infectious diseases Flashcards
gingivostomatitis in herpes infection can be treated with
oral acyclovir
chlorhexidine mouthwash
during pregnancy, when is herpes risky
primary attack of herpes in third trimester - after 28 weeks gestation
needs elective c-section
For patients with suspected Lyme disease, If the ELISA is positive or equivocal, what is the next step
Immunoblot test
Abx can be prescribed while awaiting the Immunoblot result
Lyme disease is what pathogen
Borrelia burgdorferi
What rash is seen in lyme disease
erythema migrans
If erythema migrans rash is present for Lyme disease then you can start what treatment
Doxycycline for 21 days
What is the first-line test for Lyme disease
ELISA test
assay for antibodies to Borrelia burgdoferi
The ELISA test is the first-line test for Lyme disease. If this is negative, and Lyme disease is still suspected within 4 weeks, what should you do next
Repeat ELISA 4-6 weeks after the first
The ELISA test is the first-line test for Lyme disease. If this is negative, and Lyme disease is still suspected for 12 weeks or more, what should you do next
Immunoblot test
(4-6 weeks - repeat ELISA)
What treatment is given for disseminated lyme disease
ceftriaxone
Eron classification is used for cellulitis. What management is used for Stage 1-4
1: oral Abx
2: unwell with comorbidity. May not need admission if community IV Abx and monitoring can happen.
3-4: need admission for IV Abx i.e. periorbital
Genital wart treatment for multiple, non-keratinised warts
topical podophyllum
2nd line = imiquimod
For adults with mild facial cellulitis, prescribe …?
co-amoxiclav 7 days
(or clarithro if pen allergic)
Genital wart treatment for solitary, keratinised warts
cryotherapy
Genital warts (aka condylomata accuminata) are caused by which HPV
HPV 6 and 11
Pathogen of bacterial vaginosis
Gardnerella vaginalis
Amsel’s criteria for bacterial vaginosis. 3 out of the 4 following points must be present:
- Thin, white homogenous discharge
- Clue cells on MC&S
- Vaginal pH >4.5
- Whiff test +ve
MC&S slide shows:
Clue cells, stippled vaginal epithelial cells
what is diagnosis
bacterial vaginosis
Asymptomatic bacterial vaginosis Rx
NOT required
Incidental swab findings
ONLY treat if woman is having a TOP
Symptomatic bacterial vaginosis Rx
Oral metronidazole for 5-7 days
OR
single dose of 2g metronidazole
(can also use topical metronidazole or clindamycin as alternatives)
Bacterial vaginosis in pregnancy - symptomatic treatment
Oral metronidazole for 5-7 days or topical treatment
The stat 2g dose is not recommended
Both the National Chlamydia Screening Programme and SIGN guidelines support the screening of asymptomatic patients for Chlamydia. Which age group should be targeted?
Sexually active patients aged 15-24
Investigation of chice for chlamydia
NAAT technique:
Men - 1st pass urine
Women - vulvovaginal swab or cervical swab
When should chlamydia testing be carried out after possible exposure
2 weeks
Treatment of chlamydia
doxycycline 7 day
If contraindicated/not tolerated: azithromycin 1g OD for one day then 500mg OD for 2 days
If a patient with chlamydia is pregnant what are the antibiotic options
Azithromycin
Erythromycin
Or Amoxicillin
For patients with chlamydia, they should contact all partners since what timeframe:
(a) men with urethral symptoms
(b) women and asymptomatic men
(a) men with urethral symptoms - 4 weeks before symptoms
(b) women and asymptomatic men - partners from 6 months, or the most recent sexual partner
What is the most common cause of diarrhoea in patients with HIV infection
Cryptosporidium
For patients with gonorrhoea, if the patient refuses IM ceftriaxone, what is the alternative oral treatment
oral cefixime 400mg + oral azithromycin 2g
First line treatment for gonorrhoea
IM ceftriaxone 1g
