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Step 3 > ID and Pulm > Flashcards

ID and Pulm Flashcards

1
Q

What is the next step after a PPD is positive?

A

rule out active TB - chest xray

check LFTs to get a baseline for thinking about giving isoniazid

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2
Q

What are the diagnostic criteria for spontaneous bacterial peritonitis?

A

paracentesis with PMN > 250 or total WBC >500 in the ascitic fluid
gram stain is helpful if positive, but not is negative (can’t rule out)

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3
Q

How do you dx cryptococcal meningitis?

A

hx of HIV with CD4 <100
cryptococcal antigen test >90%
India ink test will be positive in 50-70%

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4
Q

How do you treat lyme disease with advanced disease? (heart block)

A

IV ceftriaxone

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5
Q

Why don’t we give patients with a fib heparin before starting warfarin?

A

because they don’t already have a clot burden, so warfarin necrosis doesn’t happen (pt unliekly to have protein C or S deficiency)

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6
Q

How do you treat cryptococcal meningitis?

A

IV amphotericin then flucytosine for 2 weeks, then oral fluconazole until CD4 > 100 or 3 months
*make sure HIV pts also on HAART

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7
Q

What organisms commonly cause cellulitis?

A

staph (MSSA ) or group A strep (S. pyogenes)

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8
Q

What is the treatment for Hepatitis C?

A

check genotype
check viral load - tx if elevated RNA viral load
interferon with ribavarin
if type 1: also give sofosbuvir or simeprevir for 12 wks

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9
Q

What vital change can you see with OSA?

A

HTN

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10
Q

How do you treat osteomyelitis?

A
  1. GET A BONE BIOPSY to ID organism

2. Start antibiotics (no empiric coverage, only targeted treatment)

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11
Q

How do you treat osteomyelitis with MSSA?

A

IV oxacillin or nafcillin or cefazolin for 6-12 wks

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12
Q

How do you decide if a pt with penumonia needs to be hospitalized?

A 
CURB-65 (1 pt for each)
Confusion
Blood urea nitrogen >19.6
RR >/= 30
Systolic BP <90 or Diastolic BP <60
Age >/=65
If 2 positive or greater -> hospitalize
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13
Q

What is the most common cause of an asthma exacerbation?

A

Viral infections

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14
Q

What antibiotic do you use if patient is allergic to vancomycin?

A

daptomycin

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15
Q

What tests do you get to look for a pulmonary embolism?

A

lytes, EKG, chest xray, D-dimer, ProBNP, lactrate, ABG, pulse ox
CT Angio “gold standard”
*V/Q scan if renal failure or contrast allergy

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16
Q

What is the differential for bradycardia with heart block?

A
  1. hypothyroidism
  2. Lyme Disease
  3. Beta-blocker or calcium channel blocker
  4. Ischemic heart disease
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17
Q

What is the natural hx of spontaneous bacterial peritonitis?

A

70% will recur, if take prophylactic antibiotics it goes down to <20%

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18
Q

What are the hallmark signs of legionella?

A
  1. atypical pneumnonia
  2. hyponatremia due to SIADH
  3. diarrhea
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19
Q

What organisms can cause subacute bacterial endocarditis?

A

strep -50-60% mostly viridans, bovus assoc with GI neoplasm (get a GI study)
staph - 30%
enterococci 5-10% (strep species - cocci in pairs and chains)

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20
Q

How do you dx meningitic TB?

A

CSF stain/culture
LP - looks like viral w/ elevated protein and low glucose
Meningeal biopsy

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21
Q

What abx do we use to treat MSSA?

A

nafcillin or oxacillin, could also do a first gen cephalosporin (cefazolin)

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22
Q

What would a CT show with necrotizing fasciitis?

A

gas formation within the fascia

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23
Q

What diseases are assocaited with erythema nodosa?

A

Sarcoid, IBD, TB, lymphona, fungal infections, bacterial infections

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24
Q

How do you dx urinary tract infection?

A

increased WBC and nitrate positive and bacteria +

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25
Q

What must be consdiered in young patients with emphysema involving the base of the lung and liver abnormalities?

A

alpha-1-antitrypsin deficiency

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26
Q

How do you treat uncomplicated UTI?

A
  1. trimethoprim-sulfamethoxazole (3 days)
  2. fosfomycin (1 dose)
  3. nitrofurantoin (5 days)
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27
Q

What organisms do you have to consider with community acquired pneumonia?

A
  1. pneumococcal pneumonia
  2. haemophilus
  3. atypicals (legionella, chlamydia, mycoplasma)
  4. TB
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28
Q

How do you work up elevated liver enzymes?

A

hepatitis serologies
MRI can show increased iron
sonography shows fat infiltration

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29
Q

How do you change management with red man syndrome from vancomycin?

A

slow the infusion

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30
Q

How do you treat mixed flore necrotizing fasciitis?

A

vancomycin, daptomycin, tigacycline, ceftaroline, linezolid (to cover MRSA)
+
imipenem/meropenem, pip/tazo, ticarcillin/clavulinate, cefepime w/ metronidozole (to cover gram neg, including pseudomonas and anaerobes)
+
clindamycin (for toxin production)

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31
Q

What must you consider in a pt with meningitic symptoms and a low DC4 count?

A

cryptococcal meningitis

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32
Q

What are the 2 types of asthma?

A
  1. Intrinsic (nonallergic - 50%)

2. Extrinsic - (allergic 20%)

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33
Q

How do you treat HIV with CD4 < 200?

A

prophylaxis for penumocystis jiroveci: tmp/smx (*if allergic, dapsone or atovaquone)

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34
Q

Who needs a booster for the pneumococcal vaccine (PPSV23)?

A

anyone who received it prior to age 60 at age 65.
those at risk of fatal infection
NO ONE gets more than 1 booster

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35
Q

What is the possible serious side effect of nafcillin or oxacillin? What do you do?

A

Allergic interstitial nephritis (fever, rash, acute renal failure) Confirm dx with urine eosinophils. Stop agent

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36
Q

How you you empiracally tx eikenella (human bites/mouth)?

A

amox + clauv

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37
Q

What do you do if a pt isn’t responding to treatment in3-5 days for pyelonephritis?

A

Get a CT to look for an abscess - drain it!

