mg twice daily for 1 week is effective if started early - Andrews' Diseases of the Skin - Severe leptospirosis (Weil's disease): IV penicillin as soon as diagnosis is considered, or ceftriaxone as alternative - Harrison's 22E; Sherris & Ryan's - Supportive care for complications: dialysis for acute kidney injury, transfusion/ventilatory support for pulmonary hemorrhage, careful fluid/electrolyte management - Watch for Jarisch-Herxheimer-like reaction after starting antibiotics |
| Abscess (skin/soft tissue or visceral) | - Clinical exam: fluctuance, erythema, warmth, tenderness +/- systemic signs of sepsis - Ultrasound - useful bedside tool to confirm fluid collection and guide drainage - CT (with contrast) for deep/visceral abscesses (hepatic, intra-abdominal, intraperitoneal) - Sabiston Textbook of Surgery; Yamada's Gastroenterology - Blood cultures, FBC/inflammatory markers (CRP, WBC) if systemic involvement, pus culture and sensitivity from aspirate/drainage to guide antibiotic choice | - Core principle: source control - drainage (incision and drainage, or image-guided percutaneous aspiration/catheter drainage) is the definitive treatment; antibiotics alone are inadequate for most abscesses ≥3-5 cm - Mulholland & Greenfield's Surgery - Small abscesses (<3 cm, e.g., in diverticulitis) may respond to antibiotics alone; larger ones need drainage plus antibiotics - Mulholland & Greenfield's Surgery - Broad-spectrum empirical antibiotics pending culture, then narrow based on sensitivities; cover anaerobes for intra-abdominal/dental sources, MRSA-active agents for skin/soft tissue abscesses with risk factors - Identify and treat the underlying cause (e.g., perforation, foreign body, hematogenous seeding) to prevent recurrence - Yamada's Gastroenterology - Surgical drainage remains mainstay when percutaneous approach fails or is inaccessible (e.g., loculated empyema, deep-seated collections) |
Quick summary of investigation logic
- Airway diseases (asthma, COPD): diagnosis rests on spirometry; the key distinguishing feature is reversibility (asthma) vs. persistent, largely fixed obstruction (COPD).
- Tropical febrile illnesses (dengue, malaria, leptospirosis): all can present similarly (fever, myalgia, headache) — differentiate with NS1/serology (dengue), blood film/RDT (malaria), and serology/culture with renal-hepatic involvement pattern (leptospirosis). In endemic areas, test for all three in an undifferentiated febrile illness.
- TB: microbiological confirmation (smear, GeneXpert, culture) is central and also determines infectiousness and drug-resistance risk.
- Abscess: imaging identifies the collection, but management is procedural (drainage) first, antibiotics second.
If useful, I can expand any single condition (e.g., full GINA step-up therapy table, WHO malaria treatment doses, or MDR-TB regimens) into more detail.
Create a downloadable PDF quick-reference guide for these diagnoses
Reading File
Reading File
Running Command
mkdir -p /tmp/workspace/medical-quickref/output && ls -la /tmp/workspace/
Writing File
~/medical-quickref/build_pdf.py
# -*- coding: utf-8 -*-
from reportlab.lib.pagesizes import letter
from reportlab.lib import colors
from reportlab.lib.units import inch
from reportlab.platypus import (
SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
PageBreak, HRFlowable, KeepTogether
)
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.pdfgen import canvas
OUT = "/tmp/workspace/medical-quickref/output/Quick_Reference_Guide_Diagnoses.pdf"
styles = getSampleStyleSheet()
title_style = ParagraphStyle('TitleStyle', parent=styles['Title'], fontSize=26,
textColor=colors.HexColor('#0B3D66'), spaceAfter=6, alignment=TA_CENTER)
subtitle_style = ParagraphStyle('SubtitleStyle', parent=styles['Normal'], fontSize=13,
textColor=colors.HexColor('#444444'), alignment=TA_CENTER, spaceAfter=4)
disclaimer_style = ParagraphStyle('Disclaimer', parent=styles['Normal'], fontSize=8.5,
textColor=colors.HexColor('#777777'), alignment=TA_CENTER)
cond_title_style = ParagraphStyle('CondTitle', parent=styles['Heading1'], fontSize=19,
textColor=colors.white, spaceAfter=0, spaceBefore=0,
leftIndent=0)
section_head_style = ParagraphStyle('SectionHead', parent=styles['Heading3'], fontSize=12.5,
textColor=colors.HexColor('#0B3D66'), spaceBefore=8, spaceAfter=4)
body_style = ParagraphStyle('BodyCell', parent=styles['Normal'], fontSize=9.3, leading=12.5)
bullet_style = ParagraphStyle('BulletCell', parent=styles['Normal'], fontSize=9.3, leading=12.8,
leftIndent=8, bulletIndent=0)
toc_style = ParagraphStyle('TOCItem', parent=styles['Normal'], fontSize=12, leading=20,
textColor=colors.HexColor('#0B3D66'))
ACCENT = {
"Pneumonia": "#1B4F72",
"Asthma": "#1E8449",
"COPD": "#6C3483",
"Dengue": "#B03A2E",
"Malaria": "#B9770E",
"Tuberculosis (TB)": "#117864",
"Leptospirosis": "#2C3E50",
"Abscess": "#7B241C",
}
def bl(items):
"""Build bullet list HTML for a Paragraph cell."""