+/- oral ciprofloxacin 500mg if sensitivities are known
Most common pathogen cause of septic arthritis in young adults
Neisseria gonorrhoea
3 key features of disseminated gonococcal infection
Tendosynovitis
Migratory polyarthritis
Dermatitis (lesions can be maculopapular or vesicular)
Haematological complication of mycoplasma pneumoniae
Cold agglutins (IgM) can cause a haemolytic anaemia
Thrombocytopenia
What rashes are seen with mycoplasma pneumoniae
erythema multiforme
(erythema nodosum too)
Investigations to diagnose mycoplasma pneumoniae
Mycoplasma serology
Management for mycoplasma pneumoniae
doxycycline
or macrolide (erythro/clarithro)
EBV associated malignancies:
Burkitt’s lymphoma
Hodgkin’s lymphoma
Nasopharyngeal carcinoma
The non-malignant condition hairy leukoplakia is associated with which viral infection
EBV
Treatment of erysipelas
Fluclocloxacillin
(clarithro if pen allergic)
What is the pathogen that usually causes erysipelas (superficial infection of the dermis)
B-haemolytic group A strep
2 commonest pathogen causes of cellulitis
- Strep pyogenes
- Staph aureus
HIV seroconversion (flu-like illness) typically occurs after how long post-infection
3-12 weeks after
Legionella investigation
Urinary antigen
Management of legionella
Erythromycin or clarithromycin
What are the three types of Leishmaniasis
- Cutaneous
- Mucocutaneous
- Visceral (kala-azar)
Cutaneous leishmaniasis presents with…
ulcers
crusted lesion at site of the bite
Dx = punch biopsy
What is cutaneous leishmaniasis caused by
Leishmania tropica or maxicana
Mucocutaneous leishmaniasis is caused by…
Leishmania braziliensis
Visceral leishmaniasis (kala-azar) is caused by…
Leishmania donovani
Visceral leishmaniasis (kala-azar) caused by Leishmania donovani presents with..
Fevers, rigors
Splenomegaly
Hepatomegaly
Weight loss
Grey skin
Pancytopenia
What is the gold standard test for diagnosis of visceral leishmaniasis (Leishmania donovani)
Bone marrow or splenic aspirate
n.b. in cutaneous leishmaniasis, punch biopsy of bite/crusting ulcer can be done
Which HPV strains are linked to cancers
16, 18, 33
HPV vaccines are offered to
All 12-13 year olds
MSM under 45
First line pregnant woman UTI symptomatic treatment
Nitrofurantoin 7 days
(avoid near term)
(Avoid trimethoprim in 1st trimester)
Asyptomatic bacteriuria (UTI) in pregnant women are still treated with antibiotics - what length of course
7 days
Nitro (avoid near term), amoxi or cefalexin
Men are treated with a course of UTI antibiotics for what time frame
7 days
If a patient who is catheterised has a UTI, what length of Abx course is given?
7 days
A patient with acute pyelonephritis should be given broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for how long
10-14 days
What is the latest time that HIV post-exposure prophylaxis may be given?
72 hours post exposure event
Trichomonas vaginalis - treat with…
Oral metronidazole for 5-7 days
(or one-off dose of 2g metronidazole)
microscopy of a wet mount for trichomonas vaginalis shows…
motile trophozoites
what is the typical temperature (C) range that the vaccines need to be stored at?
2-8 degrees celsius
what pathogen causes croup
parainfluenza virus
Travelled to India
Went swimming
Non-bloody diarrhoea
Long incubation period
Bloating
Trophozoite and cysts MC&S
What is likely organism
Giardiasis
What is the treatment for giardiasis
Metronidazole
Flu-like symptoms
RUQ pain
Tender hepatomegaly
Raised BR
Raised ALT/AST
Normal/slightly raised ALP
what is likely condition
Hepatitis
transmission of hepatitis A
faecal-oral route
Hep C and D transmission
Blood-borne
Hepatitis D only occurs in people who are also infected with
Hepatitis B
Which hepatitis do people usually make a full recovery
Hepatitis A
85% of people with hep A recover within 3-6 months. There is no chronic liver disease.
