Infectious Disease

Question 1

What separates severe sepsis from septic shock?

Answer 1

Severe sepsis is responsive to fluids while shock is not

Question 2

Sepsis + low blood pressure, dx and next step?

Answer 2

Severe sepsis, give fluid bolus

Question 3

What are the SIRS criteria (4)?

Answer 3

Temp gt 38 or lt 36
WBC gt 12 or lt 4
HR gt 90
RR gt 20

Question 4

In sepsis, early goal directed therapy, what are the goals for CVP, MAP, Uoutput, and SvO2?

Answer 4

CVP 8-12
MAP gt 65 (use pressors if needed)
Uoutput gt 0.5 cc/kg/hr
SvO2 gt 70%

Question 5

What are the main actions to take in patients with sepsis (6)?

Answer 5

1/2) Antibiotics and fluids; 3) Pressors (if in shock); 4) lactate (trend lactate for clearance); 5) Oxygen (improve oxygen delivery to tissues); 6) Source control (remove lines, catheters, drain abscesses)

Question 6

Antibiotics for cholangitis?

Answer 6

gram negative and anaerobic coverage - cipro + metronidazole

Question 7

Alternate for pip/tazo?

Answer 7

meropenem, cefepime

Question 8

Antibiotics for community acquired pneumonia?

Answer 8

Ceftriaxone and azithromycin (moxifloxacin is appropriate)

Question 9

Alternate for vancomycin?

Answer 9

Linezolid

Question 10

Antibiotics for diverticulitis?

Answer 10

gram negative and anaerobic coverage - cipro + metronidazole

Question 11

Antibiotics for a young woman with pyelonephritis but ambulatory and can tolerate po?

Answer 11

cipro

Question 12

Antibiotics for health care associated pneumonia?

Answer 12

vanc + zosyn

Question 13

Antibiotics for a young woman with pyelo who is toxic?

Answer 13

Ceftriaxone (pip/tazo also okay)

Question 14

You woman with a UTI but no sepsis?

Answer 14

nitrofurantoin, TMP-SMX, amoxicillin

Question 15

Alternate for ceftriaxone?

Answer 15

ceftazidime

Question 16

CD4 count less than 100, what infxn do you worry about and what’s ppx? less than 50 and what’s ppx?

Answer 16

Toxo, TMP-SMX; MAC, Azithromycin

Question 17

What test do you order when pt has flu-like symptoms, flu is negative, and the question is about HIV?

Answer 17

viral load (NOT an ELISA because it is too early for the antibody to be formed)

Question 18

PCP prophylaxis if G6PD deficient?

Answer 18

atovaquone (both TMP-SMX and dapsone are no good)

Question 19

White stuff you can easily scrape off the mouth, WITH dysphagia, what’s the dx and tx?

Answer 19

esophageal candidiasis, oral fluconazole (need systemic therapy!)

Question 20

PCP prophylaxis with a sulfa allergy?

Answer 20

Dapsone

Question 21

White stuff you can easily scrape off the mouth, no dysphagia, dx and tx?

Answer 21

oral candidiasis, nystatin swish and spit

Question 22

CD4 count less than 200, what do you worry about and how do you ppx?

Answer 22

PCP, TMP-SMX

Question 23

Uncomplicated vs complicated parapneumonic effusions: pleural fluid analysis: pH, glucose, WBC

Answer 23

uncomplicated: pH gt/= 7.2, glucose gt/= 60, WBC lt/= 50,000 (opposite for complicated)
(uncomplicated = sterile exudate in pleural space; complicated = bacterial invasion of pleural space - often loculated; gram stain often neg due to low bacterial count)

Question 24

The PPD is 16 mm, who is that positive for?

Answer 24

People who have no risk factors

Question 25

For immunocompromised, what is the lowest that a PPD is positive?

Answer 25

5mm

Question 26

AFB smear is positive for TB, how do you tx?

Answer 26

Isolation and RIPE therapy

Question 27

The PPD is 6mm. Who is that positive for?

