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AII Week 3 > Clinical Medicine > Flashcards

Clinical Medicine Flashcards

1
Q

What is endocartitis

A

Bacterial (or rarely fungal) infection of cardiac valves. Involves the left side of the heart (mitral and aortic valves). Right side infections seen with drug users

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2
Q

What is the most common predisposing factor for infective endocarditis

A

Presence of structurally abnormal cardiac valves

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3
Q

What types of patients are at higher risk for endocarditis

A
  1. Hx of rheumatic or congenital heart disease
  2. Prosthetic heart valve
  3. Hx of prior endocarditis
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4
Q

Etiology of endocarditis

A
  1. Viridians, Group B/A streptococci
  2. Staph aureus!!!!! (subacute = coagulase - staph aureus)
  3. Enterococci
  4. HACKE group (very uncommon)
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5
Q

Risk factors of endocarditis

A
  1. IV drug users
  2. pt with recent dental work
  3. Genitourinary infections
  4. long term IV lines
  5. cardiac impants
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6
Q

What is a classic physical stigma associate with endocarditis

A
  1. Sustained high-grade bacteremia, which activates humoral and cellular immune response
  2. Increased serum levels of rheumatoid factor and hypergammaglobulinemia.
  3. Acute glomerulonephritis
  4. Splenomegaly
  5. Conjunctival/splinter hemorrhages
  6. Roths spots - spots in the retina
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7
Q

What are 2 cutaneous findings that suggest endocartitis

A
  1. Osler Nodes - painful papules on pads of fingers/toes

2. Janeway lesions -Painless hemorrhagic lesions on the palms/soles

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8
Q

Bacteremia

A

Presence of bacteria in the blood

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9
Q

Septicemia

A

“blood poisoning” Occurs when a bacterial infection enters the bloodstream. Can quickly progress to sepsis. Systemic

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10
Q

Sepsis

A

Severe response to the cytokines released following a bacterial exposure. Caused by vasodilation which leads to hypotension, which ultimately leads to septic shock and organ dysfunction.

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11
Q

SIRS

A

systemic inflammatory response syndrome. Dysregulated inflammation. A level of sepsis. Both infectious and noninfectious

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12
Q

Clinical criteria for SIRS (sepsis)

A
  1. Temp less than 36 or greater than 38C
  2. HR >90bpm
  3. RR >20, PaCO2 12,000 or less than 4000
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13
Q

Clinical criteria for severe sepsis

A
  1. BP 3sec
  2. Intravascular coagulation
  3. Acute renal failure or urine output 2mg/dl
  4. Acute lung injury
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14
Q

Clinical criteria for septic shock

A

Same as severe sepsis except with refractory hypotension (BP4

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15
Q

How does organ failure occur in a septic patient

A

The inflammatory mediators (cytokines) are released in such large quantities in response to the bacteria that it causes destruction of surround tissue.

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16
Q

What is the foundation of the early goal directed therapy

A
  1. Early administration of fluids and ABX.
  2. Tx hypoxemia and hypotension
  3. Stabilize airway
  4. Restore perfusion to peripheral tissues (goes with #1)
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17
Q

Fever of Unknown Origin (FUO)

A
  1. Illness of at least 3 weeks
  2. Fever over 38.3C on many occasions
  3. No dx after 3 OP visit or 3 days of hospitalization
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18
Q

Common causes of FUO (differential Dx)

A
  1. Infections - TB, endocartitis, CMV, UTI, pneumonia
  2. Neoplasms - lymphoma, leukemia
  3. Misc - GB disease, drug fever, hyperthyroidism
  4. Autoimmune - SLE, cryoglobulinemia, RA
  5. Viral causes
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19
Q

Clinical presentation of FUO

A

Fever, tachycardia, chills, piloerection

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20
Q

Diagnostic work up of FUO

A
  1. CBC with diff
  2. Rheumatoid factor
  3. CXR
  4. ABD CT
  5. Potential BX
  6. Urinalysis
  7. Always test for HIV
  8. See slide 36 for more
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21
Q

