### Diabetes Mellitus (DM)
**Diagnostic Criteria for Diabetes Mellitus (ADA Guidelines)**
A diagnosis is confirmed if one of the following four criteria is met (results must be confirmed by repeat testing in the absence of unequivocal symptomatic hyperglycemia):
* **Fasting Plasma Glucose (FPG):** \ge 126 mg/dL (fasting defined as no caloric intake for at least 8 hours).
* **2-Hour Plasma Glucose:** \ge 200 mg/dL during a 75-g Oral Glucose Tolerance Test (OGTT).
* **Hemoglobin A1c:** \ge 6.5%.
* **Random Plasma Glucose:** \ge 200 mg/dL in a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis.
**Screening and Management of Complications**
* **Microvascular:**
* *Retinopathy:* Annual dilated/comprehensive eye exam. Manage with optimized glycemic and blood pressure control; laser photocoagulation or anti-VEGF for advanced disease.
* *Nephropathy:* Annual screening with urinary albumin-to-creatinine ratio (UACR) and eGFR. Manage with ACE inhibitors or ARBs (if hypertensive or UACR \ge 300 mg/g) and SGLT2 inhibitors.
* *Neuropathy:* Annual comprehensive foot exam (10-g monofilament + pinprick/vibration testing). Manage pain with pregabalin, duloxetine, or gabapentin.
* **Macrovascular (Coronary Artery Disease, Cerebrovascular Disease, PAD):**
* *Screening:* Blood pressure checks at every visit, annual lipid profile, routine ASCVD risk assessment, and ABI testing if PAD symptoms exist.
* *Management:* Statin therapy (moderate to high intensity), aggressive BP control, antiplatelet therapy (aspirin) for secondary prevention (or primary if high risk), and utilizing GLP-1 RAs or SGLT2 inhibitors with proven cardiovascular benefit.
**First-Line Pharmacological Management & Contraindications**
* **First-line:** Metformin (in conjunction with comprehensive lifestyle modifications).
* **Contraindications:** Severe renal impairment (eGFR < 30 mL/min/1.73m²), acute or chronic metabolic acidosis (including DKA), and conditions predisposing to tissue hypoxia (e.g., severe heart failure, respiratory failure, acute myocardial infarction) due to the risk of lactic acidosis.
**Medication Adjustments in Chronic Kidney Disease (CKD)**
* **Metformin:** Halve the dose if eGFR is 30–45 mL/min/1.73m²; discontinue if eGFR drops below 30.
* **SGLT2 Inhibitors:** Highly recommended for renal protection to slow CKD progression, but initiation and dosing depend on specific eGFR cutoffs (usually initiated if eGFR \ge 20).
* **Insulin/Sulfonylureas:** Doses generally must be decreased as renal clearance declines to prevent severe hypoglycemia. AVOID glyburide entirely in CKD.
### CVA vs. TIA
**Clinical and Radiological Differentiation**
* **Clinical:** A Transient Ischemic Attack (TIA) is defined by transient neurological deficits that typically resolve entirely within 1-2 hours (always < 24 hours). A Cerebrovascular Accident (CVA/Stroke) presents with neurological deficits that persist beyond 24 hours.
* **Radiological:** A TIA shows **no** evidence of acute infarction on neuroimaging. A CVA shows permanent tissue infarction, best and earliest visualized as restricted diffusion on a Diffusion-Weighted MRI (DWI).
**tPA Time Window & Contraindications**
* **Time Window:** Standard window is up to 3 hours from the *last known normal*, extended to 4.5 hours in highly selected patients.
* **Absolute Contraindications (Three Examples):**
1. Evidence of intracranial hemorrhage on non-contrast CT.
2. Active internal bleeding or known bleeding diathesis (e.g., platelets < 100,000, elevated INR > 1.7).
3. Recent intracranial/intraspinal surgery or significant head trauma within the past 3 months.
**Immediate Diagnostic Workup for Acute Stroke (Right-sided weakness & aphasia)**
1. **Non-Contrast Head CT:** The most critical first step to rule out hemorrhagic stroke, which dictates immediate management and completely contraindicates tPA.
2. **Fingerstick Blood Glucose:** To rule out hypoglycemia, which can perfectly mimic stroke symptoms.
3. **Vitals & Neuro Exam:** Assess ABCs, stabilize hemodynamics, and calculate the NIH Stroke Scale (NIHSS) score.