return "<br/>".join(f"• {i}" for i in items)
def make_condition_table(name, investigations, management, key_points=None):
color = colors.HexColor(ACCENT.get(name, "#0B3D66"))
flow = []
# Header bar
header_tbl = Table([[Paragraph(name.upper(), cond_title_style)]], colWidths=[6.9*inch])
header_tbl.setStyle(TableStyle([
('BACKGROUND', (0,0), (-1,-1), color),
('TOPPADDING', (0,0), (-1,-1), 10),
('BOTTOMPADDING', (0,0), (-1,-1), 10),
('LEFTPADDING', (0,0), (-1,-1), 12),
]))
flow.append(header_tbl)
flow.append(Spacer(1, 10))
# Investigations / Management two-column table
inv_para = Paragraph(bl(investigations), body_style)
mgmt_para = Paragraph(bl(management), body_style)
data = [
[Paragraph("<b>INVESTIGATIONS</b>", section_head_style),
Paragraph("<b>MANAGEMENT</b>", section_head_style)],
[inv_para, mgmt_para]
]
t = Table(data, colWidths=[3.4*inch, 3.5*inch])
t.setStyle(TableStyle([
('BACKGROUND', (0,0), (-1,0), colors.HexColor('#EAF1F8')),
('BOX', (0,0), (-1,-1), 0.75, colors.HexColor('#B0B0B0')),
('INNERGRID', (0,0), (-1,-1), 0.5, colors.HexColor('#CCCCCC')),
('VALIGN', (0,0), (-1,-1), 'TOP'),
('LEFTPADDING', (0,0), (-1,-1), 8),
('RIGHTPADDING', (0,0), (-1,-1), 8),
('TOPPADDING', (0,0), (-1,-1), 6),
('BOTTOMPADDING', (0,0), (-1,-1), 8),
]))
flow.append(t)
if key_points:
flow.append(Spacer(1, 8))
kp_tbl = Table([[Paragraph("<b>RED FLAGS / KEY POINTS</b><br/>" + bl(key_points), body_style)]],
colWidths=[6.9*inch])
kp_tbl.setStyle(TableStyle([
('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#FDF2E9')),
('BOX', (0,0), (-1,-1), 0.75, colors.HexColor('#E5B98C')),
('LEFTPADDING', (0,0), (-1,-1), 10),
('RIGHTPADDING', (0,0), (-1,-1), 10),
('TOPPADDING', (0,0), (-1,-1), 6),
('BOTTOMPADDING', (0,0), (-1,-1), 6),
]))
flow.append(kp_tbl)
return flow
CONDITIONS = [
{
"name": "Pneumonia",
"investigations": [
"Severity score: CURB-65 (Confusion, Urea>7, RR≥30, BP≤90/60, Age≥65) or CRB-65 in primary care",
"Pulse oximetry / ABG if hypoxic or severe",
"FBC, U&E/creatinine, LFTs, CRP or procalcitonin",
"Chest X-ray - confirm infiltrate, extent, effusion/cavitation",
"Sputum Gram stain & culture (best pre-antibiotics)",
"Blood cultures (moderate-severe CAP, all HAP)",
"Urinary antigen: S. pneumoniae, Legionella (mod-severe cases)",
"Respiratory viral PCR panel (flu, RSV, SARS-CoV-2)",
"Pleural fluid sampling if significant effusion",
"CT chest if complication suspected (abscess/empyema)",
],
"management": [
"Oxygen to target SpO2 94-98% (88-92% if CO2 retention risk)",
"Low severity: amoxicillin PO 5 days (doxycycline/clarithromycin if allergic)",
"Moderate: amoxicillin + macrolide, or doxycycline",
"High severity (CURB-65 3-5): IV beta-lactam + macrolide; consider corticosteroid 4-7 days",
"HAP/VAP: cover MRSA/Pseudomonas if risk factors present",
"Review IV->oral switch at 48h; treat 5 days minimum if stable",
"IV fluids, VTE prophylaxis, analgesia, chest physiotherapy",
"Escalate to HDU/ICU for shock or respiratory failure",
"Repeat CXR at 6 weeks if persistent symptoms, smoker, or age>50",
],
"key_points": [
"Failure to improve at 48-72h: re-image, repeat cultures, consider empyema/resistant organism",
"Watch for parapneumonic effusion/empyema (3-5% of cases), lung abscess, sepsis, ARDS",
],
},
{
"name": "Asthma",
"investigations": [
"Spirometry: obstructive pattern with reversibility (≥12% & 200mL FEV1 rise post-bronchodilator)",
"Peak expiratory flow (PEF) - monitoring/self-management, not primary diagnosis",
"Bronchoprovocation (methacholine challenge) if spirometry normal but suspicion high",
"FeNO (fractional exhaled NO), allergy skin-prick/IgE testing",
"CXR only to exclude alternative diagnosis",
],
"management": [
"Stepwise (GINA): as-needed SABA/low-dose ICS-formoterol → low-dose ICS-LABA → medium/high-dose ICS-LABA → add LAMA/biologics",
"Acute exacerbation: O2 to target 94-98%, nebulized salbutamol +/- ipratropium",
"Systemic corticosteroids (oral prednisolone / IV hydrocortisone)",
"IV magnesium sulfate if severe/life-threatening",
"ICU escalation for silent chest, exhaustion, rising CO2",
"Written action plan, inhaler technique review, trigger avoidance, vaccination",
],
"key_points": [
"Life-threatening features: silent chest, cyanosis, bradycardia, hypotension, exhaustion, confusion, SpO2<92%",
],
},
{
"name": "COPD",
"investigations": [
"Spirometry mandatory: post-bronchodilator FEV1/FVC <0.70 confirms diagnosis (GOLD)",
"GOLD grading 1-4 by FEV1% predicted + ABE symptom/exacerbation grouping",
"CXR/CT chest - hyperinflation, bullae, exclude malignancy",
"ABG if hypoxemic/hypercapnic",
"Alpha-1 antitrypsin level if early-onset or family history",
"Sputum culture during exacerbations, FBC, pulse oximetry",
"6-minute walk test / BODE index for prognosis",
],
"management": [
"Smoking cessation - single most effective intervention",
"Bronchodilators: LAMA/LABA; add ICS if frequent exacerbations with eosinophilia",
"Pulmonary rehabilitation, vaccinations (flu, pneumococcal)",
"Long-term O2 if PaO2<55 mmHg",
"Exacerbation: controlled O2 (avoid hyperoxia), nebulized bronchodilators, oral corticosteroids 5 days, antibiotics if purulent sputum",
"NIV for hypercapnic respiratory failure; invasive ventilation if NIV fails",
],
"key_points": [
"Avoid uncontrolled high-flow O2 in hypercapnic patients - risk of worsening CO2 retention",
],
},
{
"name": "Dengue",
"investigations": [
"NS1 antigen - detectable early (day 1-7), highly specific",
"IgM/IgG serology (ELISA) - IgM rises day 3-5; test RNA/NS1 if early IgM negative",
"RT-PCR for dengue RNA - early confirmation/serotyping",
"FBC: thrombocytopenia, rising hematocrit (hemoconcentration = warning sign)",
"Tourniquet test (capillary fragility)",
"LFTs, serial hematocrit/platelet monitoring",
"USG/CXR for pleural effusion or ascites in severe dengue",
],
"management": [
"No specific antiviral - supportive care is mainstay",
"Fluid management guided by hematocrit trend (careful judicious IV fluids for warning-sign/severe cases; oral fluids for uncomplicated)",
"Avoid NSAIDs/aspirin (bleeding risk) - use paracetamol for fever/pain",
"Close monitoring for warning signs: abdominal pain, persistent vomiting, mucosal bleeding, lethargy",
"Severe dengue managed in experienced center with careful fluid resuscitation +/- blood products",
],
"key_points": [
"Critical phase (defervescence, day 3-7) is when plasma leakage/shock risk peaks - highest vigilance period",
],
},
{
"name": "Malaria",
"investigations": [
"Thick & thin blood film (Giemsa) - gold standard; thick=detection, thin=species ID & % parasitemia",
"Rapid diagnostic test (RDT) - antigen-based (HRP-2/pLDH) when microscopy unavailable",
"Repeat films if initial negative but suspicion persists (P. falciparum can be falsely negative early)",
"Parasitemia % (>20% mature forms = poor prognosis), FBC, glucose, renal/liver function, lactate",
],
"management": [
"Uncomplicated P. falciparum: artemisinin-based combination therapy (ACT), e.g. artemether-lumefantrine",
