PANRE-LA cheat sheet

STEMI: primary PCI within 90 minutes of first medical contact at a PCI-capable center; fibrinolysis within 30 minutes when PCI is unavailable and symptom onset is under 12 hours.

ACS: chewed aspirin 162–325 mg at first contact, plus a P2Y12 inhibitor and anticoagulant unless contraindicated.

HFrEF: quadruple therapy - ARNI (or ACE inhibitor/ARB), evidence-based beta-blocker (carvedilol, bisoprolol, metoprolol succinate), mineralocorticoid receptor antagonist, SGLT2 inhibitor - each reduces mortality.

Atrial fibrillation: anticoagulate when CHA2DS2-VASc is ≥2 in men or ≥3 in women; a score of 1 in men or 2 in women is a reasonable consideration.

Hypertension: first-line options are thiazide-type diuretic, ACE inhibitor or ARB, or dihydropyridine calcium channel blocker; never combine an ACE inhibitor with an ARB.

Severe aortic stenosis: valve area ≤1.0 cm², mean gradient ≥40 mmHg, or peak velocity ≥4 m/s; classic symptom triad is angina, syncope, and exertional dyspnea.

Acute pericarditis: positional pleuritic pain, diffuse ST elevation with PR depression, and friction rub; treat with NSAID plus colchicine.

Infective endocarditis: draw three sets of blood cultures before antibiotics; Staphylococcus aureus is the most common cause; apply modified Duke criteria.

COPD: LABA plus LAMA is initial maintenance for most symptomatic patients; only smoking cessation and long-term oxygen (PaO2 ≤55 mmHg or SpO2 ≤88%) change mortality.

Asthma: use inhaled corticosteroid-containing therapy at every severity step; short-acting beta-agonist alone is not adequate maintenance.

Pulmonary embolism: Wells score or PERC guides D-dimer and CTPA; hemodynamic instability warrants systemic thrombolysis or embolectomy.

CAP outpatient without comorbidity: amoxicillin or doxycycline; with comorbidity: amoxicillin-clavulanate plus macrolide, or respiratory fluoroquinolone monotherapy.

Tension pneumothorax: immediate needle decompression before imaging, followed by tube thoracostomy.

ARDS (Berlin definition): onset within 1 week, bilateral opacities, PaO2/FiO2 ≤300 mmHg on PEEP ≥5 cmH2O, not fully explained by cardiac failure.

Obstructive sleep apnea: AHI ≥5 with symptoms or AHI ≥15 alone; positive airway pressure is first-line therapy.

Latent tuberculosis: 3 months of weekly isoniazid plus rifapentine, or 4 months of daily rifampin; exclude active disease before starting.

GERD: 8-week PPI trial; alarm features (dysphagia, weight loss, anemia, bleeding, new symptoms after age 60) warrant endoscopy.

H. pylori: urea breath test or stool antigen for test-and-treat; bismuth quadruple therapy for 14 days after macrolide exposure or penicillin allergy.

Nonvariceal upper GI bleed: IV PPI plus endoscopy within 24 hours; variceal bleed: octreotide, ceftriaxone, and endoscopic band ligation.

Acute pancreatitis: diagnose with 2 of 3 (typical pain, lipase >3× upper limit of normal, imaging); lactated Ringer's resuscitation and early enteral feeding.

Ascites: spironolactone plus furosemide in a 100:40 ratio; ascitic PMN count ≥250 cells/mm³ defines SBP - give ceftriaxone plus albumin.

Hepatic encephalopathy: lactulose titrated to 2–3 soft stools daily; add rifaximin to prevent recurrence.

Celiac disease: tissue transglutaminase IgA with total IgA, confirmed by duodenal biopsy; lifelong gluten-free diet.

Refeeding syndrome: hypophosphatemia is the hallmark; give thiamine before feeding and replete phosphate, potassium, and magnesium.

Knee osteoarthritis: exercise, weight loss, topical NSAID, and intra-articular glucocorticoid; avoid chronic oral opioids.

Septic arthritis: arthrocentesis before antibiotics; synovial WBC >50,000/mm³ with >90% neutrophils is typical; start IV vancomycin plus ceftriaxone.

Gout: needle-shaped, negatively birefringent urate crystals; treat flares with NSAID, colchicine, or glucocorticoid; continue urate-lowering therapy during a flare.

Pseudogout: rhomboid, positively birefringent calcium pyrophosphate crystals with chondrocalcinosis; associate with hyperparathyroidism, hemochromatosis, hypomagnesemia.

Carpal tunnel syndrome: median nerve distribution, nocturnal symptoms, positive Phalen and Tinel signs; EMG confirms; splint, then injection or release.

