Internal Medicine Flashcards
1
Q
Principles of answering infectious disease questions
A
- The radiologic test is never the most accurate test.
- Risk factors for an infection are not as important as the individual presentation.
- Beta-lactam antibiotics have greater efficacy than other classes
2
Q
Penicillin
A
Viridans group Strep Strep Pyogenes oral anaerobes Syphilis Leptospira
3
Q
Ampicillin and Amoxicillin
A
same as penicillin
E. coli
Lyme disease
Gram neg bacilli
4
Q
Most accurate test for an infectious disease?
A
Culture
5
Q
Bacteria covered by Amox
A
HELPS
H Flu E coli listeria proteus salmonella
6
Q
What conditions is Amox the best initial therapy for?
A
otitis media
dental infection and endocarditis prophylaxis
lyme disease limitd to rash joint or 7th cranial nerve involvement
UTI in pregnant women
Listeria
enterococcal infections
7
Q
Penicillinase-resistant penicillins (PRPs)
A
oxacillin, cloxacillin,dicloxacillin, and nafcillin
8
Q
PRPs treat
A
Skin infections: cellulitis, impetigo, erysipelas
Endocarditis, meningitis, bacteremia from staphylococci
osteomyelitis and septic arthritis when bacteria is susceptible
9
Q
Methicillin
A
Never the right answer it causes renal failure from allergic interstitial nephritis
really meaning oxacillin sensitive or resistant
10
Q
Piperacillin, ticarcillin, azolcillin, mezolcillin
A
cover gram negative bacillin (ecoli and proteus) from large enterobaceriaciae group and pseudomonads
best initial therapy for: cholecystitis and ascending cholangitis pyelonephritis bacteremia hospital acquired and ventilator associated pneumonia neutropenia and fever
always use with beta lactam inhibitor
11
Q
Medications that cover MRSA
A
vancomycin daptomycin ceftaroline linezolid tedizolid dalbavancin telavancin tigecycline
12
Q
the amount of cross reaction with penicillins and cephalosporins is
A
13
Q
All cephalosporins will cover
A
group a b and c strep
viridans strep
e coli
klebsiella
proteus mirabilis
14
Q
is the case describes a rash to penicillin
A
answer cephalosporins
15
Q
if the case describes anaphylaxis
A
answer a non-beta-lactam antibiotic
16
Q
First Generation Cephalosporins
A
Cefazolin, cephalexin, cephradrine, cefadroxyl
staph: methicillin sensitive=oxacillin sensitive=cephalosporin sensitive
streptococci (except enterococci)
some gram neg bacillus like e coli but not pseudomonas
osteomyelitis, septic arthritis, endocarditis, cellulitis
17
Q
Second Generation Cephalosporins
A
cefotetan, cefoxitin, cefaclor, cefprozil, cefuroxime, loracarbef
same coverage as first generation but add anaerobes and more gram neg bacilli
18
Q
listeria mrsa and enterococcus are resistant to all forms of
A
cephalosporins
19
Q
of the cephalsporins only cefotetan and cefoxitin cover
A
anaerobes
20
Q
Best initial therapy for pid combined with doxycycline
A
cefotetan and cefoxitin
21
Q
cefotetan and cefoxitin warning
A
increase the risk of bleeding and give a disulfiramlike rxn with alcohol
22
Q
cefuroxime, loracarbef, cefprozil, and cefaclor
A
respiratory infections such as bronchitis, otitis media, and sinusitis
23
Q
Third Genertation Cephalosporins
A
Ceftriaxone, cefotaxime, ceftazidime
24
Q
Ceftriaxone uses
A
first line for pneumococcus, including partially insensitive organisms
meningitis
cap w/macrolides
gonorrhea
lyme involving the heart or brain
25
Avoid ceftriaxone in neonates because of
impaired bilirubin metabolism
26
Ceftazidime has
pseudomonal coverage
27
Fourth Generation Cephalosporin
Cefepime
better staph coverage than 3rd gen
neutropenia and fever
ventilator associated pneumonia
28
Cefotaxime
superior to ceftriaxone in neonates
spontaneous bacterial peritonitis
29
Fifth Generation Cephalosporin
Ceftaroline
Gram neg bacilli and MRSA, not pseudomonas
30
Ceftaroline is the first Cephalosporin to cover