"Uncomplicated non-falciparum: chloroquine (if sensitive) + primaquine/tafenoquine radical cure (check G6PD first)",
"Severe/complicated malaria: IV artesunate first-line - do NOT delay for confirmation",
"Supportive care: correct hypoglycemia, manage seizures, dialysis for renal failure",
"Exchange transfusion considered in extreme hyperparasitemia",
"Chemoprophylaxis and vector control for prevention",
],
"key_points": [
"Severe malaria criteria: impaired consciousness, acidosis, hypoglycemia, severe anemia, renal failure, pulmonary edema, shock, DIC, hyperparasitemia",
],
},
{
"name": "Tuberculosis (TB)",
"investigations": [
"Sputum smear microscopy (acid-fast bacilli / Ziehl-Neelsen) - 3 specimens",
"GeneXpert MTB/RIF (molecular PCR) - rapid detection + rifampin resistance",
"Mycobacterial culture (liquid/solid media) - gold standard + full drug-susceptibility testing",
"CXR (cavitation, upper lobe infiltrates, hilar lymphadenopathy); CT for extrapulmonary/complicated disease",
"TST (Mantoux) or IGRA for latent TB screening",
"HIV testing recommended in all TB patients",
],
"management": [
"Active TB: 6-month regimen - 2 months intensive (Isoniazid, Rifampin, Pyrazinamide, Ethambutol) + 4 months continuation (Isoniazid+Rifampin)",
"Directly observed therapy (DOT) recommended",
"Drug-resistant (MDR/RR-TB): longer regimens with second-line agents (e.g. bedaquiline-based) per WHO",
"Latent TB: isoniazid preventive therapy (6-9 months) or shorter rifapentine-based regimens",
"Contact tracing, airborne isolation for smear-positive pulmonary disease, notify public health",
"Monitor LFTs (hepatotoxicity) and visual acuity (ethambutol)",
],
"key_points": [
"Infectiousness correlates with smear-positive sputum, productive cough, and cavitary disease",
],
},
{
"name": "Leptospirosis",
"investigations": [
"Serology: MAT (microscopic agglutination test) = reference standard; ELISA IgM for rapid screening",
"Note: serology may be falsely negative in first week of illness",
"Blood culture (first week / leptospiremic phase) or urine culture (second week / leptospiruric phase)",
"PCR for early detection",
"FBC, renal function (creatinine - AKI common), LFTs (jaundice in Weil's disease), CK (myositis)",
"CXR if pulmonary hemorrhage suspected",
],
"management": [
"Mild disease: oral doxycycline 100mg twice daily x 1 week (start early)",
"Severe leptospirosis (Weil's disease): IV penicillin as soon as diagnosis considered, or ceftriaxone as alternative",
"Supportive care for complications: dialysis for AKI, transfusion/ventilatory support for pulmonary hemorrhage",
"Careful fluid and electrolyte management",
],
"key_points": [
"Watch for Jarisch-Herxheimer-like reaction after starting antibiotics",
"Weil's disease triad: jaundice, renal failure, hemorrhage",
],
},
{
"name": "Abscess",
"investigations": [
"Clinical exam: fluctuance, erythema, warmth, tenderness +/- systemic sepsis signs",
"Ultrasound - bedside confirmation of fluid collection, guides drainage",
"CT with contrast for deep/visceral abscesses (hepatic, intra-abdominal)",
"Blood cultures if systemic involvement",
"FBC/inflammatory markers (CRP, WBC)",
"Pus culture & sensitivity from aspirate/drainage to guide antibiotics",
],
"management": [
"Core principle = SOURCE CONTROL: incision & drainage or image-guided percutaneous drainage is definitive treatment",
"Antibiotics alone inadequate for most abscesses ≥3-5cm; small (<3cm) may respond to antibiotics alone",
"Broad-spectrum empirical antibiotics pending culture, then narrow per sensitivities",
"Cover anaerobes for intra-abdominal/dental sources; MRSA-active agents for at-risk skin/soft tissue abscesses",
"Identify and treat underlying cause to prevent recurrence (perforation, foreign body, hematogenous seeding)",
"Surgical drainage when percutaneous approach fails or inaccessible (e.g. loculated empyema)",
],
"key_points": [
"Do not rely on antibiotics alone for a drainable collection - delayed source control worsens outcomes",
],
},
]
def build():
doc = SimpleDocTemplate(OUT, pagesize=letter,
topMargin=0.6*inch, bottomMargin=0.6*inch,
leftMargin=0.55*inch, rightMargin=0.55*inch)
story = []
# ---- Cover page ----
story.append(Spacer(1, 1.6*inch))
story.append(Paragraph("Clinical Quick-Reference Guide", title_style))
story.append(Spacer(1, 6))
story.append(Paragraph("Investigation & Management Summary", subtitle_style))
story.append(Spacer(1, 4))
story.append(HRFlowable(width="60%", thickness=1.2, color=colors.HexColor('#0B3D66'), hAlign='CENTER'))
story.append(Spacer(1, 18))
conditions_list = ", ".join(c["name"] for c in CONDITIONS)
story.append(Paragraph(f"<b>Covers:</b> {conditions_list}", ParagraphStyle(
'CoverList', parent=styles['Normal'], fontSize=11.5, alignment=TA_CENTER,
textColor=colors.HexColor('#333333'), leading=16)))
story.append(Spacer(1, 0.9*inch))
story.append(Paragraph(
"For use as a bedside/clinical study aid. Not a substitute for full clinical "
"guidelines, local antimicrobial policy, or specialist advice. Always confirm "
"doses and regimens against current local/national protocols before prescribing.",
disclaimer_style))
story.append(Spacer(1, 30))
story.append(Paragraph("Generated: August 2026", disclaimer_style))
story.append(PageBreak())
# ---- Table of contents ----
story.append(Paragraph("Contents", ParagraphStyle('TOCTitle', parent=styles['Heading1'],
fontSize=18, textColor=colors.HexColor('#0B3D66'))))
story.append(Spacer(1, 8))
for i, c in enumerate(CONDITIONS, start=1):
story.append(Paragraph(f"{i}. {c['name']}", toc_style))
story.append(PageBreak())
# ---- Condition pages (2 per page where possible via KeepTogether groups) ----
for idx, c in enumerate(CONDITIONS):
block = make_condition_table(c["name"], c["investigations"], c["management"],
c.get("key_points"))
story.extend(block)
if idx != len(CONDITIONS) - 1:
story.append(Spacer(1, 16))
story.append(HRFlowable(width="100%", thickness=0.5, color=colors.HexColor('#DDDDDD')))
story.append(Spacer(1, 16))
def add_footer(canvas_obj, doc_obj):
canvas_obj.saveState()
canvas_obj.setFont('Helvetica', 8)
canvas_obj.setFillColor(colors.HexColor('#999999'))
canvas_obj.drawString(0.55*inch, 0.35*inch, "Clinical Quick-Reference Guide - For educational use only")
canvas_obj.drawRightString(letter[0]-0.55*inch, 0.35*inch, f"Page {doc_obj.page}")
canvas_obj.restoreState()
doc.build(story, onFirstPage=add_footer, onLaterPages=add_footer)
print("PDF created at", OUT)
if __name__ == "__main__":
build()
Running Command
cd /tmp/workspace/medical-quickref && python build_pdf.py
Running Command
cd /tmp/workspace/medical-quickref/output && python3 -c " from pypdf import PdfReader r = PdfReader('Quick_Reference_Guide_Diagnoses.pdf') print('Pages:', len(r.pages)) " && ls -la
The PDF quick-reference guide is ready - 6 pages covering all 8 diagnoses (Pneumonia, Asthma, COPD, Dengue, Malaria, TB, Leptospirosis, Abscess), each with a color-coded section showing side-by-side Investigations and Management, plus a "Red Flags / Key Points" box, a cover page, and a table of contents.