Ankylosing spondylitis: inflammatory back pain, sacroiliitis on imaging, HLA-B27 association; NSAIDs first-line, TNF inhibitors for persistent disease.

Osteoporosis: T-score ≤ -2.5 at hip or spine; bisphosphonate first-line with calcium and vitamin D repletion.

Cauda equina syndrome: saddle anesthesia, bowel or bladder dysfunction, bilateral leg weakness - emergent MRI and decompression.

AKI (KDIGO): creatinine rise ≥0.3 mg/dL within 48 hours, rise to ≥1.5× baseline within 7 days, or urine output <0.5 mL/kg/h for 6 hours.

Hyperkalemia with ECG changes: IV calcium gluconate first, then insulin with glucose and inhaled beta-agonist; dialysis for refractory cases.

Nephrotic syndrome: proteinuria >3.5 g/day, hypoalbuminemia, edema, hyperlipidemia; minimal change disease is the most common cause in children.

Nephritic syndrome: hematuria with RBC casts, hypertension, oliguria; poststreptococcal glomerulonephritis and IgA nephropathy are common causes.

Uncomplicated cystitis: nitrofurantoin for 5 days or TMP-SMX for 3 days; avoid nitrofurantoin when creatinine clearance is below 30 mL/min.

Acute pyelonephritis: fluoroquinolone or ceftriaxone; admit for sepsis, intractable vomiting, or pregnancy, where IV beta-lactam is preferred.

Calcium oxalate stones are most common; acute colic is treated with an NSAID plus tamsulosin for distal ureteral stones 5–10 mm.

BPH: alpha-blocker for rapid symptom relief; 5-alpha reductase inhibitor for prostates >30–40 mL; combine when progression risk is high.

Acute ischemic stroke: noncontrast head CT first; IV thrombolysis within 4.5 hours if BP <185/110 mmHg; thrombectomy up to 24 hours in selected large-vessel occlusion.

Status epilepticus: benzodiazepine first, then levetiracetam, fosphenytoin, or valproate; refractory cases need intubation and continuous infusion.

Migraine: triptan plus NSAID for acute attacks; prophylaxis with propranolol, topiramate, amitriptyline, or a CGRP monoclonal antibody.

Subarachnoid hemorrhage: thunderclap headache; noncontrast CT within 6 hours is highly sensitive; if negative, lumbar puncture for xanthochromia or CT angiography.

Multiple sclerosis: McDonald criteria using MRI dissemination in space and time; CSF oligoclonal bands support; acute relapse treated with IV methylprednisolone.

Myasthenia gravis: fatigable ptosis and weakness with anti-acetylcholine receptor antibodies; infection and certain drugs precipitate crisis.

Parkinson disease: bradykinesia plus rigidity or rest tremor; levodopa-carbidopa is the most effective therapy.

Bell palsy: glucocorticoids within 72 hours improve recovery; add antiviral for severe disease; protect the eye with lubrication and taping.

DKA: glucose >250 mg/dL, ketones, anion gap acidosis; treat with isotonic fluids, insulin infusion, and potassium replacement - hold insulin if K <3.3 mEq/L.

HHS: glucose >600 mg/dL, osmolality >320 mOsm/kg, minimal ketosis; volume resuscitation is the priority.

Hypothyroidism: levothyroxine titrated to TSH; recheck TSH 6–8 weeks after any dose change.

Graves disease: suppressed TSH, elevated free T4/T3, diffuse goiter, ophthalmopathy, TSH receptor antibodies; treat with thionamide, beta-blocker, or radioactive iodine.

Thyroid storm: thionamide first, iodine at least 1 hour later, beta-blocker, glucocorticoid, and supportive care.

Adrenal crisis: hypotension unresponsive to fluids; give hydrocortisone immediately, then confirm with cosyntropin stimulation testing.

Primary aldosteronism: elevated aldosterone-to-renin ratio in resistant hypertension or hypokalemia; confirm with salt loading, then adrenal CT and vein sampling.

Type 2 diabetes: metformin first-line; add an SGLT2 inhibitor or GLP-1 receptor agonist when ASCVD, heart failure, or chronic kidney disease is present.

Iron deficiency: low ferritin, low serum iron, high TIBC, low transferrin saturation; evaluate men and postmenopausal women with GI endoscopy.

B12 deficiency: macrocytic anemia with neurologic symptoms; check intrinsic factor antibodies and treat with replacement.

HIT: platelet drop >50% at 5–10 days with thrombosis rather than bleeding; stop heparin and start argatroban, bivalirudin, or fondaparinux.

Febrile neutropenia: ANC <500/mm³ with fever ≥38.3°C; give antipseudomonal beta-lactam within 60 minutes.