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38
Q

What is the difference between HSV 1 and 2?

A

HSV 2 is harder to treat and tends to recurr more.

*they can both cause oral/genital lesions, but general HSV 1:oral, HSV 2: genital

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39
Q

How do you ddx OSA?

A

sleep study is dx and tx - split night nocturnal polysomnography w/ CPAP titration with apnea hyponea index > 15

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40
Q

Colon cancer screening recs for 1st degree relative with colorectal cancer <60 yo or many first degree relatives with it

A

Whatever happens first

  • age 40 or age that is 10 yrs prior to the age at which the youngest relative was dx
  • colo every 5 yrs
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41
Q

What are the classic symptoms of active TB?

A

weight loss
fever
cough, sputum
night sweats

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42
Q

What are the criteria for home O2 for emphysema?

A

PaO2 = 55 or sat <88%
pt has cor pulmonale and PaO2 <60
If on 6 min walk test, they desat on exertion

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43
Q

How do you treat a pt with lyme dz with the classic rash?

A

give doxycycline, don’t send titers (too early for them to be positive)

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44
Q

How do you test and dx active TB?

A

chest xray with cavitary lesion in RU lobe, respiratory sputum x3 sample for acid-fast bascillus stain and culture (NO PPD - not helpful in active TB)

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45
Q

What are the 3 indications for daptomycin?

A

MRSA skin and soft tissue infection, right-sided endocarditis, and bacteremia due to line sepsis

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46
Q

Side effects of necleoside reverside transcriptase inhibitors?

A

general malaise, vomiting, nasuea

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47
Q

How to treat patients with advanced cancer who have a PE?

A

they need to be treated with LMWH (not warfarin) long term

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48
Q

How do you treat gram negative osteomyelitis?

A

can use oral ciprofloxacin! Awesome - get the bone biopsy so that it is possible to do this!

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49
Q

When do we use thrombolysis in pulmonary emobolism?

A

shock!

tPA if sys BP < 90 or decr >40 from baseline or MAP <70

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50
Q

What might you see on ABG with OSA?

A

elevated bicarb - chronic hypoxemia that is compensating

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51
Q

Cervical cancer screening recs

A

Pap test from 21-65 every 3 years (regardless of sexual activity)

  • can do Pap +HPV q5 yrs from 30-65
  • may need after 65 for high risk women
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52
Q

What are pts with asbestos exposure at risk for?

A
  1. Lung cancer
    If normal risk is 1, + tobacco =10x risk, +tobacco and asbestos = 75x risk
  2. much lower risk, but also, mesothelioma
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53
Q

Which antibiotics cover pseudomonas?

A 
cefepime
ceftazidime
pip/tazo 
ticarillin/clavulanate
imipenem/meropenem (NOT ertapenem) *use for PCN allergy
Aztreoonam * use for PCN allergy
aminoglycosides 
ciprofloxacin
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54
Q

What is the work up for pneumonia?

A

chest xray, sputum gram stain, sputum culture, pulse ox, CBC, blood cx

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55
Q

What travelers should get a polio vaccine?

A

if going to developing country, get a booster or if never vacinnated - get the whole 3 shot series (all inactivated).

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56
Q

How do you treat syphilis?

A

1 dose of penicillin for primary, secondary, and early latent
3 doses of late latent
14 days IV penicillin for neurosyphilis
*if allergy to penicillin, must sensitize them

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57
Q

What is a consideration about how to give rabies vaccines?

A

Give IM if also getting malaria prophylaxis bc chloroquine can blunt the response with the intradermal form of the rabies vaccine

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58
Q

How do you treat Pelvic inflammatory disease?

A

Ceftriaxone (single dose) AND

azitrhomycin or doxycycline for 14 days to cover chlamydia

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59
Q

How do you treat Calcium channel blocker overdose?

A

Give calcium

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60
Q

How do you prescribe RIPE tx for active TB?

A

RIPE x 2 months (or whenever you get the resistance pattern back)
RI x 4 more (or combo that the TB is sensitive to)
(TOTAL has to be 6 months)

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61
Q

What complication do you need to think about when treating spontaneous bacterial peritonitis?

A

hepatorenal syndrome

  • give IV albumin if Cr is >1.5 to mitigate
  • DO NOT GIVE diuretics or do a large volume paracetesis unless pt is having respiratory distress
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62
Q

What are the side effects of TMP/SMZ?

A

sulfa allergy - inhibits folic acid synthesis (myelosuppresion - thrombocytopenia)
Renally cleared - if given in renal failure can drop pt’s platelets
type 4 RTA (can’t secrete K and get hyperkalemia)

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63
Q

What are the most common causes of hypoglycemia in adult diabetic pts?

A

change in dietary habit
increase in metabolic demand (increased activity)
medication overdose
new onset renal failure

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64
Q

How do you treat small abscesses without surrounding erythema?

A

I & D (no need for Abx unless risk factors present- old/young, immunosuppressed…etc)
Always drain abscesses!

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65
Q

What organisms need to be covered in peritonitis?

A

E. Coli and Strep pneumoniae

*do not need to cover anaerobes bc not an intraabdominal infection (just the fluid not open to the gut)

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66
Q

If you get a positive PPD, what is the next step?

A

chest xray

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67
Q

How do you treat pneumocystis pneumoniae?

A

Bactrim - first line (tri/sulfa)
*if allergic to sulfa - IV pentamidine (lots of side effects) or clindamycin with primaquine or atovaquone
give prenisone if P02 < 70 or A-a gradient >35

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68
Q

Side effects of interferon?

A

severe depression and SI *can give an SSRI in addition

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69
Q

What is a measure that you can use to follow sarcoidosis lung disease?

A

PFTS (restrictive pattern (decr FEV and FVC, but ratio normal to high because they can move air in and out just fine, just small lung volumes d/t interstitial dz)

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70
Q

How do we use ritonavir for HIV treatment?

A

It is a protease inhibitor but not good on it’s own - so it is always given in a low dose in addition to another PI.

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71
Q

How do you work up interstitial lung disease?

A

Chest xray, EKG, PFTs, ECHO (if worried about pulm HTN and right sided heart failure)

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72
Q

What follow up needs to be done with PE?