Quick Reference Guide Diagnoses
PDF Document · PDF
Note: this is a study/bedside aid summarizing standard textbook and guideline material - always cross-check drug doses and regimens against your local antimicrobial policy before prescribing. Let me know if you'd like any condition expanded, dosing tables added, or the styling adjusted.
the same way for stroke, diabetic neuropathy, heart failure, thallesemia, anaemia , ACS, ascites, CKD , AKI , liver cirrhosis
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Investigation and Management Chart: Stroke, Diabetic Neuropathy, Heart Failure, Thalassemia, Anaemia, ACS, Ascites, CKD, AKI, Liver Cirrhosis
| Condition | Key Investigations | Management |
|---|---|---|
| Stroke | - Non-contrast CT head (immediate) - exclude hemorrhage before thrombolysis; CT/MR angiography for large vessel occlusion; MRI-DWI for early ischemic changes - NIHSS scoring for severity/eligibility assessment - Harrison's 22E; Tintinalli's - Blood glucose (exclude hypoglycemia mimic), FBC, coagulation profile, U&E, ECG (AF as cause), lipid profile, carotid Doppler/echo for source in ischemic stroke | - Ischemic stroke: IV thrombolysis (alteplase/tenecteplase) within 4.5h of onset if no contraindication; mechanical thrombectomy for large vessel occlusion up to extended windows with favorable imaging - Minor/nondisabling stroke (NIHSS 0-5): aspirin or short-term dual antiplatelet (aspirin + clopidogrel) rather than thrombolysis - Harrison's 22E - Hemorrhagic stroke: BP control, reverse anticoagulation, neurosurgical evacuation if indicated, ICP management - Secondary prevention: antiplatelets/anticoagulation (AF), statin, BP control, carotid revascularization if significant stenosis - Early rehabilitation (physio/speech/OT), swallow assessment before oral intake |
| Diabetic Neuropathy | - Clinical screening: 10g monofilament testing, vibration perception (biothesiometer), ankle reflexes - to detect loss of protective sensation (LOPS) - Harrison's 22E - Nerve conduction studies if diagnosis unclear or atypical pattern - HbA1c, B12 level, TFTs, renal function (exclude alternative/contributing causes) - Comprehensive foot exam for ulceration risk - Miller's Review of Orthopaedics | - Optimize glycemic control (reduces progression) - primary intervention - Neuropathic pain: first-line agents - pregabalin/gabapentin, duloxetine, amitriptyline - Foot care education, protective footwear, regular podiatry review to prevent ulceration - Manage cardiovascular risk factors (BP, lipids) - autonomic neuropathy screening (postural BP, gastroparesis symptoms) - Refer for ulceration/Charcot foot to multidisciplinary diabetic foot team |
| Heart Failure | - BNP / NT-proBNP - key biomarker; markedly elevated in HF, normal-ish (BNP <200 pg/mL) in pure pericardial constriction - Goldman-Cecil Medicine - Echocardiography - assess LVEF, HFrEF vs HFpEF (HFpEF now ~50% of HF population, BNP >35 pg/mL threshold) - Miller's Anesthesia - 12-lead ECG, CXR, U&E/creatinine, glucose, FBC - Swanson's Family Medicine Review - Consider coronary angiography if ischemic etiology suspected | - HFrEF: guideline-directed medical therapy - ACEi/ARB/ARNI + beta-blocker + MRA + SGLT2 inhibitor ("four pillars"); diuretics for congestion - HFpEF: SGLT2 inhibitors, diuretics for symptom control, manage comorbidities (HTN, AF, obesity) - Acute decompensation: IV diuretics, oxygen, vasodilators if hypertensive, inotropes/mechanical support if cardiogenic shock - Device therapy (CRT/ICD) in selected reduced-EF patients; fluid/salt restriction, daily weight monitoring, cardiac rehab |
| Thalassemia | - Hemoglobin electrophoresis / HPLC - confirms globin chain abnormality; raised HbA2 in beta-thalassemia trait - Creasy & Resnik's Maternal-Fetal Medicine - FBC: microcytic hypochromic anemia with disproportionately low MCV for degree of anemia - Iron studies to distinguish from iron deficiency (ferritin normal/high in thalassemia vs low in iron deficiency) - DNA analysis for genotype confirmation, especially in carrier screening - Emery's Elements of Medical Genetics - Family/genetic counseling and antenatal screening in high-prevalence populations | - Thalassemia minor/trait: usually no treatment needed, genetic counseling - Thalassemia major: regular blood transfusions to maintain Hb, plus iron chelation therapy (deferoxamine, deferasirox, deferiprone) to prevent iron overload - Tietz Textbook of Laboratory Medicine - Splenectomy considered for hypersplenism/high transfusion requirement - Folic acid supplementation, monitor for endocrinopathies/cardiac iron overload (T2* MRI) - Curative option: hematopoietic stem cell transplant in eligible patients |
| Anaemia | - FBC with MCV to classify (microcytic/normocytic/macrocytic), reticulocyte count - Iron studies: serum iron, ferritin, TIBC/transferrin saturation - core work-up for iron deficiency - Harrison's 22E - Peripheral blood film, B12/folate levels, LFTs/renal function - Consider anemia of chronic disease/inflammation if ferritin elevated despite low iron - Tietz Textbook of Laboratory Medicine - Investigate underlying cause (GI blood loss - endoscopy/colonoscopy if iron deficient without clear source) | - Treat underlying cause first (e.g., identify and manage GI bleeding source) - Iron deficiency: oral iron supplementation (ferrous sulfate); IV iron if intolerant/malabsorption/ongoing losses - B12/folate deficiency: replacement (IM B12 or oral high-dose, folic acid) - Anemia of chronic disease: treat underlying inflammatory/chronic condition; erythropoiesis-stimulating agents in select CKD patients - Transfusion for severe/symptomatic anemia or hemodynamic instability |
| ACS (Acute Coronary Syndrome) | - 12-lead ECG immediately - identify STEMI vs NSTEMI/UA; serial ECGs if initial non-diagnostic - Murray & Nadel's; Goldman-Cecil Medicine - High-sensitivity cardiac troponin - serial measurement per 0h/1h or 0h/3h protocols; predicts short and long-term risk of MI/death - Goldman-Cecil Medicine - History/exam/ECG alone cannot confirm or exclude ACS - troponin is essential - CXR, echo (wall motion, complications), coronary angiography for definitive anatomy | - STEMI: immediate reperfusion - primary PCI (preferred, door-to-balloon <90 min) or fibrinolysis if PCI unavailable within window - NSTEMI/UA: dual antiplatelet therapy (aspirin + P2Y12 inhibitor), anticoagulation (heparin/enoxaparin), risk-stratify (GRACE score) for early invasive vs conservative strategy - All ACS: beta-blocker, high-intensity statin, ACEi/ARB if LV dysfunction, nitrates/morphine for symptom relief - Cardiac rehabilitation and secondary prevention (lifestyle, risk factor control) post-discharge |