4. **Ancillary Tests:** ECG (check for atrial fibrillation), basic metabolic panel, CBC, coags (PT/INR, aPTT), and cardiac troponins. (Do not delay tPA for labs unless bleeding abnormality is suspected).
**Long-Term Secondary Prevention for TIA**
* **Antiplatelet Therapy:** Aspirin, Clopidogrel, or short-term Dual Antiplatelet Therapy (DAPT) for 21-90 days if the ABCD2 score is high.
* **Lipid Management:** High-intensity statin therapy (e.g., Atorvastatin 80mg) with a target LDL < 70 mg/dL.
* **Hypertension Control:** Target BP < 130/80 mmHg using ACEi/ARBs or thiazides.
* **AFib/Carotid Screening:** Continuous cardiac monitoring to detect paroxysmal atrial fibrillation (switch to anticoagulants if found) and carotid duplex ultrasound (consider endarterectomy for symptomatic stenosis > 70%).
### DKA vs. HHS
**Key Laboratory and Clinical Differences**
* **DKA (Diabetic Ketoacidosis):** Typically seen in Type 1 DM. Rapid onset. Glucose usually 250-600 mg/dL. Severe high anion gap metabolic acidosis (pH < 7.3, Bicarbonate < 18 mEq/L). **Positive** serum and urine ketones.
* **HHS (Hyperosmolar Hyperglycemic State):** Typically seen in Type 2 DM. Insidious onset (days to weeks). Extreme hyperglycemia (Glucose often > 600-1000 mg/dL). Profound dehydration and hyperosmolality (Serum Osmolality > 320 mOsm/kg). Minimal to no acidosis (pH > 7.3) and trace or absent ketones.
**Fluid Resuscitation Protocol for DKA**
1. **Initial Volume Expansion:** Start with isotonic 0.9% Normal Saline at 15-20 mL/kg/hr (approx. 1-1.5 L) for the first 1-2 hours to restore intravascular volume and renal perfusion.
2. **Maintenance:** Reassess hydration status and check corrected serum sodium.
* If corrected sodium is normal or elevated \rightarrow switch to 0.45% NaCl at 250-500 mL/hr.
* If corrected sodium is low \rightarrow continue 0.9% NaCl at 250-500 mL/hr.
**Addition of Dextrose**
* Add 5% Dextrose (D5W) to the IV fluids when the blood glucose drops to **200 mg/dL** in DKA (or 250 mg/dL in HHS).
* **Why:** This prevents hypoglycemia. Insulin must be continued to shut down ketogenesis and close the anion gap. If insulin is stopped too early because glucose normalizes, the patient will remain acidotic.
**Managing Potassium Shifts & Insulin Contraindication**
* **Shifts:** Severe acidosis shifts K+ out of cells, making serum K+ look falsely normal or high despite total-body K+ depletion. IV Insulin drives K+ back into the cells, risking fatal hypokalemia.
* **Management:** Add K+ (usually 20-30 mEq/L) to IV fluids once serum K+ falls below 5.2 mEq/L and urine output is adequate.
* **Contraindication:** IV regular insulin administration is **absolutely contraindicated** if the serum potassium is **< 3.3 mEq/L**. Potassium must be aggressively replaced prior to starting the insulin drip.
### Hypertension: Urgency vs. Emergency
**Parameters Separating Urgency vs. Emergency**
* Both involve severe blood pressure elevation (usually Systolic > 180 and/or Diastolic > 120 mmHg).
* **Emergency:** Accompanied by evidence of new, acute, or worsening **target end-organ damage** (e.g., acute pulmonary edema, aortic dissection, hypertensive encephalopathy, acute kidney injury, ACS, or papilledema).
* **Urgency:** Severe elevation with *no* clinical or laboratory evidence of acute end-organ damage.
**Target BP Reduction in Emergency**
* Lower the Mean Arterial Pressure (MAP) by **no more than 20% to 25%** within the first hour.
* If stable, further reduce to approximately 160/100-110 mmHg over the next 2-6 hours, followed by a gradual return to normal over 24-48 hours.
**Exceptions to Gradual Reduction**
* **Acute Aortic Dissection:** Rapid and aggressive reduction is required. Target SBP < 120 mmHg and Heart Rate < 60 bpm within 20 minutes (using Beta-blockers like Esmolol first, then vasodilators like Nitroprusside).