Answer 27

Immunocompromised and close contacts to people with TB

Question 28

How do we screen someone with a positive PPD in the past that was treated for TB?

Answer 28

Chest xrays

Question 29

If a person has had BCG vaccine, how can you screen for TB?

Answer 29

Gamma interferon assay

Question 30

PPD is positive, next step?

Answer 30

Chest xray

Question 31

PPD is positive, chest X-ray is positive, next step?

Answer 31

AFB smear

Question 32

PPD is positive, chest Xray is positive, AFB is negative, next step?

Answer 32

tx with INH and B6 for 9 months (also do same if PPD is positive and chest xr is negative)

Question 33

Brain mass on CT, AIDS negative in vignette, next step?

Answer 33

biopsy (if they have AIDS and toxo ag is positive, tx for toxo)

Question 34

What are the FAILS criteria and what is it for?

Answer 34

``` To determine if an LP is safe to do Focal neurologic deficit Altered mental status Immunocompromised Lesion over site of LP Seizures ```

Question 35

Fever and a headache and positive FAILS, next step?

Answer 35

IV Abx, then CT scan

Question 36

Brain mass on CT, AIDS positive in vignette, next step?

Answer 36

Treat for too 4-6 weeks

Question 37

Flaccid paralysis and encephalopathy, likely dx?

Answer 37

West Nile

Question 38

What is the empiric treatment for bacterial meningitis?

Answer 38

Vancomycin + ceftriaxone + steroids (+/- ampicillin for immunocompromised)

Question 39

Lyme meningitis - tx?

Answer 39

ceftriaxone

Question 40

Temporal lobe and encephalitis, likely dx?

Answer 40

HSV

Question 41

Fever and a headache, no fails criteria are positive, next step?

Answer 41

LP

Question 42

Tx for HSV encephalitis? West nile, St. Louis, or Equine encephalitis?

Answer 42

Acyclovir; tx is supportive

Question 43

Uncomplicated vs complicated parapneumonic effusions: pleural fluid analysis: pH, glucose, WBC

Answer 43

uncomplicated: pH gt/= 7.2, glucose gt/= 60, WBC lt/= 50,000 (opposite for complicated)

Question 44

Pneumonia in a dialysis pt? How do you tx?

Answer 44

HAP; vanco + zosyn

Question 45

Fever and a cough, consolidation on XR, not toxic, how do you tx?

Answer 45

azithromycin (+ceftriaxone?)

Question 46

Pneumonia in a nursing home pt: diagnosis/tx?

Answer 46

HAP; vanc + zosyn

Question 47

Fever and a cough, consolidation on X-ray, septic; how do you tx?

Answer 47

ceftriaxone and azithromycin

Question 48

Fever and a cough, no consolidation on X-ray, how do you tx?

Answer 48

doxycycline or azithromycin (po) | think bronchitis

Question 49

Pneumonia but foul breath and a CXR shows cavitation, dx and tx?

Answer 49

abscess; ceftriaxone (3rd gen ceph) + clindamycin

Question 50

Bilateral white out in an AIDS pt, dx and tx?

Answer 50

PCP; IV TMP-SMX + steroids (if PaO2 is less than 70)

Question 51

Healthy woman with pyelo, can tolerate po, tx and how long?

Answer 51

cipro x 7 days | ambulatory pyelo = complicated cystitis

Question 52

Woman with severe pyelo, tx and how long?

Answer 52

ceftriaxone IV x 10 days

Question 53

Healthy man with a UTI and no sepsis, tx and how long?

Answer 53

Nitrofurantoin x 7days (could also use TMP-SMX, fosfomycin) | complicated cystitis

Question 54

Healthy woman with a UTI and no sepsis, tx and how long?

Answer 54

Nitrofurantoin x3days (could also use TMP-SMX, fosfomycin)

Question 55

Three days into a pyelo dx and the pt hasn't improved, next step?

Answer 55

CT scan (or U/S if pregnant) looking for perinephric abscess)

Question 56

White blood cell casts, likely dx?

Answer 56

pyelonephritis

Question 57