A

lower extremity u/s for DVT/find the source

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73
Q

Recommendations for breast cancer screening

A

starting at 50 mammogram every 1-2 yrs

*if multiple first degree relatives consider prophylactic tamoxifen

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74
Q

What are the most common bacterial food poisonings?

A

Campylobacter and Salmonella

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75
Q

What feature should make you think about covering MRSA in cellulitis?

A

if purulent!

* on exam - will probably also give a risk factor

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76
Q

Is the PPD always positive in active TB?

A

No = negative 25% of the time because the system is overwhelmed and can’t mount a response

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77
Q

What travelers should receive rabies vaccines?

A

travel to india, mexico, asia (where rabies is common in domesticated animals)

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78
Q

What is a side effect of foscarnet?

A

acute tubular necrosis (Hydrate!!!!)

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79
Q

What travelers should get the typhoid vaccine?

A

travel to developing countries with prolonged exposure to food and water

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80
Q

When do patients get heprain induced throbocytopenia?

A

3-5 days on heparin for naïve pts

sooner in pts who have been exposed to heparin before

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81
Q

What other tests should you send when you are thinking about sarcoidosis?

A

cxray, rule out TB with PPD and lupus with ANA, elevated 24 hr Ca may be high, tissue dx with lung biopsy if worried it could be lymphoma

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82
Q

What pathology is seen on cardiac biopsy in rheumatioc heart disease?

A

pancarditis - myocarditis with aschoff bodies

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83
Q

How to diagnosis disseminate gonococcal infection?

A

Hard to dx: do urine test (nucleic acid amplicafication - same as for uretritis)

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84
Q

What physical finding in an asthmatic patient should make you think twice about using aspirin/NSAIDs?

A

nasal polyps - can have an asthma exacerbation when taking aspirin/NSAIDs

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85
Q

When to do a TTE vs TEE for infective endocarditis?

A

Significant valvular regurgiation
Risk factors for perivalvular abscess
-new conduction delay (abscess could be causing this)
-aortic valve endocarditis
persistent bacteremia or fever despite appropriate therapy

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86
Q

How do you differentiae between OSA and primary snoring?

A

no cessation of breath in the primary snoring

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87
Q

How do you treat strep endocarditis?

A

penicillin G or ceftriaxone for 4 weeks

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88
Q

What is the current recommendation for screening smokers for abdominal aortic aneurysms?

A

screen male smokers >65 yo once with U/S

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89
Q

How do you tx symptoms of emphysema/COPD?

A

tx symptoms with inhaled bronchodilators (ipratropium and tiotropium)
if severe - tx with inhaled corticosteroids also

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90
Q

What do you need to do in addition to antifungals to treat cryptocaccal meningitis with high opening pressures?

A

daily LPs to decrease the CSF pressure

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91
Q

How do you treat osteomyelitis with MRSA?

A

vancomycin for 6-12 wks

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92
Q

What is the gold standard to dx sarcoidosis?

A

bronchoscopy with biopsy showing noncaseating granulomas (though that is not pathopneumonic for sarcoid, it could be other things - the clinical picture also has to fit)

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93
Q

How do you dx asthma?

A

clinical and PFTs (showing reversible obstruction)

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94
Q

How do you dx pleural TB?

A 
plueral fluid stain/culture
adenosine deaminase
macobacterium TB PCR
Quant gold on fluid
Pleural biopsy (gold standard)
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95
Q

How do you treat necrotizing fasciitis?

A

Clindamycin - to inhibit exotoxin production

Penicillin - to kill replicating cells by inhibiting cell wall synthesis

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96
Q

Do you treat asymptomatic pts found to have hilar lymphadenopathy concerning for sarcoid?

A

NO! only tx with steroids if have symptoms

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97
Q

Side effect of gentamicin

A

acute tubular necrosis (DON’T USE IN RENAL FAILURE)

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98
Q

What are side effects of pyrazinamide and ethambutol?

A

Gout

Ethambutol - also optic neuritis (why we don’t use in kids)

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99
Q

How does disseminated lyme disease present neurologically?

A

cranial nerve palsy (bell’s palsy like), aseptic meningitis, radiculopathy

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100
Q

How do you treat MRSA pneumonia?

A

Ceftriazone + azitromycin + vancomycin/linezolid/clindamycin
or
Ceftaroline + azithromycin
*can never use daptomycin (neutralized by surfactant)

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101
Q

how do you treat pts with uremia who are bleeding?

A

desmopressin

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102
Q

What does an xray show in active TB?

A

Apical lesions

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103
Q

What is the work up for severe asthma attack?

A
  1. Arterial blood gas (only for severe to see how they are doing)
  2. PA and lateral chest xray (look for secondary pneumothorax/pneumonia)
  3. Peak flow (baseline to help see if treatment is working)
  4. Influenza nasal swab, sputum culture and grain stain
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104
Q

How do you confirm interstitial lung disease?

A

Bronchoscopy with lavage and BIOPSY!

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105
Q

What is the most common cause of viral encephalitis?

A

Herpse Simplex Virus Type 1

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106
Q

How do tx chronic hepatitis B?

A

tenofovir, - goal to treat HBsAg pos to HBsAg neg

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107
Q

What is the most common cause of chronic cough?

A

post-nasal drip (but always think about asthma)

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108
Q

How do you treat gas gangrene (clostridium perfringens from deep wounds or heroin use injected into tissue)?

A

penicillin + clindamycin

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109
Q

How do you dx HSV?

A

Clinical if classic presentation or HSV PCR if unsure

DO NOT USE Tzanck prep anymore

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110
Q

What is the ddx for pulmonay nodule?

A
  1. malignancy (bronchogenic carcinoma, pulm metastases, carcinoid tumors)
  2. benign (granulomas, hamartomas, resolving infection, rhuem nodule, AV malformation, old trauma, rounded atelectasis)
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111
Q

What bacteria most likely causes navtive valve subacute endocarditis?

A

streptococci (50-60%) - mostly viridans

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112
Q

What is the side effect of rifabutin?

A

uveitis and activates p450 system

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113
Q

What antibiotic can we use for gram negatives that are producing carbapenemases?

A

Tigacycline

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114
Q

Risk factors for OSA?