* **Acute Ischemic Stroke:** "Permissive hypertension" is allowed to maintain cerebral perfusion. Do not lower BP unless it is > 220/120 mmHg, or > 185/110 mmHg if the patient is a candidate for tPA.
* **Intracerebral Hemorrhage:** Rapid reduction of SBP to < 140 mmHg is often indicated to prevent hematoma expansion.
**Preferred Intravenous Agents**
* **Hypertensive Encephalopathy:** IV Nicardipine, Clevidipine, or Labetalol.
* **Acute Heart Failure / Pulmonary Edema:** IV Nitroglycerin or Nitroprusside (reduces preload/afterload). **Avoid** Beta-blockers (like Labetalol) as they decrease cardiac inotropy.
### Electrolyte Imbalances
**Classic ECG Changes in Hyperkalemia**
1. **Mild (5.5 - 6.5 mEq/L):** Tall, peaked T waves with a narrow base (earliest sign).
2. **Moderate (6.5 - 8.0 mEq/L):** Loss of P waves, prolonged PR interval, ST-segment depression.
3. **Severe (> 8.0 mEq/L):** Widening of the QRS complex, merging with the T wave to form a **sine wave** pattern, eventually leading to ventricular fibrillation or asystole.
**Acute Medical Management (With ECG changes)**
1. **Stabilize the Myocardium:** **IV Calcium Gluconate** (or Calcium Chloride if central line). This does not lower potassium but instantly antagonizes the membrane effects of hyperkalemia, preventing fatal arrhythmias.
2. **Shift K+ Intracellularly:** IV Regular Insulin + 50% Dextrose (D50), Albuterol nebulizers, Sodium Bicarbonate (if severe metabolic acidosis is present).
3. **Excrete K+:** Loop diuretics (Furosemide), Gastrointestinal cation-exchange resins (Patiromer), or emergent Hemodialysis (if refractory or renal failure).
**Calculating Corrected Sodium in Hyperglycemia**
* Formula: For every 100 mg/dL increase in glucose above normal (100 mg/dL), the measured serum sodium decreases by **1.6 mEq/L**.
* *Note: Some modern formulas use a factor of 2.4 for glucose levels > 400 mg/dL.*
**Rapid Correction of Hyponatremia**
* **Danger:** Rapid correction of chronic hyponatremia causes fluid to shift out of brain cells, leading to **Osmotic Demyelination Syndrome** (Central Pontine Myelinolysis), causing irreversible flaccid paralysis, dysarthria, and "locked-in" syndrome.
* **Target Correction Rate:** Limit correction to **6-8 mEq/L** in any 24-hour period (absolute maximum of 8-10 mEq/L/24 hrs).
### Sepsis
**Definitions (Sepsis-3 Guidelines)**
* **Sepsis:** Life-threatening organ dysfunction caused by a dysregulated host response to infection. Diagnosed by a suspected/confirmed infection + an acute increase in the SOFA score by \ge 2 points. (SIRS criteria are no longer officially used to define sepsis. qSOFA is a quick bedside prompt to identify high-risk patients outside the ICU, though not a diagnostic criterion itself).
* **Septic Shock:** Sepsis associated with profound circulatory, cellular, and metabolic abnormalities. Defined clinically by the need for vasopressors to maintain a MAP \ge 65 mmHg **AND** a serum lactate > 2 mmol/L despite adequate fluid resuscitation.
**Hour-1 Bundle Components**
1. Measure lactate level (remeasure if initial lactate is > 2 mmol/L).
2. Obtain blood cultures **prior** to administration of antibiotics.
3. Administer broad-spectrum antibiotics.
4. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate \ge 4 mmol/L.
5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP \ge 65 mmHg.
**Initial Fluid Resuscitation**
* **Choice:** Balanced crystalloids (Lactated Ringer's or Plasma-Lyte) are preferred over 0.9% Normal Saline due to the risk of hyperchloremic metabolic acidosis with large volumes of NS.
* **Volume:** **30 mL/kg** given rapidly within the first 3 hours.
**First-Line Vasopressor**
* **Norepinephrine** (Levophed) is the universally recommended first-line vasopressor for septic shock.
### Tachy-Bradycardia
**Narrow Complex vs. Wide Complex Tachycardia (Acute Management)**
* *Is the patient stable or unstable?* (Unstable = hypotension, altered mental status, signs of shock, ischemic chest pain). If **Unstable**, proceed immediately to **Synchronized Cardioversion**.