Tx of FUO

A
  1. Do not begin empiric ABX or corticosteroids - suppresses fever and increase the spread of infection
  2. Admit pt if rapidly losing weight
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22
Q

Organism involved in catheter associated UTI (CAUTI)

A
  1. E. coli
  2. Nosocomial gram - bacilli
  3. Enterococci
  4. Candida
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23
Q

Prevention of CAUTI

A
  1. Only use bladder caths when absolutely necessary
  2. Aseptic technique
  3. Minimize manipulation or opening of drainage system
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24
Q

Organisms involved in ventilator associated pneumonia (VAP)

A
  1. Nosocomial oropharyngeal flora
  2. Strep pneumoniae
  3. Haemophilus species
  4. Staph aureus
  5. p. Aeruginosa
  6. Enterobacter
  7. Klebsiella
  8. Acinetobacter
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25
Q

Prevention of VAP

A
  1. Elevate head of bed 30-45
  2. Decontaminate oropharynx regularly with chlorhexidine (controversial)
  3. Give sedation vacation
  4. Assess readiness to extubatne daily
  5. Use peptic ulcer disease prophylaxis
26
Q

Organisms involved in surgical site infections (SSI)

A
  1. Staph aureus
  2. Coagulase negative staphylococci
  3. Enteric and anaerobic bacteria
  4. Group A strep/clostridium - only in rapid manifestations (24hrs post op)
27
Q

Prevention of SSI

A
  1. Prophylactic ABX 1hr preop
  2. Limit any hair removal - use clippers or do not remove hair
  3. Chloraprep
  4. Maintain normal glucose levels
28
Q

Organisms involved in central line associated bloodstream infections (CLABSI)

A
  1. Coagulase negative staph
  2. Staph aureus (MRSA)
  3. Enterococci
  4. Nosocomial gram - bacilli
  5. Candida
29
Q

Prevention of CLABSI

A

Catheter insertion bundle!!

  1. Daily review of line necessity
  2. Use chlorprep
  3. Maximal barrier precautions (ie sterile technique)
  4. Use a checklist to enhance adherence to bundle
30
Q

Common sites of infection of anaerobic bacteria

A
  1. CNS
  2. URI
  3. Dental
  4. Deep neck infections
  5. Misc - chronic sinusitis, chronic otitis media, and mastoiditis
  6. Lower Resp (usually from aspiration of oral secretions
31
Q

Clinical signs of anaerobic infections

A
  1. Putrid drainage
  2. Polymicrobial flora on gram stain
  3. Infection from normal flora in the wrong spot
  4. Abscess formation
32
Q

Management of anaerobic infections

A
  1. Abscess drainage

2. ABS tx - usually empiric

33
Q

Acute otitis media

A

fluid and mucosal inflammation in middle ear. Common in young children (by 3 many children have already had one episode)

34
Q

Causes of acute otitis media

A

VIRAL or bacterial upper respiratory infections. Cause disruption of eustachian tube drainage. (2nd bacterial infection from s. pneumonia, h. flu, strep)

35
Q

Clinical presentation of acute otitis media (mostly effects children)

A
  1. Fever
  2. Chills
  3. Ear pain
  4. Ear drainage!
  5. Inflammation of mucosa
  6. Erythema!
  7. Hearing issues
    Tympanic membrane erythematous, loss of landmarks and bulging - will be immobile with air puff
36
Q

Management (tx) of acute otitis media

A
  1. Most are caused by viruses which will not respond to ABX

2. if ABx is necessary give HIGH dose amoxicillin

37
Q

Otitis externa clinical presentation

A
  1. Swimmers ear.
  2. Inflammation of the external auditory canal
  3. Ear pain
  4. Pruritus
  5. Discharge
38
Q

Causes of otitis externa

A
  1. Acute bacterial infection!!! Pseudomonas, staph aureus
  2. Allergy
  3. Dermatologic disease
39
Q