Painless penile ulcers are usually caused by
syphilis
i.e. treponema pallidum
incubation period of syphilis
9-90 days
chancre - painless ulcer is seen in which STI
syphilis
(treponema pallidum)
primary features of syphilis
chancre
local non-tender lymphadenopathy
secondary features of syphilis (6-10 weeks after primary infection)
systemic: fevers
rashes on trunk, palms, soles
buccal snail track ulcers
condylomata lata
tertiary features of syphilis
gummas - granulomatous lesions of skin and bones
Argyll-Robertson pupil
tabes dorsalis
aortic aneurysms
What eye pupil condition is seen in tertiary syphilis
Argyll-Robertson pupil
blunted upper incisor teeth (Hutchinson’s teeth)
‘mulberry’ molars
rhagades (linear scars at the angle of the mouth)
keratitis
saber shins
saddle nose
deafness
these are seen in which congenital condition
congenital syphilis
what transmission is hepatitis E
faecal-oral spread
what hepatitis infections are spread via faecal oral route
hepatitis A
hepatitis E
what are the tests used for diagnosis and screening of HIV
combination tests
(HIV p24 antigen and HIV antibody)
Needlestick injury from HIV positive patient - what is the chance of contracting HIV
0.3%
Campylobacter is what type of pathogen
Gram negative bacillus
First-line antibiotic for severe campylobacter
Clarithromycin
for contacts of patients (within 7 days before onset) with bacterial meningococcal meningitis, what medications can be used
oral ciprofloxacin (single dose) or rifampicin
If meningococcal disease is suspected then what medication should be given immediately
IM benzylpenicillin
IV antibiotics to treat meningitis (with delayed LP) for patients aged 3 months to 50 years
Cefotaxime (or ceftriaxone)
IV antibiotics to treat meningitis (with delayed LP) for patients aged over 50 years
Cefotaxime (or ceftriaxone)
And amoxicillin (or ampicillin)
sore throat, fever, a fine red rash over the entire body, flushed face with sparing around the mouth, and ‘strawberry tongue’
what is the diagnosis
scarlet fever
(group A strep)
what is scarlet fever treated with
10 day course of penicillin (or erythromycin if allergic)
A 44-year-old farmer presents with headache, fever and muscle aches. He initially thought he had a bad cold but his symptoms have got progressively worse over the past week. During the review of systems he reports nausea and a decreased urine output. On examination his temperature is 38.2ºC, pulse 102 / min and his chest is clear. Subconjunctival haemorrhages are noted but there is no evidence of jaundice. What is the most likely diagnosis?
Leptospirosis
What are investigations for leptospirosis
Serology - antibodies develop after 7 days
PCR
Culture
Management of leptospirosis
High dose benzylpenicillin
Or doxycycline
unilateral painful ulcer, painful inguinal lymph node enlargement
ragged, undermined border
what is the diagnosis
chancroid
caused by haemophilus ducreyi
Pregnant women who have travelled to a Zika virus area are referred immediately to secondary care for what investigations
regular ultrasound of the foetus
Which 2 malaria prophylaxis medications are contraindicated in epilepsy
Chloroquine
Mefloquine (Larium)
5 options for malaria prophylaxis
- Atovaquone + proguanil (Malarone)
- Chloroquine
- Doxycycline
- Mefloquine (Lariam)
- Proguanil
- Proguanil + chloroquine
What malaria prophylaxis can pregnant women have
Chloroquine
Proguanil - with folate supplementation
diethyltoluamide (DEET) 20-50% has been shown to repel up to 100% of mosquitoes if used correctly. It can be used in children over how old
2 months
doxycycline is only licensed in the UK for children over the age of…
12 years
Genital ulcers
painful
what two ddx
Herpes
Chancroid (unilateral)
Genital ulcers
painless
what two ddx
syphilis
lymphogranuloma venereum
treatment for initial herpes infection
acyclovir for 7-10 days
infectious mononucleosis (glandular fever) is caused by EBV - which HHV virus is this
HHV-4
(can also be caused by CMV and HHV-6)
Triad of infectious mononucleosis (glandular fever)
Sore throat
Fever
Lymphadenopathy
Diagnosis of infectious mononucleosis (glandular fever) - what tests should be done in the 2nd week of illness
Heterophil antibody test (Monospot test)
+ FBC
Management of glandular fever (infectious mononucleosis)
Rest
Analgesia
Avoid contact sports for 4 weeks
which antimalarials can be stopped 7 days after returning from a malarial zone
atovaqone + proguanil (malarone)
A 40-year-old man develops pneumonia following an episode of influenza. what is the likely causative organism
Staph aureus
The most common pathogen causing pyelonephritis is
E. coli
Investigation for acute pyelonephritis
MSU
before starting Abx
What swabs for chlamydia and gonorrhoea in women should be taken
vulvo-vaginal (introitus) swab
antibiotic of choice for cellulitis in pregnancy if the patient is penicillin allergic
Erythromycin
NOT clari
Management of salmonella
Ciprofloxacin
UTIs in pregnancy - what should be done following completion of Abx to test for cure
Repeat urine culture
Responders with anti-HBs levels greater than or equal to what level do not require any further primary doses?