| Ascites | - Diagnostic paracentesis - test of choice for new-onset ascites; provides both diagnosis and symptomatic relief - Yamada's Gastroenterology; Pfenninger & Fowler's Procedures - SAAG (Serum-Ascites Albumin Gradient): ≥1.1 g/dL suggests portal hypertension (cirrhosis, cardiac); <1.1 g/dL suggests other causes (malignancy, TB, pancreatitis) - Harrison's 22E - Ascitic fluid cell count/differential (neutrophils >250/mm3 = SBP), total protein, culture, cytology if malignancy suspected - Cardiac ascites: high ascitic protein (≥2.5 g/dL) despite high SAAG - Sleisenger & Fordtran's | - Treat underlying cause (cirrhosis, heart failure, malignancy, TB) - Cirrhotic ascites: sodium restriction, diuretics (spironolactone +/- furosemide), therapeutic large-volume paracentesis for tense/refractory ascites with albumin replacement - Spontaneous bacterial peritonitis (neutrophils >250): empirical antibiotics (e.g., third-generation cephalosporin) + albumin, prophylactic antibiotics for recurrence prevention - Refractory ascites: consider TIPS or liver transplant evaluation - Avoid NSAIDs (worsen renal function/fluid retention) |
| CKD (Chronic Kidney Disease) | - eGFR (via creatinine-based equations) and urine albumin-to-creatinine ratio (UACR) - both independently predict progression; combined for KDIGO staging (G1-G5, A1-A3) - Comprehensive Clinical Nephrology; National Kidney Foundation Primer - Renal ultrasound (size, obstruction, cystic disease), urinalysis/microscopy - Identify underlying cause (diabetes, hypertension, glomerulonephritis workup if indicated), electrolytes, PTH/calcium/phosphate, Hb (anemia of CKD) | - Treat underlying cause and slow progression: BP control (ACEi/ARB first-line, especially with proteinuria), SGLT2 inhibitors, glycemic control in diabetics - Manage complications: phosphate binders, vitamin D analogs and PTH management (CKD-MBD), erythropoiesis-stimulating agents/iron for anemia, bicarbonate for metabolic acidosis - Avoid nephrotoxins (NSAIDs, contrast when possible), dose-adjust renally cleared drugs - Plan for renal replacement therapy (dialysis/transplant) as eGFR declines toward end-stage; dietary/nutritional counseling |
| AKI (Acute Kidney Injury) | - KDIGO criteria - staging by rise in serum creatinine (≥0.3 mg/dL in 48h, or ≥1.5x baseline in 7 days) and/or urine output <0.5 mL/kg/h for 6h - Brenner & Rector's; Sabiston Textbook of Surgery - Historically RIFLE and AKIN criteria, now merged into KDIGO classification - Comprehensive Clinical Nephrology - Identify pre-renal/intrinsic/post-renal cause: urinalysis, urine electrolytes/FENa, renal ultrasound (obstruction), review of drugs/contrast exposure, volume status assessment | - Identify and treat the cause: optimize volume status (fluid challenge if pre-renal, avoid overload), stop nephrotoxic drugs, relieve obstruction (catheterization/nephrostomy) if post-renal - Monitor U&E, fluid balance, and urine output closely; treat hyperkalemia, acidosis, volume overload as they arise - Renal replacement therapy (dialysis) indications: refractory hyperkalemia, severe acidosis, fluid overload unresponsive to diuretics, uremic complications (encephalopathy, pericarditis) - Most AKI is reversible with prompt correction of the underlying cause; avoid contrast/nephrotoxins during recovery |
| Liver Cirrhosis | - Child-Pugh score and MELD score - both used to grade severity and predict survival/prioritize transplant listing - Current Surgical Therapy - LFTs (may be near-normal in compensated cirrhosis), FBC (thrombocytopenia from hypersplenism), coagulation profile (INR) - Ultrasound/elastography (Fibroscan) for fibrosis staging; liver biopsy if diagnosis uncertain - Screen for complications: endoscopy for varices, AFP + imaging for HCC surveillance, ascites work-up (SAAG/paracentesis) | - Treat underlying cause (antivirals for viral hepatitis, alcohol cessation, weight loss/metabolic control for MASLD) - Manage complications: non-selective beta-blockers or banding for variceal bleeding prophylaxis, diuretics/paracentesis for ascites, lactulose/rifaximin for hepatic encephalopathy - Regular surveillance: 6-monthly ultrasound + AFP for HCC, periodic endoscopy for varices - Vaccinations (hepatitis A/B, pneumococcal, influenza), avoid hepatotoxins/NSAIDs/alcohol - Liver transplant evaluation for decompensated cirrhosis (rising MELD, refractory complications) |
Now let me build these into the same downloadable PDF format as before.
Reading File
Writing File
~/medical-quickref/build_pdf_2.py
# -*- coding: utf-8 -*-
from reportlab.lib.pagesizes import letter
from reportlab.lib import colors
from reportlab.lib.units import inch
from reportlab.platypus import (
SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
PageBreak, HRFlowable
)
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER
OUT = "/tmp/workspace/medical-quickref/output/Quick_Reference_Guide_Diagnoses_Set2.pdf"
styles = getSampleStyleSheet()
title_style = ParagraphStyle('TitleStyle', parent=styles['Title'], fontSize=26,
textColor=colors.HexColor('#0B3D66'), spaceAfter=6, alignment=TA_CENTER)
subtitle_style = ParagraphStyle('SubtitleStyle', parent=styles['Normal'], fontSize=13,
textColor=colors.HexColor('#444444'), alignment=TA_CENTER, spaceAfter=4)
disclaimer_style = ParagraphStyle('Disclaimer', parent=styles['Normal'], fontSize=8.5,
textColor=colors.HexColor('#777777'), alignment=TA_CENTER)
cond_title_style = ParagraphStyle('CondTitle', parent=styles['Heading1'], fontSize=18,
textColor=colors.white, spaceAfter=0, spaceBefore=0,
leftIndent=0)
section_head_style = ParagraphStyle('SectionHead', parent=styles['Heading3'], fontSize=12.5,
textColor=colors.HexColor('#0B3D66'), spaceBefore=8, spaceAfter=4)
body_style = ParagraphStyle('BodyCell', parent=styles['Normal'], fontSize=9.1, leading=12.3)
toc_style = ParagraphStyle('TOCItem', parent=styles['Normal'], fontSize=12, leading=20,
textColor=colors.HexColor('#0B3D66'))
ACCENT = {
"Stroke": "#1B4F72",
"Diabetic Neuropathy": "#8E44AD",
"Heart Failure": "#B03A2E",
"Thalassemia": "#117864",
"Anaemia": "#2C3E50",
"ACS (Acute Coronary Syndrome)": "#C0392B",
"Ascites": "#6C3483",
"CKD (Chronic Kidney Disease)": "#1E8449",
"AKI (Acute Kidney Injury)": "#B9770E",
"Liver Cirrhosis": "#7B241C",
}
def bl(items):
return "<br/>".join(f"• {i}" for i in items)
def make_condition_table(name, investigations, management, key_points=None):
color = colors.HexColor(ACCENT.get(name, "#0B3D66"))
flow = []
header_tbl = Table([[Paragraph(name.upper(), cond_title_style)]], colWidths=[6.9*inch])
header_tbl.setStyle(TableStyle([
('BACKGROUND', (0,0), (-1,-1), color),
('TOPPADDING', (0,0), (-1,-1), 10),
('BOTTOMPADDING', (0,0), (-1,-1), 10),
('LEFTPADDING', (0,0), (-1,-1), 12),
]))
flow.append(header_tbl)
flow.append(Spacer(1, 10))
inv_para = Paragraph(bl(investigations), body_style)
mgmt_para = Paragraph(bl(management), body_style)
data = [
[Paragraph("<b>INVESTIGATIONS</b>", section_head_style),
Paragraph("<b>MANAGEMENT</b>", section_head_style)],
[inv_para, mgmt_para]
]
t = Table(data, colWidths=[3.4*inch, 3.5*inch])
t.setStyle(TableStyle([
('BACKGROUND', (0,0), (-1,0), colors.HexColor('#EAF1F8')),
('BOX', (0,0), (-1,-1), 0.75, colors.HexColor('#B0B0B0')),
('INNERGRID', (0,0), (-1,-1), 0.5, colors.HexColor('#CCCCCC')),
('VALIGN', (0,0), (-1,-1), 'TOP'),
('LEFTPADDING', (0,0), (-1,-1), 8),
('RIGHTPADDING', (0,0), (-1,-1), 8),
('TOPPADDING', (0,0), (-1,-1), 6),
('BOTTOMPADDING', (0,0), (-1,-1), 8),
]))
flow.append(t)
if key_points:
flow.append(Spacer(1, 8))
kp_tbl = Table([[Paragraph("<b>RED FLAGS / KEY POINTS</b><br/>" + bl(key_points), body_style)]],