A 
older age
male
obesity
craniofacial abnormalities
upper airway soft tissue abnormalities
smoking
family hx of OSA
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115
Q

How do you treat moderate persistent asthma?

A

long acting beta-2 agonist (salmeterol) + glucocorticoids (fluticasone)

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116
Q

Common side effect of linezolid?

A

thrombocytopenia

serotonin syndrome in combo with SSRIs

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117
Q

How do you treat cryptosporidiosis?

A

Nitazoxanide

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118
Q

Tx for MSSA endocarditis

A

4-6 wks IV abx (nafcillin or oxacillin) + gentamicin x1 wk for synergy

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119
Q

How do you treat hospital acquired penumonia?

A

Give 2 agents for pseudomonas + MRSA

ex. cefepime, gentamicin, vanc

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120
Q

What antiretroviral should never be given in pregnancy?

A

efavirenz

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121
Q

What population is more infective in TB (kids or adults)?

A

ADULTS! Because they get the cavitary lesions in their lungs.

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122
Q

What is a side effect of tenofavir?

A

fanconi syndrome

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123
Q

How do you tell is someone with chronic hep B is infectious?

A

If surface antigen posiitive -> infectious

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124
Q

How do you treat resisent HSV?

A

foscarnet

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125
Q

What is the differential for elevated liver enzymes?

A
  1. chronic viral hep (B or C)
  2. drug-induced hepatitis
  3. wilson’s dz, hemochromatosis, autoimmune hepatitis
  4. choledocholethiasis
  5. Fatty liver
  6. celiac sprue
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126
Q

When does getting the BCG shot cause a positive PPD test?

A

It might cause a mild PPD reaction in the first 5-7 yrs, but it will not cause a positive test in adulthood!
*can always confirm with quantiferon
CONSIDER A POS PPD AS LATENT TB (whether or not the pt got BCG at some pt!)

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127
Q

What is the coverage for ciprofloxacin?

A

gram negatives. NO gram positive coverage.

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128
Q

How do you treat an HIV pt with CD4<100 who has a ring enhancing lesion on CT?

A

Assume toxoplasmosis, start pyrimethamine with sulfadiazine and repeat CT in 2 weeks to confirm improvement/diagnosis (if doesn’t shrink do brain biopsy for CNS lymphoma

129
Q

How do you treat immune reconstitution inflammatory syndrome?

A

Stop antiretrovirals and treat the underlying infection and tx symptoms

130
Q

How do you treat GERD?

A

give PPI for a short period of time (1-2 wks) and see if it improves

131
Q

When can you not give HIV pts live vaccines?

A

when CD4 < 200

132
Q

Do not send lyme serologies with non-specific symptoms!

A

need specific symptoms (rash, polyarthritis, bell’s palsy…etc)

133
Q

How to treat traveler’s diarrhea

A

if non-febrile, ok to take loperimide. Use fluoroquinolone or azithromycin for pts with bloody diarrhea

134
Q

What are pulmonary complications of TB?

A

hemoptysis, penumothorax, bronchiectasis, extensive pulm destruction, lung cancer, chronic pulmonary aspergillosis

135
Q

How do you treat giardiasis?

A

metronidazole

136
Q

What are the most common bacteria causing necrotizing fasciitis?

A

Group A strep or polymicrobial

137
Q

What 2 types of abscesses do not get drained?

A
  1. Lung - tx with clindamycin or penicillin

2. Liver - tx with metronidazole (enteromebous enterylitica)

138
Q

Ddx of obstructive sleep apnea

A

OSA
primary snoring
poor sleep hygeine w/ insuff sleep
hypersomnias - narcolepsy, neuro d/o (thalamus/hypothalamus dysfx, alzheimers)

139
Q

What is the most common cause of prosthetic valve endocarditis?

A

staph in first 2 months, then strep viridans

140
Q

What is the goal o2 sat in COPD pts?

A

90-92%

141
Q

What medications can lead to hypoglycemia?

A

insulin and sulfonylureas (esp in renal failure because renally cleared and stick aroun dlonger in body)

142
Q

What is the mechanism of acyclovir?

A

inhibit polymerase that makes viral DNA

143
Q

Liver enzyme ratio that suggests alcoholic liver disease?

A

AST/ALT >2 and always under 500

144
Q

What testing is needed for cellulitis dx?

A

none! Clinical! Can do an u/s to r/o DVT in lower extremities

145
Q

Ho do you treat enterococcal endocarditis?

A

beta-lactam abx (penicillin or ampicillin) + gentamicin for entire 4-6 wks

146
Q

With a GI bleed, what can the BUN give you a clue about?

A

The location of the bleed. If high BUN, upper GI bleed bc blood is getting reabsorbed as it travels through the gut causing the BUN to increase *do an upper endoscopy first, if pt hypotensive and high BUN!!

147
Q

Malaria prophylaxis for pregnant women

A

chloroquine

148
Q

How do you treat a severe asthma exacerbation?

A
  1. Nebulizer with bronchodilator and anti-cholinergic (albuterol + ipratropium)
  2. supplemental oxygen if hypoxemic
  3. IV glucocorticoids (Methylprednisone) (for a few days, the switch to oral to complete 10-14 days)
149
Q

How do you test for cryptococcal?

A

india ink and serum cryptococcal antigen titer and fungal cultures

150
Q

Why is aortic stenosis associated with angiodysplasia?

A

turbulent flow is destroying vWF and platelet disruption which leads to bleeding of the AVMs, so neeed to replace aortic valve to prevent futher bleeding

151
Q

What are 2 variants of asthma that you should keep in mind?

A

cough variant asthma (think about with chronic cough esp worse at night)
exercise-induced asthma

152
Q

With antibiotics, when treating pts with heart disaese and prolonged QT interval should be avoided?

A

macrolides and fluoroquinolones

153
Q

What vaccines do new HIV pts need?

A

pneumococcal pneumonia
hep a and b
flu

154
Q

When worried about mengitis - who needs a head CT before the LP?

A

papilledema, confusion, focal deficits, seizures, severely immunocompromised (HIV or transplant)
*signs of mass effect, increased ICP

155
Q

When do you avoid imipenem?

A

brain injuriy/seziures

*lowers seizure threshold

156
Q

How do you treat HSV?