100
Responders with antiHBs levels of what range should receive one additional dose of vaccine at that time.
10-100
(over 100 do not need more doses)
When antibody levels for anti-HBs response to Hep B vaccine are <10 (i.e. non-response to vaccine), what should be done
Test for current/past infection
Repeat vaccine course
Retest 1-2 months after second course
What percentage of patients with genital Chlamydia infection are asymptomatic?
70% women
50% men
annual flu and pneumococcal (one-off) vaccine is recommended for ages above what
65 years
What condition are there Negri bodies (cytoplasmic inclusion bodies) found in infected neurons
Rabies
Following an animal bite in at-risk rabies countries what steps should be taken?
- Wash wound
- If patient is already immunised, then further 2 doses of vaccine should be given
- If not previously immunised, give human rabies Ig (HRIG) with full course of vaccination
- +/- Abx
Women who suffer regular urinary tract infection following sexual intercourse can be offered
single dose use post-coital Abx prophylaxis
cochlear implant she is at risk of what infections
pneumococcal
therefore now eligible for the vaccine
what type of vaccine is the intranasal influenza vaccine
live vaccine
What is the most appropriate type of chemical to clean up body fluid spillage e.g. vomit
hypochlorite
(chlorine in oxidation state +1)
granular/powder form
or Virkon in some NHS trusts
Testing for HIV in asymptomatic patients should be done at what time frame after exposure
4 and 12 weeks after
(for antibodies and p24 antigen)
Post-exposure prophylaxis for HIV
Oral antiretroviral therapy for 4 weeks
Mumps is caused by
RNA paramyxovirus
occurs inwinter and spring
fever
malaise, muscular pain
parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
what is the condition
mumps!
what is the management for mumps
rest
analgesia
notifiable disease
what are 4 complications of mumps
orchitis
hearing loss - unilateral, transient
meningoencephalitis
pancreatitis
microscopy shows flagellated protozoa
discharge
what is the condition
trichomonas vaginalis
what is the treatment for pubic lice
malathion lotion or permethrin cream
apply and then wash off after 12 hours
reapply 7 days again
infective exacerbation of COPD treatment
amoxicillin or tetracycline or clarithromycin
how many injections does the HPV vaccine require
2 injections
pneumococcal vaccine is usually a one-off but every 5 years a booster is given if the patient has…
splenectomy
or chronic kidney disease
in the UK, how many doses of the tetanus vaccine are given over the course of routine immunisation schedule
5 doses
which pathogen causing diarrhoea has shortest incubation period
bacillus cereus
approx 6-15hrs
(also staph aureus)
pregnant women are advised to have what vaccine from weeks 16-32
whooping cough (pertussis) vaccine
all at risk drug misusers should be offered vaccination against
hepatitis B
BCG live attenuated vaccine is what bacteria
Mycobacterium bovis
any person being considered for the BCG vaccine must first be given
tuberculin skin test i.e. Heaf or Mantoux
(intradermal)
5 contraindications to BCG vaccine
Previous BCG vaccine
Past history of TB
HIV
Pregnancy
Positive tuberculin test
BCG is not given to anyone over the age…
35
what hepatitis is curable
hep C
painless genital ulcer and painful lymphadenopathy
lymphogranuloma venereum
Lymphogranuloma venereum usually involves three stages:
- painless ulcer
- painful lymphadenopathy
- proctocolitis
preventing the spread of norovirus - handwashing should be done with what
soaps + warm water
alcohol gels are less effective
what is the treatment for extensive otitis externa
flucloxacillin
what is the triple Abx treatment for pelvic inflammatory disease
doxycycline
metronidazole
ceftriaxone
can patients have HPV against parental wishes when they are a child
yes
What is the most likely complication from repeated infection of gonorrhoea in women
infertility
secondary to pelvic inflammatory disease
Lymphogranuloma venereum (painless ulcer, painful lymphadenopathy) is caused by what pathogen
chlamydia trachomatis
suppression of MRSA from a carrier once identified - treatment for nose and skin
Nasal mupirocin + chlorhexidine for the skin
Live attenuated vaccines (seven)
BCG
MMR
Influenza (intranasal)
oral rotavirus
oral polio
yellow fever
oral typhoid
Inactivated preparation vaccines (three)
rabies
hepatitis A
influenza (intramuscular)
Toxoid (inactivated toxins) vaccines (three)
tetanus
diphtheria
pertussis
Subunit and conjugate vaccines (five)
pneumococcus (conjugate)
haemophilus (conjugate)
meningococcus (conjugate)
hepatitis B
HPV
Retro-orbital headache, fever, facial flushing, rash, thrombocytopenia in returning traveller
what is a differential
dengue
raised eosinophils tend to be seen in which tropical viral infection
Chagas disease
Dengue fever is a RNA virus of Flavivirus. What is it transmitted by
Aedes aegypti mosquito
Severe dengue haemorrhagic fever can result in disseminated intravascular coagulation (DIC) which results in..