* **Stable Narrow Complex (SVT):** Vagal maneuvers \rightarrow IV Adenosine \rightarrow IV Beta-blockers or non-dihydropyridine Calcium Channel Blockers (Diltiazem/Verapamil).
* **Stable Wide Complex (presumed VTach):** IV Amiodarone or Procainamide. (Avoid AV nodal blockers).
**Atrial Fibrillation Management**
* **Synchronized Cardioversion:** Indicated if the patient is hemodynamically unstable, or if the AFib is symptomatic and new-onset (< 48 hours).
* **Pharmacological Rate Control:** Indicated for stable patients, asymptomatic patients, or those with AFib lasting > 48 hours (to avoid dislodging a clot). Rate control is typically achieved with Beta-blockers or Diltiazem.
**Bradycardia & Atropine**
* **Indications:** IV Atropine is the first-line drug for symptomatic sinus bradycardia or 1st-degree/Mobitz I AV blocks.
* **Next Steps if Atropine Fails (or for high-grade blocks):** Transcutaneous pacing, or continuous chronotropic infusions such as Dopamine or Epinephrine.
**Tachy-Brady Syndrome (Sick Sinus Syndrome)**
* **Risk:** Characterized by alternating periods of supraventricular tachycardias (usually AFib) and severe bradycardia/sinus pauses. The major risk is syncope during the pauses and thromboembolism from the AFib.
* **Definitive Management:** Placement of a **Permanent Pacemaker** (to prevent the dangerous bradycardic episodes), which then allows the safe use of AV-nodal blocking medications to control the tachycardic episodes.
### Anemia
**Classification based on MCV**
* **Microcytic (MCV < 80 fL):** Iron Deficiency Anemia, Thalassemia, Lead poisoning, Sideroblastic anemia.
* **Normocytic (MCV 80-100 fL):** Acute blood loss, Anemia of Chronic Disease (often starts normocytic), Hemolytic anemias (usually).
* **Macrocytic (MCV > 100 fL):** Vitamin B12 deficiency, Folate deficiency, Alcoholism/Liver disease.
**Iron Deficiency vs. Anemia of Chronic Disease**
* **Iron Deficiency Anemia (IDA):** Low Serum Iron, **High** TIBC (Total Iron Binding Capacity), **Low** Ferritin (stores are depleted).
* **Anemia of Chronic Disease (AOCD):** Low Serum Iron, **Low or Normal** TIBC, **Normal or High** Ferritin (iron is sequestered in macrophages due to hepcidin).
**Differentiating B12 vs. Folate Deficiency**
* Both present with macrocytic anemia and hypersegmented neutrophils.
* **B12 Deficiency:** Elevated Homocysteine **AND** elevated Methylmalonic Acid (MMA). Accompanied by neurological symptoms (subacute combined degeneration).
* **Folate Deficiency:** Elevated Homocysteine, but **NORMAL** Methylmalonic Acid (MMA). No neurological symptoms.
**Sudden Drop in Hgb, Jaundice, Elevated Reticulocyte Count**
* This triad strongly indicates a **Hemolytic Anemia**.
* **Approach:** Check LDH (elevated), haptoglobin (decreased), and indirect bilirubin (elevated). Perform a direct antiglobulin (Coombs) test to differentiate immune vs. non-immune causes, and order a peripheral blood smear (looking for schistocytes, spherocytes, or bite cells).
### Myocardial Infarction (MI) / Chest Pain
**Immediate ER Management for Acute Chest Pain**
* Assess ABCs and obtain an **ECG within 10 minutes** of arrival.
* Provide Oxygen (only if SpO2 < 90%).
* Aspirin (162-325 mg chewed).
* Nitroglycerin (sublingual, to relieve pain and reduce preload).
* High-intensity Statin, P2Y12 inhibitor (e.g., Ticagrelor or Clopidogrel), and systemic anticoagulation (e.g., Heparin).
* If STEMI, activate the Cath Lab immediately (door-to-balloon time goal < 90 minutes).
**Differentiating STEMI, NSTEMI, and Unstable Angina**
* **STEMI:** ST-segment elevations (or new LBBB) on ECG + Positive Cardiac Biomarkers (Troponins). Complete transmural occlusion.
