Aquifer Material 2 Flashcards
Clinical features of subarachnoid hemorrhage
Subarachnoid hemorrhage classically causes the “worst headache of my life,” so should be considered with a severe headache, especially in a patient with no history of headache.
Importantly, subarachnoid hemorrhage causes meningeal irritation, producing the Burdzinski and Kurnig’s signs, just like meningitis.
Headache seen with subarachnoid hemorrhage is usually of sudden onset. Photophobia can occur with a subarachnoid hemorrhage, but it is less common than with meningitis or migraines.
Initial management of suspected meningitis
Organisms requiring Droplet isolation
- B. pertussis,
- influenza virus,
- adenovirus,
- rhinovirus,
- N. meningitidis,
- and group A Streptococcus
Organisms requiring Contact isolation
All infections spread by the fecal-oral route or skin colonization with infectious fomites
Isolation precautions for C. difficile
Patients with C. difficile are a special subset of patients within Contact precautions.
Since C. difficile are spore-forming bacteria, use of alcohol gel is insufficient to eliminate hand carriage of these bacteria.
Instead, thorough handwashing with soap in addition to usual hand hygiene is the recommended method to prevent nosocomial transmission of C. difficile in addition to usual contact isolation precautions.
Organisms requiring Airborne precautions
- Rubeolla/Measles
- VZV
- TB
- Smallpox
- SARS-CoV
- MERS-Cov
Standard empiric regimen for meningitis
Vancomycin and ceftriaxone
Also, add ampicillin if:
- > 50 years old
- History of alcohol abuse
- Immunocompromised
Adding ampicillin makes the regimen cover Listeria monocytogenes and Haemophilus influenzae.
Major categories of nosocomial infection
A patient is admitted to the hospital for suspected bacterial meningitis. A lumbar puncture is performed, and the results are pending. While awaiting the cerebrospinal fluid (CSF) results, what type of isolation would be the most appropriate for this patient?
For a patient with suspected bacterial meningitis, droplet precautions are the most appropriate type of isolation while awaiting CSF results.
How long should you wait before performing orthostatic vitals?
Only a few seconds. DO NOT wait 2 minutes.
Workup for acute delirium is going to varry quite a bit depending on the history, but what two things should you always order for anyone with delirium?
CBC and Chem7
Indications for acute dialysis
Current thinking on contrast-induced nephropathy
The 2018 American College of Radiology Manual on Contrast Media concludes that CIN is a real but rare condition.
They suggest that if a renal function threshold is to be used to avoid use of iodinated contrast a cut of < 30 ml/min/1.73m2 is best supported by the available data. In the case of AKI there is a lack of data but it is prudent to avoid iodinated contrast unless the potential benefits outweigh the risk.
Avoid it if you can, but do not let it disuade you from performing a potentially lifesaving diagnostic procedure
What is going on in this patient’s eye?
Choroid tubercles
The most common occular manifestation of tuberculosis
Specific definition of fever of unknown origin
FUO is a temperature greater than 38.3°C on several occasions lasting longer than three weeks with a diagnosis that remains uncertain after careful evaluation for three outpatient visits or three days of hospitalization.
Once diagnosed, all nonessential medications should be stopped, including acetominophen and ibuprofen.
Adult onset Still’s Disease
Adult onset Still’s disease (AOSD) is a rare inflammatory disorder that affects the entire body (systemic disease). The cause of the disorder is unknown (idiopathic). Affected individuals may develop episodes of high, spiking fevers, a pink or salmon colored rash, joint pain, muscle pain, a sore throat and other symptoms associated with systemic inflammatory disease. The specific symptoms and frequency of episodes vary from one person to another and the progression of the disorder is difficult to predict.
Often shows high levels of ferritin on labs. Treat w/ prednisone.
What are the most common infectious causes of FUO?
- An occult abscess
- Tuberculosis
- Endocarditis
What are the most common malignant causes of fever of unknown origin?
Hodgkin’s and Non-Hodgkin’s lymphomas
What are the most common autoimmune/autoinflammatory causes of fever of unknown origin?
- Adult-onset Still’s Disease
- SLE
- Temporal arteritis (particularly in adults over 50)
Things to look for in a patient presenting with longstanding, untreated hypertension
- Retinal exam to look for hypertensive retinopathy
- Detailed cardiac exam to look for cardiomegaly or signs of heart failure
- Thorough examination of peripheral pulses and assessment of aortic width to assess for abdominal aortic aneurysm
- Thyroid exam – is this due to hyperthyroidism?
