Infections

Question 1

What are the SIRS criteria?

Answer 1

Have to have 2 or more of the following
Temperature >38.3 or 90bpm
RR >20
WBC count >12,000/mL or 10% immature neutrophils

Question 2

What are the significance of super antigens?

Answer 2

Rather than stimulating specific T-lymphocytes, superantigens cause widespread stimulation of T-lymphocytes leading up to 20% of total T-lymphocyte activation

Question 3

How would we describe Sepsis?

Answer 3

SIRS + Evidence of Infection

Question 4

When does Sepsis become Severe Sepsis?

Answer 4

When it is associated with organ dysfunction

Question 5

What are some of the signs of organ dysfuntion that you might look for in a septic patient?

Answer 5

Low BP

Question 6

What are the SEPSIS SIX?

Answer 6

TAKE
Blood Cultures, Check Lactate, Urine Output
GIVE
Antibiotics, IV Fluids and Oxygen 
WITHIN THE FIRST HOUR

Question 7

Where should blood cultures be taken from?

Answer 7

Peripheral Venous Site

Plus from any indwelling device e.g. cannula, central and arterial lines.

Question 8

How might a classical Pneumonia present?

Answer 8

Progressive cough and SOB over a short period of time
Purulent Sputum
Pleuritic Pain
Haemoptysis
Fever

Question 9

Atypical Pneumonia’s tend to present differently, how might they present?

Answer 9

Vague flu like illness, headache, with a dry cough

Tend to present over weeks rather than days

Question 10

What investigation would you do in a patient who presents with pneumonia?

Answer 10

CXR
Sputum and Blood Cultures
If atypical organism is likely - then serology for organsims such as legionella and mycoplasma should be requested along with urine samples to look for the relevant antigens

Question 11

Describe the CURB-65 score for Pneumonia and what each score means in terms of the management of the patient?

Answer 11

Confusion >8 on AMTS
Urea >7mmol/L
Respiratory Rate > 30
Blood Pressure 65

0-1  = Managed in the community
2-3 = Managed on Ward
4-5 = Consider Intensive Care

Question 12

How might a septic arthritis present?

Answer 12

Hot, swollen, red joint
Extremely tender
With a limited range of movement

Question 13

What investigations should be done in a suspected septic arthritis?

Answer 13

Joint aspiration is vital to establish the diagnosis - aspirate should be sent for culture and mircoscopy
Blood cultures should also be sent
X-Rays to assess the amount of joint destruction

Question 14

What is the management of septic arthritis?

Answer 14

Antibiotics - must cover staph and achieve good joint penetration
Liase with orthopaedic surgeons or rheumatologists
In severe cases joint wash out by arthroscopy is necessary
Physiotherapy is essential to recover joint function

Question 15

What are the clinical signs of cellulitis?

Answer 15

Rapidly sreading erythema
Skin will feel hot and may be tender
May see blistering or skin necrosis in severe cases

Question 16

In severe cases of cellulitis, what else should be examined?

Answer 16

Examine the nerves and vascular system in the area to check they are not compromised by compartment syndrome.

Question 17

In a rapidly spreading cellulitis with destruction of underlying tissues, what diagnosis would you worry about?

Answer 17

Necrotising Fasciitis

Question 18

How might an infected post-operative surgical wound present?

Answer 18

Pain
Erythema
Purulent Discharge
Heat around the incision

Question 19

How might an anastomotic leak present in a patient who has had recent large bowel surgery.

Answer 19

Usually presents with an acute deterioration in a patient who initially made a good recovery - around 5-10 days after the operation
May get tachycardia, cardiac arryhtmia, no return of normal bowel function

Question 20

What investigtions would you do in a patient who you suspect an anastomotic leak?

Answer 20

Bloods - WCC, CRP
Erect CXR - look for free air under the diaphragm (24-36 hours post-op)
Gastrografin Enema or contrast enhanced CT scan

Question 21

What condition is associated with fever on the 4th day, if the starting day is counted as one?

Answer 21

Plasmodium Malariae

Question 22

What condition is associated with fever on the third day, if the starting day is counted as one?

Answer 22

P.Ovale

P.Vixax

Question 23

What fever is associated with a bradycardia?

Answer 23

Typhoid Fever

Question 24

How might we define Pyrexia of Unknown Origin?

Answer 24

Illness lasting > 2 weeks
With fever > 38 on several occasions
No aetiology found after 3 days in hospital or 1 week as an outpatient.

Question 25

What contacts do we give chemoprophylaxis too in meningitis patients?

Answer 25

Household contacts and kissing contacts

Question 26

What form of chemoprophylaxis do we give for different causative agents?

Answer 26

Nisseria - ciproflaxacin stat dose

H.influenzae - rifampicin 4 days

Question 27

Describe what normal CSF is like?

Answer 27

Opening pressure half serum level

WCC - no neutrophils and very low or no lymphocytes

Question 28

Describe what CSF is like in bacterial mengingitis infection

Answer 28

Opening pressure +++ >30
Turbid/Cloudy Appearance
Protein ++ >1
Glucose low 
Increased neutrophils

Question 29

Describe what the CSF is like in a viral meningitis infection?

Answer 29

Opening pressure normal/slightly increased
Normal clear appearance
Protein slightly increased 0.5-1
Glucose - normal
WCC increased lymphocytes

Question 30

What virus is aciclovir used to treat?

Answer 30

Herpes Simplex

Question 31

Whats the main differentiating clinical feature between meningitis and encephalitis?

Answer 31

In encephalitis you have an altered mental state. Including altered consciousness, convulsions and focal neurological signs

Question 32

What forms of meningitis can you be vaccinated against?

Answer 32

Men C - now univesal childhood vaccination
Men A, C, W135 and Y if travelling to endemic areas
Current debate about Men B vaccine being introduced.

Question 33

Which fungus looks like little eyes on india ink stain?

Answer 33

Cryptococcus Neoformans

Question 34

List some of the common features of Legionella infection and what diagnostic test might you do?

Answer 34

Recent foreign travel
Flu like symptoms
Hyponatraemia
Pleural Effusion
Dx - urine antigen