* **NSTEMI:** ST-segment depressions or T-wave inversions on ECG + Positive Cardiac Biomarkers (Troponins). Subendocardial infarction.
* **Unstable Angina (UA):** Ischemic symptoms at rest/increasing frequency, ischemic ECG changes (or normal ECG), but **Negative** Cardiac Biomarkers (no necrosis yet).
**Inferior Wall MI**
* **ECG Leads:** ST elevations in Leads **II, III, and aVF**.
* **Occluded Artery:** Typically the Right Coronary Artery (RCA) (80% of the time) or the Left Circumflex (LCx) (20% of the time).
**Caution with Nitroglycerin in Inferior/RV MI**
* The RCA supplies the Right Ventricle. An RV infarction causes the heart to become highly **preload-dependent** to maintain forward flow. Nitroglycerin is a potent venodilator that decreases preload; administering it can precipitate a sudden, profound, and life-threatening drop in blood pressure. (Treat hypotension in these patients with IV fluids).
### COPD / Asthma
**Differentiating Acute Asthma vs. COPD Exacerbation**
* **Clinical:** Asthma is often diagnosed in childhood, triggered by specific allergens/exercise, and features symptom-free intervals. COPD typically presents in patients > 40 with a heavy smoking history, featuring a chronic, progressive baseline cough and dyspnea.
* **PFTs:** Both show an obstructive pattern (FEV1/FVC < 0.70). Asthma exhibits **reversibility** (an increase in FEV1 by > 12% and > 200 mL after albuterol administration). COPD is largely **irreversible**.
**Step-Wise Management for Severe Asthma in the ER**
1. Oxygen to maintain SpO2 > 90%.
2. High-dose Short-Acting Beta-Agonists (SABA, e.g., Albuterol) + Short-Acting Muscarinic Antagonists (SAMA, e.g., Ipratropium) via nebulizer.
3. Systemic Corticosteroids (IV Methylprednisolone or PO Prednisone) immediately to reduce inflammation.
4. IV Magnesium Sulfate if there is no response to initial bronchodilators.
5. NIPPV (BiPAP) or endotracheal intubation if respiratory failure is imminent.
**BiPAP Criteria for COPD Exacerbation**
* Acute respiratory acidosis (pH \le 7.35 and PaCO2 \ge 45 mmHg).
* Severe dyspnea with clinical signs of respiratory muscle fatigue, increased work of breathing, or use of accessory muscles.
**Titrating Oxygen in Chronic COPD**
* Chronic COPD patients live with a chronically elevated PaCO2 and rely partially on mild hypoxia to drive their respiratory effort (hypoxic drive). Over-oxygenating them causes V/Q mismatching and the Haldane effect (decreased affinity of Hb for CO2), which dangerously increases PaCO2, leading to hypercapnic coma and respiratory failure.
* **Target:** Keep SpO2 strictly between **88% - 92%**.
### Pancreatitis / Cholecystitis / Appendicitis
**Acute Pancreatitis**
* **Diagnostic Criteria (need 2 of 3):** 1) Acute onset of severe, persistent epigastric pain radiating to the back. 2) Serum lipase or amylase elevated \ge 3 times the upper limit of normal. 3) Characteristic findings of acute pancreatitis on imaging (Contrast CT, MRI, or Ultrasound).
* **Most Common Causes:** Gallstones (most common) and Alcohol abuse (second most common).
**Acute Cholecystitis vs. Acute Cholangitis**
* **Acute Cholecystitis:** Inflammation of the gallbladder due to a cystic duct stone. Presents with RUQ pain, fever, leukocytosis, and a positive Murphy's sign.
* **Acute Cholangitis:** Infection of the biliary tree due to common bile duct obstruction. Presents with **Charcot's Triad** (RUQ pain, Fever, Jaundice). Severe cases progress to **Reynolds' Pentad** (+ Hypotension/Shock and Altered Mental Status).
**Appendicitis Physical Exam Signs**
* **McBurney's Point Tenderness:** Maximal tenderness 1/3 of the distance from the anterior superior iliac spine (ASIS) to the umbilicus.
* **Rovsing's Sign:** Palpation of the Left Lower Quadrant (LLQ) elicits pain in the Right Lower Quadrant (RLQ).
* **Psoas Sign:** RLQ pain with passive extension of the right hip (indicates a retrocecal appendix).