Colorectal cancer screening begins at age 45 for average risk; colonoscopy every 10 years or annual FIT.

Tumor lysis syndrome: hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia; prevent with hydration plus allopurinol or rasburicase.

Sickle cell disease: hydroxyurea reduces vaso-occlusive crises; acute chest syndrome is a leading cause of death.

Hodgkin lymphoma: painless cervical lymphadenopathy, B symptoms, Reed-Sternberg cells; stage with PET-CT.

Melanoma: ABCDE warning signs; Breslow thickness determines excision margins and sentinel lymph node biopsy (≥0.8 mm or ulcerated).

Basal cell carcinoma: pearly papule with telangiectasia and rolled border; treat with excision or Mohs micrographic surgery.

Squamous cell carcinoma: hyperkeratotic, ulcerated plaque on sun-exposed skin; higher risk with immunosuppression.

Psoriasis: well-demarcated plaques on extensor surfaces with silvery scale, Auspitz sign, Koebner phenomenon; topical steroid, phototherapy, or biologics.

Atopic dermatitis: flexural eczematous lesions; emollients plus topical corticosteroid; dupilumab for refractory disease.

Cellulitis: nonpurulent cellulitis treated with cephalexin; fluctuant abscess needs incision and drainage plus MRSA-active coverage.

Herpes zoster: antivirals within 72 hours shorten illness and reduce postherpetic neuralgia; vaccinate adults aged 50 and older.

Tinea: KOH preparation shows septate hyphae; topical terbinafine is effective for most dermatophyte infections.

Sepsis: measure lactate, obtain cultures, give broad-spectrum antibiotics within 1 hour, and 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.

HIV: screen all adults; antiretroviral therapy for everyone; PrEP with tenofovir-emtricitabine; post-exposure prophylaxis within 72 hours for 28 days.

Syphilis: benzathine penicillin G for primary, secondary, and latent disease; IV penicillin for neurosyphilis; anticipate Jarisch-Herxheimer reaction.

C. difficile: fidaxomicin or oral vancomycin first-line; metronidazole only when neither is available; fecal microbiota transplant for recurrent disease.

Bacterial meningitis: dexamethasone plus vancomycin and ceftriaxone; add ampicillin for age >50 or immunocompromise.

Lyme disease: erythema migrans is diagnostic; doxycycline for early localized disease.

Influenza: oseltamivir within 48 hours for high-risk patients or severe illness.

Tuberculosis: RIPE regimen for 6 months; airborne isolation until sputum smears are negative.

Major depression: PHQ-9 for diagnosis and severity; SSRI first-line; continue treatment 6–12 months after remission.

Bipolar disorder: mood stabilizer such as lithium, valproate, or lamotrigine; avoid antidepressant monotherapy because of mania risk.

Schizophrenia: antipsychotic therapy with monitoring of weight, glucose, lipids, and QT interval.

Generalized anxiety disorder: CBT plus SSRI or SNRI; buspirone is an alternative.

Alcohol withdrawal: symptom-triggered benzodiazepines guided by CIWA-Ar; thiamine before glucose; delirium tremens peaks 48–96 hours after last drink.

Opioid use disorder: buprenorphine-naloxone or methadone maintenance; naloxone reverses overdose.

Serotonin syndrome: clonus, hyperreflexia, and hyperthermia; stop serotonergic agents and use cyproheptadine for moderate cases.

Suicide risk: ask directly about ideation, plan, intent, and access to means; document a safety plan.

Preeclampsia: BP ≥140/90 after 20 weeks plus proteinuria or end-organ dysfunction; severe features at ≥160/110 mmHg; treat with magnesium sulfate and delivery.

Ectopic pregnancy: serial hCG with transvaginal ultrasound; methotrexate if hemodynamically stable, unruptured, low hCG, and no fetal cardiac activity.

Gestational diabetes: screen at 24–28 weeks with a 50-g glucose challenge; treat with diet, then insulin if targets are not met.

Combined oral contraceptives are contraindicated with migraine with aura, smoking at age ≥35, and uncontrolled hypertension; LARC methods are most effective.

PCOS: Rotterdam criteria require 2 of 3 - oligo-ovulation, hyperandrogenism, polycystic ovaries; treat with weight loss, metformin, or combined OCPs.

PID: ceftriaxone plus doxycycline plus metronidazole; treat partners and test for gonorrhea and chlamydia.

Postpartum hemorrhage: uterine atony is most common; oxytocin first, then misoprostol, carboprost, or tranexamic acid.

Menopause hormone therapy is most effective for vasomotor symptoms; use the lowest effective dose, ideally started within 10 years of menopause.