MRSA
31
Adverse effects of cephalosporins
cefoxitin and cefotetan deplete prothrombin and increase risk of bleeding
inadequate biliary metabolism with ceftriaxone
32
Carbapenems
Imipenem, meropenem, ertapenem, doripenem
cover gram neg bacilli (a lot that are resistant), anaerobes, streptococci, staphylococci
neutropenia and fever
33
ertapenem
does not cover pseudomonas like other carbapenems
34
aztreonam
monobactam
exclusively gram negative bacilli
no cross rxn with penicillin
35
Morganella and Citrobacter are gram neg bacilli so what group of abs would work
carbapenems
36
tedizolid dalbavancin and ortivancin are exclusively for:
gram pos cocci and mrsa, found in skin and soft tissue infections
37
Fluroquinolone drugs
Cipro, gemifloxaxin, levofloxaxin, and moxifloxacin
38
Fluoroquinolone uses
best for cap, and penicillin resistant pneumococcus
gram neg bacilli and pseudomonads
ciprofloxacin for cystitis and pyelonephritis
GI infections
moxifloxacin can be used as a single agent for diverticulitis
39
Cipro and gemifloxacin and levofloxacin muct be combined with what when treating diverticulitis
metronidazole bc the don't cover anaerobes except for moxifloxacin
40
Quinolones ae
bone growth abnormalities in children and pregnant women
tendonitis and Achilles tendon rupture
gatifloxacin removed bc of glucose abnomalities
41
Aminoglycosides
Gentamicin tobramycin amikacin
game neg bacilli (bowel, urin and bactermia)
synergistic with beta lactam abs for enterococci and staphylococci
no effect against anaerobes bc they need o2
nephrotoxic and ototoxic
42
Acute coronary Syndromes occur when
a thrombus forms at the site of rupture of an atherosclerotic plaque and acutely occludes a coronary artery
43
acute mi is diagnosed based on the presence of at least 3 of the three criteria:
typical symptoms, ecg findings, and cardiac enzymes
44
early reperfusion with pci or thrombolytics reduces mortality and preserves ventricular function in pts who have
st segment elevation, no ci, and receive treatment within the first 6 to 12 hours
45
secondary prevention after mi is to prevent recurrent cardiac events and death
smoking cessation, aspirin and clopidogrel, beta blockers, ace inhibitors, and statins
46
after mi
pci can be done to recue ischemia and angina symptoms. bypass surgery may be indicated for pts with multivessel stenosis and impaired systolic function to reduce symptoms and prolong survival
47
anterior leads
v2-v4
48
lateral leads
I, aVL, v5, and v6
49
inferior leads
II, III, and avf
50
Posterior MI
R waves in v1 and v2
51
STEMI is characterized by
ischemic discomfort along with st segment elevation on ecg
52
unstable angina and NSTEMI
will not have st elevation but nstemi is diagnosed by positive cardiac biomarkers
53
Doxycycline uses
Chlamydia
lyme disease limited to rash, joint, or 7th cranial nerve palsy
rickettsia
MRSA of skin and soft tissue (cellulitis)
primary and secondary syphilis in those allergic to penicillin
borrelia, ehrlichia, and mycoplasma
54
Doxycycline adverse effects
adverse effects: tooth discoloration (children), fanconi syndrome (type II RTA proximal), photosensitivity, esophagitis/ulcer
55
Nitrofurantoin has one indication
cystitis, especially in pregnant women
56
Trimethoprim/Sulfamethoxazole
Cystitis
pneumocystis pneumonia treatment and prophylaxis
MRSA of skin and soft tissue (cellulitis)
besides rash it causes hemolysis with g6pd deficiency and bone marrow suppression because it is a folate antagonist
57
Beta lactam/beta lactamase combinations
amoxicillin/clavulanate
ticarcillin/clavulanate
ampicillin/sulbactam
piperacillin/tazobactam
beta lactamase adds coverage against sensitive staphylococci to these agent. they cover anaerobes and are a first choice for mouth and GI abscess.