* **Obturator Sign:** RLQ pain with internal rotation of the flexed right hip (indicates a pelvic appendix).
**Scoring Systems for Pancreatitis Severity**
* Ranson's Criteria.
* BISAP (Bedside Index for Severity in Acute Pancreatitis) Score.
* APACHE II Score.
* Modified Marshall Scoring System (for organ dysfunction).
### Heart Failure
**HFrEF vs. HFpEF**
* **HFrEF (Systolic HF):** Heart Failure with *Reduced* Ejection Fraction (LVEF \le 40%). Pumping problem. Management is heavily focused on Guideline-Directed Medical Therapy (GDMT) that physically remodels the heart and reduces mortality.
* **HFpEF (Diastolic HF):** Heart Failure with *Preserved* Ejection Fraction (LVEF \ge 50%). Filling/stiffness problem. Management is focused on symptom relief (diuretics for volume overload) and aggressive treatment of comorbidities (HTN, AFib). Note: SGLT2 inhibitors are now shown to improve outcomes in HFpEF as well.
**Acute Decompensated Heart Failure (Pulmonary Edema) Management**
* **LMNOP:**
* **L**oop Diuretics (IV Furosemide) to reduce fluid overload.
* **N**itrates (IV Nitroglycerin) to rapidly decrease preload.
* **O**xygen (and Non-Invasive Ventilation/BiPAP, which decreases work of breathing and reduces preload/afterload).
* **P**osition (sit the patient upright).
*(Note: Morphine is no longer routinely recommended due to worse outcomes).*
**Mortality-Reducing Medications in HFrEF**
1. **Beta-Blockers** (specifically Metoprolol succinate, Carvedilol, and Bisoprolol).
2. **ACE inhibitors / ARBs** or **ARNIs** (Sacubitril/Valsartan, which is superior).
3. **Mineralocorticoid Receptor Antagonists** (Spironolactone, Eplerenone).
4. **SGLT2 Inhibitors** (Dapagliflozin, Empagliflozin).
**Cardiogenic vs. Non-Cardiogenic Pulmonary Edema (ARDS)**
* **Cardiogenic:** Usually features an S3 gallop, elevated JVP, cardiomegaly on CXR, significantly elevated BNP, and a Pulmonary Capillary Wedge Pressure (PCWP) > 18 mmHg.
* **Non-Cardiogenic (ARDS):** Usually normal heart size, flat neck veins, normal/low PCWP (< 18 mmHg), diffuse bilateral infiltrates, and severe hypoxemia (PaO2/FiO2 ratio < 300) secondary to an underlying inflammatory insult (sepsis, trauma, pneumonia).
### Pyelonephritis
**Clinical Differentiation (Lower vs. Upper UTI)**
* **Cystitis (Lower):** Presents with localized symptoms: dysuria, urinary frequency, urgency, and suprapubic pain. No systemic toxicity.
* **Pyelonephritis (Upper):** The infection has ascended to the kidneys. Presents with systemic symptoms: **Fever, chills, nausea/vomiting, flank pain, and Costovertebral Angle (CVA) tenderness**, often alongside dysuria.
**Empiric Antibiotic (Admitted Patient/Uncomplicated)**
* An admitted patient requires IV antibiotics. Empiric choices include **IV Ceftriaxone** or an IV Fluoroquinolone (e.g., Ciprofloxacin/Levofloxacin, provided local resistance is low). IV Piperacillin-Tazobactam or Cefepime can be used if Pseudomonas is suspected.
**Indications for Imaging (CT or Ultrasound)**
Imaging is not required for a classic, uncomplicated presentation but should be ordered if:
* The patient fails to improve after 48-72 hours of appropriate antibiotic therapy (ruling out perinephric abscess or obstruction).
* There is a history of nephrolithiasis or previous urologic surgery.
* The patient is severely ill, septic, or immunosuppressed.
* There is diagnostic uncertainty.
**Management in a Pregnant Patient**
* Acute pyelonephritis in pregnancy is considered a medical emergency due to high risks of sepsis, ARDS, and preterm labor.
* **Management:** Admit the patient for inpatient observation and IV antibiotics (typically **IV Ceftriaxone** or Ampicillin/Gentamicin).
* *Contraindications:* Fluoroquinolones (cartilage damage) and Tetracyclines (bone/teeth defects) are absolutely contraindicated in pregnancy.