colWidths=[6.9*inch])
kp_tbl.setStyle(TableStyle([
('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#FDF2E9')),
('BOX', (0,0), (-1,-1), 0.75, colors.HexColor('#E5B98C')),
('LEFTPADDING', (0,0), (-1,-1), 10),
('RIGHTPADDING', (0,0), (-1,-1), 10),
('TOPPADDING', (0,0), (-1,-1), 6),
('BOTTOMPADDING', (0,0), (-1,-1), 6),
]))
flow.append(kp_tbl)
return flow
CONDITIONS = [
{
"name": "Stroke",
"investigations": [
"Non-contrast CT head immediately - exclude hemorrhage before thrombolysis",
"CT/MR angiography for large vessel occlusion; MRI-DWI for early ischemic change",
"NIHSS scoring for severity and treatment eligibility",
"Blood glucose (exclude hypoglycemia mimic), FBC, coagulation profile, U&E",
"ECG (screen for AF as cardioembolic source), lipid profile",
"Carotid Doppler / echocardiogram to identify embolic source",
],
"management": [
"Ischemic stroke: IV thrombolysis (alteplase/tenecteplase) within 4.5h of onset if no contraindication",
"Mechanical thrombectomy for large vessel occlusion (extended window with favorable imaging)",
"Minor/nondisabling stroke (NIHSS 0-5): aspirin or short dual antiplatelet therapy rather than thrombolysis",
"Hemorrhagic stroke: BP control, reverse anticoagulation, neurosurgical evacuation/ICP management if indicated",
"Secondary prevention: antiplatelet/anticoagulation (AF), statin, BP control, carotid revascularization if significant stenosis",
"Early rehabilitation (physio/speech/OT), formal swallow assessment before oral intake",
],
"key_points": [
"Time is brain - door-to-needle and door-to-groin times are critical quality metrics",
"Never give thrombolysis until hemorrhage is excluded on CT",
],
},
{
"name": "Diabetic Neuropathy",
"investigations": [
"10g monofilament testing, vibration perception (biothesiometer), ankle reflexes - screen for loss of protective sensation (LOPS)",
"Nerve conduction studies if diagnosis unclear or atypical pattern",
"HbA1c, vitamin B12, TFTs, renal function - exclude/identify contributing causes",
"Comprehensive foot examination for ulceration risk",
],
"management": [
"Optimize glycemic control - primary intervention to slow progression",
"Neuropathic pain: pregabalin/gabapentin, duloxetine, or amitriptyline (first-line agents)",
"Foot care education, protective footwear, regular podiatry review to prevent ulceration",
"Cardiovascular risk factor management (BP, lipids)",
"Screen for autonomic neuropathy (postural BP drop, gastroparesis symptoms)",
"Refer ulceration/Charcot foot to multidisciplinary diabetic foot team",
],
"key_points": [
"Loss of protective sensation is the single biggest risk factor for foot ulceration and amputation",
],
},
{
"name": "Heart Failure",
"investigations": [
"BNP / NT-proBNP - key biomarker; HFpEF threshold BNP >35 pg/mL",
"Echocardiography - assess LVEF, distinguish HFrEF vs HFpEF (HFpEF ~50% of HF population)",
"12-lead ECG, chest X-ray, U&E/creatinine, glucose, FBC",
"Coronary angiography if ischemic etiology suspected",
],
"management": [
"HFrEF: guideline-directed therapy - ACEi/ARB/ARNI + beta-blocker + MRA + SGLT2 inhibitor (\"four pillars\") + diuretics for congestion",
"HFpEF: SGLT2 inhibitors, diuretics for symptoms, manage comorbidities (hypertension, AF, obesity)",
"Acute decompensation: IV diuretics, oxygen, vasodilators if hypertensive, inotropes/mechanical support if cardiogenic shock",
"Device therapy (CRT/ICD) in selected reduced-EF patients",
"Fluid/salt restriction, daily weight monitoring, cardiac rehabilitation",
],
"key_points": [
"BNP is typically only mildly elevated (<200 pg/mL) in isolated pericardial constriction - helps differentiate from HF",
],
},
{
"name": "Thalassemia",
"investigations": [
"Hemoglobin electrophoresis / HPLC - confirms globin chain abnormality; raised HbA2 in beta-thalassemia trait",
"FBC: microcytic hypochromic anemia, MCV disproportionately low for degree of anemia",
"Iron studies to distinguish from iron deficiency (ferritin normal/high in thalassemia)",
"DNA analysis for genotype confirmation, especially carrier screening",
"Family and antenatal genetic counseling in high-prevalence populations",
],
"management": [
"Thalassemia trait/minor: usually no treatment needed; genetic counseling",
"Thalassemia major: regular blood transfusions to maintain Hb + iron chelation therapy (deferoxamine, deferasirox, deferiprone)",
"Splenectomy considered for hypersplenism / high transfusion requirement",
"Folic acid supplementation",
"Monitor for endocrinopathies and cardiac iron overload (T2* MRI)",
"Curative option: hematopoietic stem cell transplant in eligible patients",
],
"key_points": [
"Iron overload from chronic transfusion is the main long-term threat - chelation adherence is critical",
],
},
{
"name": "Anaemia",
"investigations": [
"FBC with MCV to classify (microcytic / normocytic / macrocytic), reticulocyte count",
"Iron studies: serum iron, ferritin, TIBC/transferrin saturation",
"Peripheral blood film, vitamin B12/folate levels, LFTs/renal function",
"Anemia of chronic disease/inflammation suspected if ferritin elevated despite low iron",
"Investigate underlying cause (e.g. endoscopy/colonoscopy for unexplained iron deficiency)",
],
"management": [
"Treat underlying cause first (e.g. identify and manage GI bleeding source)",
"Iron deficiency: oral iron supplementation; IV iron if intolerant/malabsorption/ongoing losses",
"B12/folate deficiency: replacement (IM B12 or high-dose oral, folic acid)",
"Anemia of chronic disease: treat underlying inflammatory/chronic condition; ESAs in select CKD patients",
"Transfusion for severe or symptomatic anemia / hemodynamic instability",
],
"key_points": [
"Unexplained iron-deficiency anemia in an adult warrants GI evaluation to exclude occult malignancy",
],
},
{
"name": "ACS (Acute Coronary Syndrome)",
"investigations": [
"12-lead ECG immediately - distinguish STEMI vs NSTEMI/unstable angina; repeat serial ECGs if non-diagnostic",
"High-sensitivity cardiac troponin - serial measurement (0h/1h or 0h/3h protocols)",
"History, exam, and ECG alone cannot confirm or exclude ACS - troponin is essential",
"Chest X-ray, echocardiogram (wall motion/complications), coronary angiography for definitive anatomy",
],
"management": [
"STEMI: immediate reperfusion - primary PCI preferred (door-to-balloon <90 min) or fibrinolysis if PCI unavailable",
"NSTEMI/UA: dual antiplatelet therapy (aspirin + P2Y12 inhibitor) + anticoagulation; risk-stratify (GRACE score) for early invasive vs conservative strategy",
"All ACS: beta-blocker, high-intensity statin, ACEi/ARB if LV dysfunction, nitrates/morphine for symptom relief",
"Cardiac rehabilitation and secondary prevention (lifestyle, risk factor control) post-discharge",
],
"key_points": [
"Troponin magnitude predicts both short-term (30-day) and long-term (1-year) risk of recurrent MI and death",
],
},
{
"name": "Ascites",
"investigations": [
"Diagnostic paracentesis - test of choice for new-onset ascites; both diagnostic and symptomatically relieving",
"SAAG (Serum-Ascites Albumin Gradient): ≥1.1 g/dL = portal hypertension (cirrhosis, cardiac); <1.1 g/dL = other causes (malignancy, TB, pancreatitis)",