A

acyclovir or valacyclovir (easier to dose

test for other STDs (HIV, syphilis)

157
Q

What test do you use to evaluate TB in a pt who has received the BcG vaccine?

A

gamma-interferon releasing assay

158
Q

What can you see in chest xrays with asbestos exposure?

A

calcified pleural plaques - tells you they have had significant asbestos exposure

159
Q

How do you tx OSA?

A
  1. weight loss
  2. CPAP is the gold standard
  3. surgery is anatomical cause
160
Q

Who is high risk with hepatitis E infection?

A

pregnant women

161
Q

Tricks for remembering antiretroviral meds

A

Nucleosides (needs 2) end in “ine” except abacavir and tenofovir
+ 1 of either
Protease inhibitors all end in “navir”
NNRTIs all have “avir” buried inside the word
Integrase inbitors end in “ravir”

162
Q

What must you do if a pt comes back for one STD?

A

Test for others - esp syphilis (VDRL test) and HIV

163
Q

When do you need to cover for pseudonmonas?

A
  1. malignant otitis externa in diabetics
  2. septicemia
  3. burn victims
  4. cystic fibrosis
  5. severely neutropenic pts (<500)
  6. ventilator-associated pneumonia
164
Q

What lung findings do you see with sarcoidosis?

A

bilateral hilar adenopathy +/- paranchymal/interstitial disease

165
Q

When should we consider MRSA pneumonia?

A

IV drug users
recent or concurrent flu
severe penumonia needing intubation/ICU admission
necrotizing (cavitary) pneumonia

166
Q

How is asymptomatic (latent) syphilis categorized?

A

less than 1 year - early

over a year - late latent

167
Q

How do you dx OSA?

A

atleast 5 events per hour on sleep study + symptoms/sign of OSA

168
Q

How do you tx acute emphysema exaccerbation?

A
  1. O2 - maintain sats 90-92%
  2. inhaled bronchodilators (ipratropium or tiotropium) and/or b-agonist (careful can incr HR and cause cor pulmonale)
  3. antibiotics (azitrhomycin, CTX, fluoroquinolones)
  4. Sputum cx and graim stain
  5. corticosteroids (IV -> PO) (like asthma in acute setting)
169
Q

What is the dx and tx of a positive PPD and negative chest xray?

A

latent TB, tx with 9 months of INH + vit B6 (pyridozine)

170
Q

How do you treat bleeding esophageal varices in a cirrhotic pt?

A

at increased risk for spontaneous bacterial peritonitis, so give a prophylaxis with Ceftriaxone for 1 week

171
Q

What is a side effect of acyclovir?

A

acute tubular necrosis (Hydrate!!!!)

172
Q

What factors are associated with a poor prognosis in cryptococcal meningitis?

A

Eleveated opening pressure
Low WBC coung in CSF
Low glucose level in CSF
Positive India InkHihg cryptococcal antigen titers

173
Q

What medicine may cause chronic cough?

A

ACE-inhibitors (lisinopril, enalapril, captopril)

174
Q

How do you treat outpatient community acquired penumonia?

A

azithromycin - probably mycoplasma

levofloxacin or moxifloxacin

175
Q

How do you treat campylobacter?

A

supportive - hydration!, should resolve in 3-7 days

Avoid loperimide

176
Q

What is the side effect of daptomycin?

A

myocitis - monitor CPKs while on it

177
Q

How do you treat severe asthma?

A

LABA/systemic corticosteroids/luekotriene inhibitors

178
Q

What is the treatment for bacterial meningitis?

A 
Empiric antibiotics (CTX, vancomycin, +/- ampicillin)
Dexamethasone (improves outcomes esp for step pneumo)
179
Q

What are good narrow antibiotics?

A

ampicillin
TMP/SMX
first gen cephalosporin

180
Q

What does tigecycline cover?

A

everything except psuedomonas and proteus - very broad

181
Q

How do you treat mild intermittent asthma?

A

short-acting inhaled beta-2 agonist as needed

182
Q

What increases survival in emphysema?

A

stop smoking
home o2 if they meet the criteria
vaccines (pneumococcal + booster and flu)
lung transplant

183
Q

How do you dx necrotizing fascitiis?

A

CLINICAL though gold standard is Tissue biospy in the OR

184
Q

How do you treat lyme with a rash, bell’s palsy, or joint involvement?

A

doxycyline (tx lyme and erlichiosis - commonly co-infection) or amoxicillin (doesn’t tx erlichiosis) for pregnant/young children

185
Q

How do you vaccinate against hep A?

A

2 shots given 6 months apart = immunity x10 yrs, if leaving within 2 weeks give vaccine and immune serum globulin

186
Q

What are PFT findings in asthma?

A

obstructive
decr FEV1 and FVC
*do bronchodilator to tell different between asthma and COPD
*if normal, do a provocative challenge with methacholine, cold air, or exercise

187
Q

What are the side effects of rifampin and isoniazid?

A

liver failure - check LFTS

188
Q

Who and when should people get the pneumococcal vaccine (PPSV23)?

A

everyone at 65 yo, otherwise anyone with sickle-cell or splenectomy, cardiopulmonary dz, alcoholism, cirrhosis, alaska natives and certain antive american populations, immunocompromised (cancer, chronic renal failure, HIV-positive, immunosuppresive meds)

189
Q

How do you treat pts with a hx of spontaneous bacterial peritonitis?

A

prophylactic antibitics: norfloxacin, ciprofloxacin, or trimetho-sulfa

190
Q

How do you treat HIV in pregnancy?

A

Always treat with combo failure no matter the CD4 count to prevent transmission, start immediately (don’t wait until later in pregnancy)

191
Q

How do you treat HIV with antiretroviral therapy?

A

If CD4 <500 - start anti-retrovirals
2 nucleosides
NNRTI or protease inhibitor or an integrase inhibitor

192
Q

What is the differential for elevated liver enzymes over 1000?

A
  1. viral hepatitis
  2. drug toxicity (acetaminophen)
  3. ichemic liver dz (shock liver)
193
Q

What is the best test to detect acute HIV?

A

HIV viral load, antibody tests will be negative

194
Q

Lung cancer screening recs

A

Smokers with >30pack years from 55-80 with annual low dose CT (if current smoker or quit <15 yrs)

195
Q

How do you monitor response in HIV patients?