Complications of otitis externa

A

Periauricular cellulits and can manifest into malignant external otitis

40
Q

Management of otitis externa

A

Clean canal with dilute hydrogen peroxide, topical drugs. Fluoroquinolone

41
Q

Prevention of otitis externa

A

No q-tips! dry ears after swimming

42
Q

Complications of acute otitis media

A

Hearing loss, balance and motor problems

43
Q

Chronic otitis media

A

Recurrent infection of the middle ear (AOM) and or mastoid air cell tract (in the presence of tympanic membrane perforation

44
Q

Clinical symptoms of chronic otitis media

A
  1. Hearing loss
  2. Otorrhea (for 6weeks -3 months)
  3. Ear fullness
  4. Otalgia
  5. Vertigo (not as common)
    * Hallmark is purulent aural discharge**
45
Q

Causes of chronic otitis media

A
  1. Often follows episodes of acute otitis media
  2. P aeruginosa
  3. Proteus species
  4. Staph aureus
  5. Poor hygiene (lower socioeconomic)
46
Q

Complications of chronic otitis media

A
  1. Mastoiditis
  2. Intracranial complications (abscess)
  3. Facial nerve palsy
  4. Hearing loss
47
Q

Management of chronic otitis media

A
  1. Aural toilet - Aural irrigation

2. ABX - topical are the first line tx

48
Q

Prevention of chronic otitis media

A

Treat AOM before it becomes chronic

49
Q

Serous otitis media (OME)

A

Otitis media that has an accompanying effusion. Middle ear effusion without acute sign of infection “glue ear.” Usually caused by initial URI

50
Q

Clinical presentation of serous otitis media

A
  1. Most often absent of signs
  2. When symptomatic - hearing loss that is mild and fluctuating. (conductive hearing loss)
  3. ear pain, sleep disturbance or ear fullness
51
Q

Complications of serous otitis media

A
  1. Hearing los
  2. Tympanosclerosis
  3. Retraction pocket
  4. Cholesteatoma - dying epithelium/keratin
52
Q

Management of serous otitis media

A
  1. hearing evaluation
  2. Watching
  3. Tubes
  4. ABX, steroids, antihistamines
53
Q

Prevention of serous otitis media

A

Keep ears dry, no q-tips

54
Q

Mastoiditis

A

Inflammation of the mastoid air cells. Most common suppurative complication of AOM. May be first evidence of AOM

55
Q

Clinical presentation of mastoiditis

A
  1. Lack of symptoms
  2. Spontaneous resolution
  3. Acute - erythema, post auricular tenderness, swelling
56
Q

Cause of mastoiditis

A

During AOM the mucosa in middle ear becomes inflamed. Inadequate tx of AOM. P. pneumonia, H influx, s pyogenes

57
Q

Complications of mastoiditis

A

Extracranial abscess, facial nerve palsy, hearing loss.

Intracranial meningitis, cerebral abscess

58
Q

Management of mastoiditis

A

Acute mastoiditis requires IV ABX. Tympanocentesis to drain middle ear fluid

59
Q

Prevention of mastoiditis

A

Early treatment of AOM

60
Q

What are appropriate questions to ask during the history of FUO

A
  1. Geographic exposures
  2. Animals - pets, farm animals
  3. Do they hike, where do they hike
  4. Live in Rural/urban areas
  5. Do they eat roadkill
  6. Exposure to TB
  7. Food exposures
  8. HIV risk factors
  9. Prior surgeries- hardware
61
Q

Management of endocarditis

A
  1. Penicillin - when it is streptococcus (RESISTANT TO VANCOMYCIN). Have to be bacteriocidal! Longer durations.
  2. Surgery
  3. Surveillance of CBC
  4. Vanco/dapto- when it is MRSA (but they have a high relapse rate)
62
Q

S/Sx of endocarditis

A
  1. High grade fever/chills
  2. SOB
  3. Arthralgias/myalgias
  4. Abd Px
  5. Pleuritic chest px
  6. Back pain!!!! Think of the IV drug users

AII Week 3 (5 decks)

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