Thrombocytopenia
Bleeding
High d-dimer
High PT, APPT
Low fibrinogen
Dengue fever treatment
Symptomatic
No antivirals are available
treatment for shigella and salmonella
ciprofloxacin
lactose intolerance can develop after which GI infection
Giardiasis
Patient has had a full course of tetanus vaccines, with the last dose < 10 years ago with wound
what management
no vaccine nor tetanus immunoglobulin is required, regardless of the wound severity
Patient has had a full course of tetanus vaccines, with the last dose > 10 years ago with:
(a) tetanus prone wound
(b) high risk tetanus prone heavy contaminated wound
(a) vaccine dose
(b) vaccine dose + tetanus Ig
Patient with vaccination history is incomplete or unknown for tetanus with wound:
Vaccine dose
Tetanus Ig
if person who is not vaccinated against hep B gets a needlestick from hep B patient, how should they be treated
accelerated course of hep B vaccine
and hep B immunoglobulin
what vaccines do CKD5 patients require
Pneumococcal - every 5 years
Influenza - every year
Hep B
For a patient undergoing an elective splenectomy, when is the optimal time to give the pneumococcal vaccine?
2 weeks before
Within what time frame does Public Health England state you must submit a Notifiable Diseases form?
72 hours
A patient who was an intravenous drug user in the 1990s asks for a hepatitis C test. What is the most appropriate blood test?
Anti-HCV antibody test
The majority of malaria cases are caused by
plasmodium falciparum
(commonest non-falciparum malaria is plasmodium vivax)
Which test is used to confirm the diagnosis for brucellosis?
brucella serology
detects antibodies against brucella antigens
The most common side effect of atovaquone/proguanil is
GI upset
what is the pH in trichomonas vaginalis and bacterial vaginosis
pH >4.5
Children aged 6 months to 2 years who are at high risk of flu are offered …
annual INTRAMUSCULAR flu vaccination
live intraNASAL influenza vaccine is offered to kids aged from
2 years
before that is intramuscular
grey coating on tonsils
fever
cervical lymphadenopathy
what is likely condition
diptheria
how long does a child with erythema infectiosum i.e. fifth disease (slapped cheek syndrome) need to be excluded from school for
no exclusion
what virus causes erythema infectiosum (fifth disease or slapped cheek syndrome)
parvovirus B19
patients becoming pregnant should avoid becoming pregnant while in an area with Zika virus and for how long after their return
2 months
(3 months if male partner went too)
what should be checked before starting ethambutol
visual acuity
what is the most common Bacterial cause of otitis externa
Pseudomonas aeruginosa
An 8-year-old boy is brought in by his mother with a history of shortness of breath and fever over the last few hours. On examination, he has a toxic appearance, has inspiratory stridor, and is drooling.
what is the likely cause?
ACUTE EPIGLOTTITIS
caused by HiB
what is the most common resp infection in COPD
Haemophilus influenzae
Stat IM benzylpenicillin doses for:
0-1 years
1-10 years
>10 years
Start at 3 and double each time!
0-1 years: 300mg
1-10 years: 600mg
>10 years: 1200mg
patients with ovale or vivax malaria should be given primaquine following acute treatment with chloroquine. what is the benefit of the primaquine?