"Ascitic fluid cell count/differential (neutrophils >250/mm3 = SBP), total protein, culture, cytology if malignancy suspected",
"Cardiac ascites: high ascitic protein (≥2.5 g/dL) despite high SAAG",
],
"management": [
"Treat underlying cause (cirrhosis, heart failure, malignancy, TB)",
"Cirrhotic ascites: sodium restriction, diuretics (spironolactone +/- furosemide), large-volume paracentesis with albumin replacement for tense/refractory ascites",
"Spontaneous bacterial peritonitis (neutrophils >250): empirical antibiotics (e.g. 3rd-generation cephalosporin) + albumin; prophylactic antibiotics to prevent recurrence",
"Refractory ascites: consider TIPS or liver transplant evaluation",
"Avoid NSAIDs (worsen renal function/fluid retention)",
],
"key_points": [
"SAAG indicates portal hypertension but does not itself confirm the underlying cause",
],
},
{
"name": "CKD (Chronic Kidney Disease)",
"investigations": [
"eGFR (creatinine-based) and urine albumin-to-creatinine ratio (UACR) - combined for KDIGO staging (G1-G5, A1-A3)",
"Renal ultrasound (size, obstruction, cystic disease), urinalysis/microscopy",
"Identify underlying cause (diabetes, hypertension, glomerulonephritis work-up if indicated)",
"Electrolytes, PTH/calcium/phosphate, hemoglobin (anemia of CKD)",
],
"management": [
"Treat underlying cause and slow progression: BP control (ACEi/ARB first-line, especially with proteinuria), SGLT2 inhibitors, glycemic control in diabetics",
"Manage complications: phosphate binders, vitamin D analogs/PTH management (CKD-MBD), ESAs/iron for anemia, bicarbonate for metabolic acidosis",
"Avoid nephrotoxins (NSAIDs, contrast when possible); dose-adjust renally cleared drugs",
"Plan renal replacement therapy (dialysis/transplant) as eGFR declines toward end-stage",
"Dietary and nutritional counseling",
],
"key_points": [
"eGFR and albuminuria are independent predictors of progression - both are needed for accurate staging",
],
},
{
"name": "AKI (Acute Kidney Injury)",
"investigations": [
"KDIGO criteria: rise in serum creatinine ≥0.3 mg/dL in 48h, or ≥1.5x baseline in 7 days, and/or urine output <0.5 mL/kg/h for 6h",
"Older RIFLE and AKIN criteria now merged into KDIGO classification",
"Identify pre-renal / intrinsic / post-renal cause: urinalysis, urine electrolytes/FENa, renal ultrasound (obstruction)",
"Review drug and contrast exposure, assess volume status",
],
"management": [
"Identify and treat the cause: optimize volume status (fluid challenge if pre-renal, avoid overload), stop nephrotoxic drugs, relieve obstruction (catheterization/nephrostomy) if post-renal",
"Monitor U&E, fluid balance, and urine output closely",
"Treat hyperkalemia, acidosis, and volume overload as they arise",
"Renal replacement therapy indications: refractory hyperkalemia, severe acidosis, fluid overload unresponsive to diuretics, uremic complications",
"Avoid contrast/nephrotoxins during recovery phase",
],
"key_points": [
"Most AKI is reversible with prompt correction of the underlying cause - early recognition is key",
],
},
{
"name": "Liver Cirrhosis",
"investigations": [
"Child-Pugh score and MELD score - grade severity, predict survival, prioritize transplant listing",
"LFTs (may be near-normal in compensated disease), FBC (thrombocytopenia from hypersplenism), coagulation profile (INR)",
"Ultrasound/elastography (Fibroscan) for fibrosis staging; liver biopsy if diagnosis uncertain",
"Screen for complications: endoscopy for varices, AFP + imaging for HCC surveillance, ascites work-up (SAAG/paracentesis)",
],
"management": [
"Treat underlying cause (antivirals for viral hepatitis, alcohol cessation, weight loss/metabolic control for MASLD)",
"Variceal bleeding prophylaxis: non-selective beta-blockers or endoscopic banding",
"Ascites: diuretics/paracentesis; hepatic encephalopathy: lactulose/rifaximin",
"Regular surveillance: 6-monthly ultrasound + AFP for HCC, periodic endoscopy for varices",
"Vaccinations (hepatitis A/B, pneumococcal, influenza); avoid hepatotoxins/NSAIDs/alcohol",
"Liver transplant evaluation for decompensated cirrhosis (rising MELD, refractory complications)",
],
"key_points": [
"Decompensation (ascites, variceal bleed, encephalopathy, jaundice) marks a major prognostic turning point",
],
},
]
def build():
doc = SimpleDocTemplate(OUT, pagesize=letter,
topMargin=0.6*inch, bottomMargin=0.6*inch,
leftMargin=0.55*inch, rightMargin=0.55*inch)
story = []
story.append(Spacer(1, 1.6*inch))
story.append(Paragraph("Clinical Quick-Reference Guide", title_style))
story.append(Spacer(1, 6))
story.append(Paragraph("Investigation & Management Summary - Set 2", subtitle_style))
story.append(Spacer(1, 4))
story.append(HRFlowable(width="60%", thickness=1.2, color=colors.HexColor('#0B3D66'), hAlign='CENTER'))
story.append(Spacer(1, 18))
conditions_list = ", ".join(c["name"] for c in CONDITIONS)
story.append(Paragraph(f"<b>Covers:</b> {conditions_list}", ParagraphStyle(
'CoverList', parent=styles['Normal'], fontSize=11.5, alignment=TA_CENTER,
textColor=colors.HexColor('#333333'), leading=16)))
story.append(Spacer(1, 0.9*inch))
story.append(Paragraph(
"For use as a bedside/clinical study aid. Not a substitute for full clinical "
"guidelines, local protocols, or specialist advice. Always confirm doses and "
"regimens against current local/national protocols before prescribing.",
disclaimer_style))
story.append(Spacer(1, 30))
story.append(Paragraph("Generated: August 2026", disclaimer_style))
story.append(PageBreak())
story.append(Paragraph("Contents", ParagraphStyle('TOCTitle', parent=styles['Heading1'],
fontSize=18, textColor=colors.HexColor('#0B3D66'))))
story.append(Spacer(1, 8))
for i, c in enumerate(CONDITIONS, start=1):
story.append(Paragraph(f"{i}. {c['name']}", toc_style))
story.append(PageBreak())
for idx, c in enumerate(CONDITIONS):
block = make_condition_table(c["name"], c["investigations"], c["management"],
c.get("key_points"))
story.extend(block)
if idx != len(CONDITIONS) - 1:
story.append(Spacer(1, 16))
story.append(HRFlowable(width="100%", thickness=0.5, color=colors.HexColor('#DDDDDD')))
story.append(Spacer(1, 16))
def add_footer(canvas_obj, doc_obj):
canvas_obj.saveState()
canvas_obj.setFont('Helvetica', 8)
canvas_obj.setFillColor(colors.HexColor('#999999'))
canvas_obj.drawString(0.55*inch, 0.35*inch, "Clinical Quick-Reference Guide - For educational use only")
canvas_obj.drawRightString(letter[0]-0.55*inch, 0.35*inch, f"Page {doc_obj.page}")
canvas_obj.restoreState()
doc.build(story, onFirstPage=add_footer, onLaterPages=add_footer)
print("PDF created at", OUT)
if __name__ == "__main__":
build()
Running Command
cd /tmp/workspace/medical-quickref && python build_pdf_2.py && python3 -c " from pypdf import PdfReader r = PdfReader('output/Quick_Reference_Guide_Diagnoses_Set2.pdf') print('Pages:', len(r.pages)) "
The second quick-reference PDF is ready - 7 pages covering Stroke, Diabetic Neuropathy, Heart Failure, Thalassemia, Anaemia, ACS, Ascites, CKD, AKI, and Liver Cirrhosis, in the same format as before (color-coded sections with side-by-side Investigations/Management and a Red Flags box), plus a cover page and table of contents.