Positive urinary tract infxn on labs, pt asymptomatic, but pregnant, tx?

Answer 57

amoxicillin (nitrofurantoin if pen allergic)

Question 58

Positive urinary tract infxn on labs during a routine or screen, pt asymptomatic, tx?

Answer 58

do nothing

Question 59

Antibiotics for pyelonephritis?

Answer 59

If IV: ceftriaxone or amp-sulbactam | If po: ciprofloxacin

Question 60

Single painless ulcer with lymphadenopathy on penis? Dx? How to confirm dx? Tx?

Answer 60

primary syphilis; dark field microscopy; penicillin x1 IM

Question 61

Central umbilication?

Answer 61

Molluscum contagiosum

Question 62

Targetoid lesions on the palms and soles?

Answer 62

Syphilis (also erythema multiforme)

Question 63

Painful ulcer with lymphadenopathy on the vulva - organism and tx?

Answer 63

H. ducreyi; azithromycin

Question 64

How do you test an ulcer for herpes?

Answer 64

HSV PCR (not Tzanck prep or histology)

Question 65

Penicillin allergic and pregnant, treat tertiary syphilis with?

Answer 65

Desensitization

Question 66

Penicllin allergic and not pregnant, tx tertiary syphilis with?

Answer 66

Doxycycline

Question 67

Honey-crusted lesion, dx and tx?

Answer 67

Impetigo; amoxicillin

Question 68

Treat scabies with?

Answer 68

permethrin cream

Question 69

How to diagnose osteomyelitis with cellulitis?

Answer 69

xray, then MRI, then biopsy (no bone scan)

Question 70

Fungal skin infections that don't involve the nail, how do you tx?

Answer 70

topical antifungals

Question 71

How to diagnose osteomyelitis without cellulitis?

Answer 71

xray, then bone scan, then biopsy (MRI is best for imaging??)

Question 72

Fungal skin infections that involve the nail, how do you tx?

Answer 72

oral medications - terbinafine is the best

Question 73

Rapidly spreading cellulitis with far more pain than should be present, dx and tx?

Answer 73

necrotizing fascitis; surgical debridement asap

Question 74

Gas on X-ray, dx?

Answer 74

gas gangrene (clostridium perfringens)

Question 75

Treat lice with?

Answer 75

permethrin shampoo

Question 76

A pt with a dental procedure, and prosthetic valves gets?

Answer 76

prophylactic amoxicillin

Question 77

Pt has bacteremia and a new murmur, what diagnostic step is next?

Answer 77

TEE

Question 78

How do you tx a pt with a vegetation (endocarditis lesion) greater than 15mm?

Answer 78

Surgery

Question 79

What's the empiric prosthetic valve treatment (what does everyone get)?

Answer 79

vanc + gent; | cefepime if less than 60 days old; ceftriaxone if gt 365 days old

Question 80

What's the empiric native valve endocarditis treatment?

Answer 80

vancomycin

Question 81

When do you get a CT scan for sinusitis?

Answer 81

recurrent or refractory - to look for anatomic defects

Question 82

Non-purulent rhinorrhea, no cough, congestion: dx and mgmt?

Answer 82

common cold; supportive: decogenstants are okay, NO antibiotics

Question 83

Purulent rhinorrhea, congestion, facial tenderness, and fever: dx and mgmt?

Answer 83

sinusitis | amoxicillin-clavulanate 1st line; levofloxacin if penicillin allergic

Question 84

Pain on pulling on the pinna, child swimmer, what is it and how to tx?

Answer 84

otitis externa, pseudomonas, cipro drops

Question 85

Common cold treatment?

Answer 85

supportive

Question 86

Best diagnostic test for dx of otitis media?

Answer 86

pneumatic insufflation

Question 87

Otitis externa is tx with?

Answer 87

cipro steroid drops

Question 88

Antibiotic mgmt for ENT infxns?

Answer 88

Amoxicillin first line; azithromycin if pen allergic; amoxicillin-clavulanate if refractory