A

viral load - goal is to make viral load undetectable

196
Q

What is the triad of symptoms of disseminated gonoccal infection?

A
  1. migratory polyarthritis
  2. tenosynovitis
  3. skin lesions in 75% (hemorragic pustules, esp palms and soles)
197
Q

How do you work up a solitary pulmonary nodule?

A

CT chest with contrast

  • if > 3cm - worry about cancer
  • if mediastinal adenopathy - cancer
  • if spiculated borders - cancer
  • if central calcifications, “popcorn, onion skin, bull’s eye” - benign
198
Q

What is the length of treatment for pyelonephritis?

A

7-10 days

199
Q

How do you treat any serious skin or soft tissue infection caused by group A strep?

A

penicillin plus clindamycin

200
Q

How do you treat bleeding in a pt with vonWillebrand’s disease?

A

desmopressin

201
Q

What must be checked prior to giving a pt dapsone?

A

G6PD deficiency - bc they are at risk for hemolytic anemia with dapsone

202
Q

What do you see on a CT angio with a pulmonary emobolism?

A

filling defect

203
Q

What sites can TB affect?

A 
Lungs (80%)
Pleura
CNS
Lymphatic system
Genitourinary system
Bones and joints
Peritoneum
204
Q

What is good empiric coverage for infective endocarditis?

A

vancomycin and gentamicin

205
Q

How to treat cellulitis?

A

empirically - IV oxacllin or nafcillin 1g q4 hrs or cefazolin, elevation of leg/warm soaks
could do oral dicloxacillin or cephalexin if very mild
*if penicillin allergy - cefalexin
*if severe pcn allergy - clindamycin, macrolides, new fluoroquinolones

206
Q

How do you culture Neiseria?

A

on Thayer-Martin agar (contains abx to kill other things besides neiseria)

207
Q

How do you treat invasive aspergillus?

A

Voriconazole

208
Q

Can you get a culture for osteomyelitis?

A

NO MUST BE A BONE BIOPSY!!!

209
Q

What measure on PFTs is a hallmark of emphysema?

A 
decr DLCO (diffusion is impaired due to destruction of alveolar membranes)
FEV1 tells you how bad the emphysema is
210
Q

Why do you give vitamin B6 with isoniazid in treating TB?

A

to reduce peripheral neuropathy

211
Q

What is the best test to detect osteomyelitis?

A

MRI (but always do an xray first)

212
Q

How do you treat symptomatic sarcoidosis?

A

oral corticosteroids

213
Q

What programs have helped to increase compliance for meds in disease like TB?

A

DOT - direct observed therapy (care providers give medicine everyday in home/community)

214
Q

What are the latest blood transfusion guidelines based on hemoglobin for GI bleeds?

A

give RBCs when Hgb <7 for normal pts

give RBCs when Hgb <8-9 for cardiac dz pts

215
Q

How do you treat community acquired pneumonia?

A

(treat penumococcus, heamophilus, moxerella, atypicals (legionella)
1. Ceftriaxone (3rd gen) or amp/sulbactam
+
azithromycin or doxy or
2. moxifloxcin or levofloxacin

216
Q

What antibiotic is used for endocarditis prophylaxis?

A

amoxicillin 30-60 mins prior to procedure

- clindamycin, cephalexin, or macrolide is allergic to penicillin

217
Q

Who has a PPD cutoff of 5 mm?

A

HIV, immunocompromised, organ transplant, pts with prior TB dz

218
Q

What is a normal blood gas?

A

pH 7.35-7.45
PCO2: 35-45
PO2: >90
HCO3: 18-24

219
Q

Mortality in necrotizing fasciitis without surgical debridement?

A

100%

220
Q

How do you treat HIV + mom during delivery of baby?

A

give baby zidovudine during delivery and for 6 wks after

221
Q

What is the differential for acute diarrhea lasting more than 48 hours with blood in stool?

A

Bacterial! Salmonella, Shigella, Campylobacter, Yersinia, and E. Coli

222
Q

How do you treat chronic cough d/t post nasal drip?

A

decongestant and/or antihistamine

223
Q

What are the 3 common causes of chronic cough in a young, nonsmoker?

A

Exercise induced asthma
GERD
postnasal drip

224
Q

What else needs to be worked up with new PE?

A

malignancy

225
Q

What much be considered when a pt has recurrent Neisseria gonorrhea infections?

A

Terminal compliment deficiency (C5-C9)

226
Q

Once someone has latent TB, will their PPD become negative once treated?

A

NO! Once positive - will always be positive (unless old and lose T cell memory)

227
Q

What types of lyme dz are tx with IV ceftriaxone?

A

Lyme myocarditis, meningitis or encephalitis

228
Q

Who should receive the shingles vaccine?

A

at age 60 everyone!

229
Q

How do you evaluate and treat an HIV pt who had an exposure to TB?

A

treat them even if chest xray and PPD negative

230
Q

How do you treat chronic emphysema?

A
  1. stop smoking
  2. home oxygen x24 hours (esp at night!) (if meets criteria)
  3. vaccines (pneumococcal and flu)
  4. tx symptoms with inhaled bronchodilators (ipratropium and tiotropium)/inhaled corticosteroids if severe
231
Q

What does a CXR show in emphysema?

A

flat diaphragm, narrow cardiac silhouette, no infiltrates

232
Q

What do PFTs show in interstitial lung disease?

A

Low FEV1, low FVC, normal FEV1FVC (restricitve)

decr TLC, decr DLCO

233
Q

Traveler’s most common vaccine preventable disease

A

hep A

234
Q

Most common causes of bacterial meningitis in babies?

A

GBS
E Coli
Strep pneumo

235
Q

What is the differential for discharge from the penis?

A

Gonococcal urethritis
Non-gonococcal urethritis (chlamydia, herpes, mycoplasma, ureaplasma)
Trichomoniasis
Reiter syndrome

236
Q

How do you treat mild persistent asthma?

A

add an inhaled glucocorticoid (controller) + short acting B-2 agonist

237
Q

What type of lung dz is seen with PE findings of increased antero-posterior diameter and hyperresonance to percussion?

A

obstructive

238
Q

How do you treat latent TB?