Primaquine in non-falciparum malaria destroys liver hypnozoites and prevent relapse
Plasmodium vivax/ovale has a cyclical fever of how long
every 48 hours
Plasmodium malariae has a cyclical fever of how long
every 72 hours
Areas that are known to have malaria that is chloroquine-sensitive, WHO recommend either…
chloroquine; or
artemisin-based combination therapy (ACT)
Areas that are known to have malaria that is chloroquine-RESISTANT, WHO recommends…
artemisin-based combination therapy (ACT)
CONTRAINIDICATED IN PREGNANCY
which type of pneumococcal vaccine should adults receive:
polysaccharide or conjugate vaccine
pneumococcal POLYSACCHARIDE vaccine
for over 65 years, chronic conditions
which type of pneumococcal vaccine should children receive:
polysaccharide or conjugate vaccine
Pneumococcal conjugate vaccine
at 3, and 12-13 months
bacterial pneumonias secondary to influenza infection are more commonly caused by…
staph aureus
Triad of Behcet’s disease
Oral ulcers
Genital ulcers
Uveitis
+ clots
Is tuberculosis a notifiable disease
yes
What is the most effective single step to reduce the incidence of MRSA?
hand hygiene
Who should be screened for MRSA?
- all patients awaiting elective admissions
- all emergency admissions
which 3 antibiotics can be used in the treatment of MRSA infections
vancomycin
teicoplanin
linezolid
standard therapy for active TB (RIPE)
Rifampicin - 6 months
Isoniazid - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months
Treatment for latent TB
3 months of isoniazid (+ pyridoxine B6) and rifampicin
OR
6 months of isoniazid monotherapy (+ pyridoxine B6)
Treatment for meningeal TB
At least 12 months of RIPE
With steroids
Certain groups e.g. homeless people, poor adherence and prisoners, have directly observed therapy for tuberculosis.
What is their dosing regimen?
3 times a week dosing
side effects of rifampicin
potent liver INDUCER
orange secretions
hepatitis
flu-like symptoms
side effects of isoniazid
peripheral neuropathy - replace with B6 pyroxidine
hepatitis
agranulocytosis
liver enzyme INHIBITOR
which TB drug is a liver enzyme:
(a) inducer
(b) inhibitor
(a) rifampicin
(b) isoniazid
side effects of pyrazinamide
hyperuricaemia (causes gout)
arthralgia
myalgia
hepatitis
which TB drugs can cause hepatitis
rifampicin
isoniazid
pyrazinamide
side effect of ethambutol
optic neuritis
check visual acuity before and after treatment
For persistent BV in women with an intrauterine contraceptive device, what should be considered
removal of device
alternative contraception
Orf is caused by the parapox virus which causes scabby red-blue lesions. what animals is it usually found in
sheep/goats
FARMERS in questions
anthrax is caused by bacillus anthracis. it presents as a painless black eschar. what animals is it associated with
hides or wool
livestock animal
In acute uncomplicated sinusitis, first-line therapy as per NICE guidelines would be
phenoxymethylpenicillin
if pen allergic: doxycycline or clarithromycin
2nd line = co-amoxiclav
acute prostatitis (tender boggy prostate) with urinary symptoms
what antibiotic is appropriate
ciprofloxacin
Patients who are immunosuppressed secondary to long-term steroids or methotrexate and are exposed to chickenpox by someone else should have what
Test for varicella antibodies
VZ immunoglobulin
How is the BCG vaccine given?
intradermally
What findings in the full blood count would suggest glandular fever?
lymphocytosis
what pathogen causes the common cold
rhinovirus
After an initial negative result when testing for HIV in an asymptomatic patient i.e. at 4 weeks, when should a repeat test be done?
at 12 weeks
what % of hep C infections turn into chronic hep C
55-85%
the majority
wasp/bee allergy treatment for prophylaxis in patients with venom-specific IgE
venom immunotherapy
Ziehl-Neelsen stain of stool in patient with HIV and diarrhoea shows red cysts. what is diagnosis
Cryptosporidium
what is caused by haemophilus ducreyi
chancroid
People who’ve had a systemic reaction to an insect bite - follow up management
referral to allergy specialist