Quick table of antihypertensives, indications, and adverse effects
DASH diet
When combined with reduced sodium, the Dietary Approaches to Stop Hypertension (DASH) diet, which involves foods low in saturated fats and rich in potassium and calcium, results in a blood pressure reduction similar to that achieved with a single antihypertensive agent.
Treating a hypertensive emergency or hypertensive urgency
Patients in hypertensive emergencies are at risk for: MI, stroke, encephalopathy, renal failure, aortic dissection, retinal hemorrhage, and heart failure. Patients with hypertensive emergency must have evidence of active organ dysfunction – otherwise it is hypertensive urgency.
Hypertensive emergencies require immediate treatment, often with intravenous agents such as labetalol or nitroprusside. Meanwhile, hypertensive urgency can usually be treated over a longer period of time with oral agents.
Signs of chronic hypertension on fundoscopic exam
Retinal arteriolar narrowing and arteriovenous crossing changes (“AV nicking”) may be seen in patients with long-standing hypertension.
Moderate or severe lightening in the appearance of the arteries (so called “copper-wiring” or “silver-wiring” respectively) may also be seen with long-standing hypertension. These are caused by the arteriolar thickening, which is an adaptive response to long-standing hypertension. These findings do not imply a hypertensive emergency.
In a patient being evaluated for hypertensive emergency versus urgency, the most important retinal findings to look for, with serious prognosis, include papilledema and hemorrhages, both of which indicate a more severe response to the hypertensive episode.
What is the target to bring someone down to if they are in hypertensive urgency or emergency?
180/90
What is one way to differentiate whether rhonchi are caused by secretions on pulmonary exam?
Have the patient cough and repeat the auscultation!
If the rhonchi are gone or significantly deminished, they were caused by secretions.
Causes of common cold
First-line treatments for acute sinusitis
- Nothing (they are largely self limited)
- Amoxicillin-clavulonate
- Doxycycline (if penicillin allegic)
If the above fail or symptoms persist for more than 12 weeks, use a broader agent. Chronic sinusitis is often polymicrobial.
Interventions that have been shown to actually work to reduce symptoms of URI
- Non-selective antihistamines
- NSAIDs
- Ipratropium bromide
Five A’s and Five R’s smoking cessation framework
Evidence-based methods to aid smoking cessation in patients
- Counselling
- Nicotine patch or inhaler
- Varenicline (chantix)
- Buproprion (welbutrin)
Varenicline (chantix)
Varenicline (Chantix) is the newest smoking-cessation medication. It is a nicotine acetylcholine receptor partial agonist, and in a randomized controlled trial patients had better quit rates than those who used bupropion.
For varenicline, the quit rate was 45% at three months compared to 34% for bupropion.
The Food and Drug Administration (FDA) has put out warnings of neuropsychiatric symptoms that occurred in patients who were taking varenicline. Patients should be monitored for suicidal ideation, increased agitation, vivid dreams, and depressed mood.
Contraindications to buproprion
Bupropion frequently causes insomnia and very rarely induces seizures. Check for history of seizures, head injuries, or eating disorders.
Tetralogy of fallot signs, symptoms, etiology
- Symptoms/Signs: Minimal exercise causes hypoxemia and cyanosis which is relieved by squatting, systolic murmur of ventricular septal defect
- Etiology: Abnormal neural crest cell migration leading to deviation of the infundibular septum, resulting in VSD and overriding aorta
Febrile neutropenia predisposes to infection with. . .
. . . gram negatives, especially Pseudomonas aeruginosa.
These individuals are at particular risk for ecthyma ganrenosum, shown below.
Cardiac changes of normal aging
On histology, there is also an accumulation of “lipofuscin” pigment, a perinuclear brownish pigment that is the result of subcellular membrane lipid oxidation.
Lipofuscin
Perinuclear brownish pigment that is the result of subcellular membrane lipid oxidation.
Normally develop in an aging heart.
Adverse effets of bisphosphonates
Bacillary angiomatosis
When patients with advanced AIDS get infected with Bartonella hensleae, instead of cat scratch disease, they get bacillary angiomatosis
This is characterized by eruption of tender, red nodules with a purplish corona on the effected limbs. These nodules are highly vascular, and on histology are composed mostly of large endothelial cells producing vascular channels within the lesion, and a neutrophilic/lymphocytic infiltrate.
Findings of pulmonary hypertension
- Progressive dyspnea
- Loud P2 and RV heave on exam
Flutamide
Flutamide is a competitive testosterone antagonist
It acts at the level of the testosterone and DHT receptors in the prostate and in prostate cancer
Adenomyosis is assocaited with ___ on bimanual exam
Adenomyosis is assocaited with uniform endometrial enlargement on bimanual exam