A

Isoniazid + vitamin B6 (pyridoxine) for 9 months

check LFTs q3 months

239
Q

What drugs should be avoided in asthmatics?

A

NSAIDs, Aspirin, Beta-antagonists, coloring agents like tartrazine

240
Q

What is the risk of untreated OSA?

A

increased all-cause and cardiovascular mortality

241
Q

What med can women with factor 5 leiden NEVER take?

A

hormonal birth control

242
Q

What test is good for ruling out pulmonary embolism?

A

D-dimer in low risk pts

243
Q

If you can’t anticoagulate a pt with a PE, how do you treat them?

A

Place a vena cava filter for temporary fix, become pro-thrombotic after a couple weeks
Control bleed, take filter out and start anticoagulation

244
Q

Malaria prophylaxis

A

mefloquine (doxycycline is an alternative)

245
Q

How do you treat rocky mountain spotted fever meningitis?

A

doxycycline

246
Q

What test do you order to check for hemochromotosis?

A

transferrin saturation (iron level over the TIBC)

247
Q

How do you empirically treat pyelonephritis?

A 
Ceftriaxone
Levofloxacin/ciprofloxacin
ampicillin/sulbactam
gentamicin w/ or w/o ampicillin
aztreonam *good for severe PCN allergy
248
Q

How do treat HIV with CD4 < 50?

A

prophylaxis for Mycobacterium avium: azithromycin weekly (Macrolide for MAC)

249
Q

How do we screen for osteoporosis?

A

Screen women age 65 and greater with a DEXA exam, can start at 60 if low body weight or incr risk of fx

250
Q

How do you treat community acquired MRSA?

A

vancomycin (IV)
*can also use daptomycin, ceftaroline (5th gen cephalosporin)
For milder cases - can use clindamycin, doxycycline, or trimethoprim/sulfamethoxazole

251
Q

What travelers should get the Yellow fever vaccine?

A

travel to sub-sarahan africa and some S. america countries

252
Q

How do you dx active TB?

A

If PPD pos, chest xray pos, get acid fast TB test - if pos tx for active TB

253
Q

What travelers should receive Hep B vaccines?

A

Anyone staying >6 months, close contact with local people, having medical procedures, sexual relations.

254
Q

What needs to be screened for in COPD pts?

A

Lung cancer - low dose CT yearly

255
Q

How do we treat heparin induced throbocytopenia

A

Factor 10 inbihitor (fondoparinaux) or direc thrombin inhibitor (argatroban)
stop heparin

256
Q

Which cancers do we recommend regular screening for?

A

colon, breast, cervix, lung

257
Q

What is the most common cause of cirrhosis and HCC in the US?

A

chronic hepatitis C

258
Q

What should you think of associated with loud S2, S3, or S4?

A

loud S2 - pulm htn
S3 - dilated heart
S4 - stiff heart (diastolic dysfx)

259
Q

How is hep A transmitted?

A

food or water contamination

260
Q

What organisms can cause culture-negative endocarditis?

A

HACEK organisms (Haemophilus, actinobacillus, cardiobacterium, eikenella, kingella)

261
Q

When do you have to replace the valve in infective endocarditis?

A 
Severe regurgitation with hemodynamic compromise
myocardial abscess
repeated emboli
very large vegetations >10 mm
fungal endocarditis
prosthetic valve endocarditis
262
Q

Most common cause of bacterial mengiitis?

A

strep pneumoniae

263
Q

How do you follow a solitary pum nodule?

A

Low risk pt (short smoking/non-smoker, >15 yrs out from smoking)
- repeate imaging in 3-6 months to confirm no growth
- if there is an old xray that shows the nodule (>1 yr out), then no f/u
High risk (>45 yo, w/ sig tobacco hx)
- bronchoscopy with biopsy, ct-guided biopsy, open lung biopsy

264
Q

How do you bridge heparin to warfarin?

A

start LMWH and warfarin
keep heparin on for >5-7 days until INR is >/= 2 for 48 hours
stay on anticoagulation for 6 mos - life

265
Q

How do you dx PID?

A
  1. cervial motion tenderness
  2. adnexal tenderness
  3. uterine tenderness
266
Q

What are causes of interstitial lung disease?

A

Occupational: asbestosis, silicosis, berylliosis, coal worker’s pneumoconiosis
Non-occupational: idiopathic pulmonary fibrosis, interstiial pneumonia, hypersensitivity pneumonitis

267
Q

What is ther management for necrotizing fasciitis?

A

immediate surgical debridement

NO TIME FOR IMAGING

268
Q

How do cover prophylactic infections in post-neurosurgical or post-head trauma pts?

A

vancomycin + cefepime or meropenem or ceftazidime to cover MRSA and pseudomonas

269
Q

What is the CAGE tool to screen for alcoholism?

A 
tried to CUT down
Annoyed by critisicm about drinking
guilty about it
Eye opener
*2 of 4 is positive
270
Q

What risk factors make MRSA cellulitis more likely?

A

household contacts with MRSA, children, MSM, IV drug users, athletes in contact sports, Native Americans/Pacific Islanders

271
Q

How do you treat meningitic with TB?

A

At least 9-12 months and with steroids

272
Q

Who gets invasive aspergillus?

A

Neutropenic fever

273
Q

How do you treat a patient with a pulmonary emoblism?

A

start anticoagulation

  • Enoxaparin (low-molecular weight heparin) and warfarin on day 1-2
  • for renal failure or morbid obese pts - unfractionated heparin
274
Q

What is the work up for acute diarrhea?

A

check for blood in stool

only send cultures if lasts longer than 48 hours

275
Q

How long does it take for antibiotics to lead to clinical improvement with pneumonia?

A

72 hours (ok to have fever up to 72 hours - not tx failure until after 72 hrs)

276
Q

What organisms are not covered by cephalosporins?

A 
LAME
Listeria
Atypicals
MRSA (except ceftaroline)
Enterococcus
277
Q

What is the treatment for candidemia? (pts on TPN)

A

Fluconazole

278
Q

What must be considered with a pt with recurrent sinusitis and recurrent community acquired pneumonia?

A

C3 deficiency
IgG, IgA, and IgM for Common Variable Immunodeficiency
*get recurrent infections with encapsulated organisms

279
Q

How do you treat hospital assocaited staph line infection sepsis?