Quick Reference Guide Diagnoses Set2
PDF Document · PDF
You now have two companion guides:
- - Pneumonia, Asthma, COPD, Dengue, Malaria, TB, Leptospirosis, Abscess
Quick Reference Guide Diagnoses
PDF Document · PDF
- - Stroke, Diabetic Neuropathy, Heart Failure, Thalassemia, Anaemia, ACS, Ascites, CKD, AKI, Liver Cirrhosis
Quick Reference Guide Diagnoses Set2
PDF Document · PDF
As before, this is a study/bedside aid drawn from standard textbooks - verify drug doses and specific protocols (e.g., PCI door-to-balloon targets, KDIGO staging thresholds, chelation dosing) against your local guidelines before clinical use. Let me know if you'd like the two merged into one combined PDF, or any condition expanded further.
mid diastolic murmur
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Searching Images
mitral stenosis mid-diastolic murmur auscultation phonocardiogram diagram
Mid-Diastolic Murmur
A mid-diastolic murmur occurs after S2, once the AV valves open, and reflects turbulent flow across the mitral or tricuspid valve during rapid ventricular filling. It is a low-pitched, rumbling murmur best heard with the bell of the stethoscope.
Causes
| Cause | Distinguishing Features |
|---|---|
| Mitral stenosis (most common cause) | Low-pitched, rumbling mid-diastolic murmur best heard at the apex in the left lateral position; accompanied by a loud/accentuated S1 and an opening snap. Murmur length correlates with severity - it lengthens as stenosis worsens - Bailey & Love's Short Practice of Surgery; Mulholland & Greenfield's Surgery |
| Tricuspid stenosis | Best heard at the lower left sternal border; increases in intensity with inspiration (increased venous return to right heart); may show a prominent y descent - Harrison's 22E |
| Austin Flint murmur (severe aortic regurgitation) | Low-pitched, mid-to-late diastolic murmur at the apex caused by the AR jet impinging on the anterior mitral leaflet, producing functional/relative mitral stenosis; can be confused with true mitral stenosis - Harrison's 22E; Symptom to Diagnosis |
| Carey-Coombs murmur (acute rheumatic fever) | Short, transient apical mid-diastolic murmur due to flow through an edematous, inflamed mitral valve during active valvulitis; accompanies the murmur of mitral regurgitation - Braunwald's Heart Disease; Rheumatology 2-Volume Set |
| Left/right atrial myxoma | Large myxomas prolapsing across the mitral (or tricuspid) valve can obstruct inflow, mimicking mitral stenosis; classically accompanied by a "tumor plop" (early diastolic sound 80-120ms after S2) and systemic features (fever, weight loss, emboli, syncope) - Fuster & Hurst's The Heart; Frameworks for Internal Medicine |
| High-flow states across a normal valve | e.g., tricuspid regurgitation, ASD, anomalous pulmonary venous return - increased flow volume alone can generate a mid-diastolic murmur without structural stenosis - Harrison's 22E |
| Complete heart block | An unusual cause listed alongside atrial myxoma and rheumatic valvulitis - Harrison's 22E |
Investigations
- Echocardiography (transthoracic +/- transesophageal) - the key investigation; assesses valve anatomy/mobility, mitral valve area, transvalvular gradient, left atrial size/thrombus, pulmonary artery pressure, and can identify an atrial myxoma directly
- ECG - look for left atrial enlargement (P mitrale), atrial fibrillation (common, especially age >50 with mitral stenosis - Goldman-Cecil Medicine), or evidence of pulmonary hypertension (RV hypertrophy)
- Chest X-ray - left atrial enlargement, pulmonary venous congestion, Kerley B lines, mitral valve calcification
- Cardiac MRI - useful adjunct for valve/chamber quantification when echo is inconclusive
- Cardiac catheterization - reserved for discrepancy between clinical and echo findings or pre-intervention hemodynamic assessment
- Blood cultures + full infective endocarditis work-up if fever/embolic phenomena raise suspicion of endocarditis or if murmur is of new onset in a febrile patient
Management
- Rheumatic mitral stenosis:
- Percutaneous balloon mitral valvuloplasty is the treatment of choice for symptomatic patients with suitable valve morphology (preferred over surgery when anatomy is favorable) - Harrison's 22E; Creasy & Resnik's Maternal-Fetal Medicine
- Surgical mitral valve repair/replacement when valvuloplasty is unsuitable (heavily calcified/fibrotic valve, significant regurgitation, left atrial thrombus)
- Rate control and anticoagulation for atrial fibrillation (common complication); diuretics for pulmonary congestion; secondary rheumatic fever prophylaxis (penicillin) if rheumatic etiology
- Elevated pulmonary artery pressure is a poor prognostic sign and often drives earlier intervention - Goldman-Cecil Medicine
- Austin Flint murmur: treat the underlying severe aortic regurgitation (surgical AV repair/replacement when criteria met) rather than the murmur itself
- Carey-Coombs murmur: manage the underlying acute rheumatic fever (anti-inflammatory therapy, penicillin, rest) - the murmur typically resolves as valvulitis settles
- Atrial myxoma: surgical excision is definitive treatment, generally urgent given embolic and obstructive risk
- Tricuspid stenosis: balloon valvuloplasty or surgical repair/replacement for symptomatic disease, usually in the context of combined rheumatic valve disease
Key clinical pearl
Both mitral stenosis and Austin Flint murmur produce an apical mid-diastolic rumble, but mitral stenosis has a loud S1 and opening snap, while Austin Flint occurs with the wide pulse pressure, collapsing pulse, and early diastolic decrescendo murmur of aortic regurgitation. Echocardiography is essential to distinguish structural mitral valve stenosis from AR-induced functional stenosis, since their management is entirely different.
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