Acute and Episodic Conditions
What the exam tests
Acute and episodic questions ask: is this self-limited, bacterial, or an emergency? Your job is to recognize dangerous mimics, use severity tools, and avoid antibiotics when they do not help.
Concepts
Upper respiratory infections and acute bronchitis are viral; purulent sputum does not justify antibiotics. For pharyngitis, use Centor/McIsaac to decide on rapid strep testing and treat confirmed group A strep. Acute bacterial rhinosinusitis requires at least 10 days without improvement, severe symptoms, or double worsening. For pneumonia, confirm with imaging and use CURB-65 to decide site of care. Distinguish cystitis and pyelonephritis from asymptomatic bacteriuria; do not treat asymptomatic bacteriuria except in pregnancy or before urologic procedures. For cellulitis, mark borders and consider mimics such as stasis dermatitis and DVT. For DVT and PE, establish pretest probability first.
Traps
Treating asymptomatic bacteriuria in an older adult with confusion; prescribing antibiotics for bronchitis; missing sepsis; failing to consider ACS in epigastric pain; missing back pain red flags (fever, cancer history, neurologic deficits, new pain after age 50); and using imaging for uncomplicated musculoskeletal pain.
Worked example
A 45-year-old has 5 days of cough, low-grade fever, clear-to-purulent sputum, and no dyspnea. The exam is normal and there is no infiltrate. This is acute bronchitis; treatment is supportive. Antibiotics do not shorten illness and cause harm.
Rule of thumb
For acute infections, ask two questions: Does this patient need antibiotics, and does this patient need admission? If neither, focus on symptom control and clear return precautions.