A

4 weeks of IV Abx

280
Q

What labs do you order when thinking about osteomyelitis?

A

x-rays, ESR, CBC

281
Q

How do you treat acute viral hepatitis?

A

supportive care

282
Q

What is Immune reconstitution inflammatory syndreom?

A

inflammatory disorders that develop in pts with AIDS upon starting antiretroviral therapy
-paradoxical worsening as CD4 counter recovers when there is an infection present (TB, cryptococcal meningitis)

283
Q

How long do you treat complicated cystisi?

A

7 days (ex: man with cystitis)

284
Q

When do you treat infectious diarrhea with antibiotics and which antibiotic?

A

Severe cases - hospitalized, can’t stay hydrated not getting better
Ciprofloxacin
(could also do trimethoprim/sulf)

285
Q

What is the differential for progressive shortness of breath?

A

Interstitial lung dz
Bronchogenic carcinoma (squamous cell and small cell carcinoma)
COPD/emphysema
Congestive Heart Failure

286
Q

How do you empirically treat spontaneous bacterial peritonitis?

A

cefotaxime or ceftrixaone + IV albumin on day 1 and 3 (if Cr is greater than 1.5 to reduce risk of hepatorenal syndrome)

287
Q

How do you dx lyme dz?

A 
Lyme titers (though not very specific so only do it if you have a high pre-test probability beceaeuse there are a lot of false positives with lyme titers
*done by ELISA or Western blot
288
Q

How do you work up shortness of breath?

A

ox sat, cxr, PFTs (outpt, when not in acute episode), maybe ABG (for severity of dz)

289
Q

Who needs to be covered with ampicillin in menigitis?

A

For listeria

*infants, pts > 50, any chronic dz, immunocompromised, on agents like infliximab/etanercept (TNF alpha inhibitors)

290
Q

Who needs endocarditis prophylaxis?

A
  1. prosthetic valve
  2. previous infective endocarditis
  3. congenital heart surgery not repaired or with prosthetics material
  4. cardiac transplant with cardiac valvulopathy
291
Q

When do patients who need endocarditis prophylaxis need it?

A

dental procedures, procedures to respiratory track involving incision or biopsy, debridement of skin/soft tissue wounds

292
Q

Who and when should people get the HPV vaccine?

A

everone at age 11-12, if didn’t complete it, could do up to age 26

293
Q

What can happen if lyme dz if not treated?

A

dissemined dz or late stage with arthritic findings 60% (knee very commonly involved)

294
Q

How do you treat exercise induced asthma?

A

short acting beta-2 agonist (better for adults) to be taken before exercise or cromolyn is an alternative good for kids bc SABAs can affect height long term

295
Q

Colon cancer screening recs for normal population

A

start at 50

  • colo every 10 yrs
  • feccal occult every yr
  • sigmoid with barium enema every 5 yrs
296
Q

Can daptomycin be used in pneumonia?

A

NO! surfactant inactivates it

297
Q

What cephalosporin covers MRSA?

A

Ceftaroline (5th gen. cephalosporin) - good gram neg (except pseudomonas) and MRSA

298
Q

How do you treat meningitis with brain abscess?

A

surgical drainage plus metronidazole (bacteroides fragilis) and CTX +/- vancomycin

299
Q

How do you work up discharge from the penis?

A

best test: nucleic acid amplification urine test

300
Q

What are the drugs in the RIPE tx for active TB?

A

Isoniazide (+vit B6)
Rifampin
Pyrazinamide
Ethambutol

301
Q

Side effects of protease inhibitors?

A

increased LDLs, put on a statin (only provastatin, ruvastatin, or low-dose atorvastatin)

302
Q

What is the differential for acute diarrhea?

A 
Salmonella
Campylobacter
Shigella
norwalk virus
Yersinia
Enteroinvasive E. Coli
303
Q

What tests should be sent for a new dx of HIV?

A

CD4, HIV viral load, resistance testing of viral genome

RPR, toxoplasmosis, CBC and lytes, pap smear, chest x-ray, hep A, B, C, PPD

304
Q

How do you treat gonorrhea?

A 
Start empirically (before results come back)
Ceftriaxone IM for gonorrhea 
\+ one dose azithromycin or 1 wk doxycyline to cover chlamydia
305
Q

How do you treat Mycobacterium Avium Complex?

A

macrolide with ethambutol with/without rifabutin

306
Q

When should you follow up acute issues in CCS?

A

follow up once to make sure the issue resolved, then can click “return as needed”

307
Q

What is the natural hc of HSV?

A

Recurrence can happen anytime, frequent recurrences can be suppressed with regular doses of acyclovir

308
Q

What is the most common complication from bacterial meningitis?

A

hearing loss

309
Q

Do you hold antibiotics if your meningitis pt needs a head CT prior to LP?

A

NO, get blood cx and start Abx

310
Q

What are the empiric treatment for bacterial meningitis?

A

Ceftriaxone (strep penumo and neisseria meningitis)
Vancomycin (for penicillin resistant pneumococcus in the CSF, better concentrating than CTX in CSF))
* add Ampicillin for listeria in infants, pts >50, DM, and chronically ill pts

311
Q

How do you treat HACEK endocarditis?

A

ceftriaxone, ampicillin-sulbactam, or ciprofloxacin x4 wks

312
Q

How do you follow pts with chornic Hep B?

A

screen with liver U/S every 6 months to check for hepatocellular carcinoma

313
Q

When do you treat chronic hepatitis B?

A

NO. only pts who are actively replicating - HBeAg positive or high viral load and high transaminases

314
Q

What is the first step in treating a GI bleed?

A

Fluid resuscitation, CBC, PT/PTT, type and cross BEFORE endoscopy

315
Q

How do you treat hypoglycemia?

A

IV dextrose (50 ml %50 dextrose)

316
Q

Who should not receive the varicella vaccine?

A

bc live attenuated

*immunocompromised, HIV pos with <200 CD4, pregnant women

317
Q

What is the different in the primary complain of emphysema vs chronic bronchitis?

A

emphysema - dyspnea

chronic bornchitis - productive cough

318
Q

How do you treat lyme disease meningitis?

A

ceftriaxone

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