58
MRSA drugs
telavancin
dalbavancin
tedizolid
oritavancin
59
Gram positive cocci: staph and strep
treatments
Oxacillin, cloxacillin, dicloxacillin, nafcillin
first generation cephalosporins: cefazolin and cephalexin
fluoroquinolones
macrolides (azithromycin, clarithromycin,erythromycin) are third line agents bc they have less efficacy than oxacillin or cephalosporins. erythromycin is also more toxic
60
Oxacillin (methicillin)-resistant Staph is best treated by
vancomycin
linezolid: reversible bone marrow toxicity
daptomycin: elevated cpk
tigecycline
ceftaroline
telavancin
61
Minor MRSA infections of the skin are treated with:
tmp/smx
clindamycin
doxycycline
linezolid
62
Oral anaerobes above the diaphragm
penicillin (G, VK, ampicillin, amoxicillin)
clindamycin
63
Abdominal/GI anaerobes
Metronidazole
beta-lactam/lactamase combinations
64
Piperacillin and carbapenems and 2nd generation cephalosporins also cover
anaerobes
65
gram negative bacilli
E coli, klebsiella, proteus, pseudomonas, enterobacter, citrobacter
66
gram negative bacilli treatment
quinolones
aminoglycosides
carbapenems
piperacillin, ticarcillin
aztreonam
cephalosporins
67
all cns infections may present with fever, ha, nausea, and vomiting and all of them can lead to
seizures
68
stiff neck, photophobia, meningismus
meningitis
69
confusion
encephalitis
70
focal neurological findings
abscess
71
Meningitis
definition and etiology
infection covering the meninges
```
strep pneumo (60%)
group b strep (14%)
h flu (7%)
n meningitis (15%)
listeria (2%)
```
staph with neurosurgery
72
Meningitis
presentation
fever, ha, neck stiffness, photophobia
if confusion occurs you cannot answer what is the ostlikely diagnosis w/o a ct and lumbar puncture
cryptococcal meningitis may be present for several weeks
73
Meningitis
Aids with
croptococcus
74
Meningitis
camper/hiker, rash shaped like a target, joint pain, facial palsy, rick remembered in 20%
lyme disease
75
Meningitis
camper/hiker, rash moves from arms/legs to trunk, tick remembered in 60%
rocky mountain spotted fever (rickettsia)
76
Meningitits
pulmonary tb in 85%
tb
77
Meningitis with viral etiology presentation
none
78
meningitis
adolescent, petechial rash
neisseria
79
Best initial and most accurate diagnostic test for meningits
lp
80
Meningitis LP results
Bacterial
1000s neutros
protein elvated
glucose decreased
stain 50-70%
culture90%
81
Meningitis LP results
Cryptococcus, lyme, rickettsia
10-100s lymphocytes
possibly elevated protein
possibly dereased glucose
stain and culture are neg
82
Meningitis LP results
Tuberculosis
10-100s lymphocytes
markedly elevated protein
glucose may be low
stain and culture are neg
83
Meningitis LP results
viral
10-100s lymphocytes
protein is usually normal
glucose is usually normal
stain and culture are neg
84
when is a head ct the bets initial test in meningitis?
whenever there is possibility of a space occupying lesion
papilledema
seizures
focal neurological abnormalities
confusion interfering with neuro examination
85
if there is a ci to immediate lp
giving abs is the best initial step in management
86
you cannot do an accurate neuro exam if the pt is severely
confused
87
better to treat and decrease the accuracy of a test than to risk
permanent brain damage
88
Latex agglutination tests
if ag detection is positive they are extremely specific. if they are negative they could still have the infection
sensitivity is 50-90%
indicated when the pt has received antibiotics prior to the lp and the culture may be falsely negative
89
Most accurate diagnostic test
TB
acid fast stain and culture on 3 hig volume lumbar punctures
90
Most accurate diagnostic test
lyme and rickettsia
specific serologic testing, ELISA, western blot, PCR
91
Most accurate diagnostic test
Cryptococcus
india ink is 60-70% sensitive
ag is more than 95% sensitive and specific
culture of fungus is 100% specific
92
Most accurate diagnostic test
Viral
Dx of exclusion
93
Best initial treatment for bacterial meningitis is:
ceftriaxone vancomycin and steroids
94
Base your initial meningitis treatment on?
cell count
gram stain is good if positive howevere the false neg rate is almost 50%
protein and glucose levels are too nonspecific to allow for a treatment decision
95
thousands of neutrophils on csf=
ceftriaxone, vancomycin and steroids. add ampicillin if immunocompromised for listeria
96
steroids have only been proven to lower mortality in what type of meningitis and why do we give them initially
strep pneumonia
bc we wont know cultures for a few days
97
Listeria treatment
resistant to cephalosporins but sensitive to penicillins
must add ampicillin to ceftriaxone and vancomycin if these risk factors are present:
eldery
neonates
steroid use
aids or hiv
immunocompromised, including alcoholism
pregnant
98
Neisseria Menignitidis: additional management
resp isolation
rifampin Cipro or ceftriaxone to close contacts to decrease nasopharyngeal carriage (household contacts kissing or sharing cigarettes or eating utensils, work and school does not count, healthcare workers only count if they intubated the pt or performed suction or came in contact with resp droplets
99
what is almost always the wrong answer on step 2
consultation
100
what is the most common neurological deficit of untreated bacterial meningitis?
eight cranial nerve deficit or deafness
101
encephalitis
look for the acute onset of fever and confusion. herpes simplex is by fare the most common cause. must do a head ct first bc of the confusion
102
most accurate test of herpes encephalitis?
PCR of CSF
103
initial test on a genital ulcerative lesion
tzanck, viral culture is most accurate
104
herpes encephalitis treatment
acyclovir is the best initial therapy, fam and vala are not IV drugs
105
what is used for acycylovir resistant herpes
foscarnet
106
Renal toxicity in herpes encephalitis
Foscarnet>Acyclovir
107
Otitis Media
redness immobility bulging and a decreased light reflex o the tympanic membrane, pain is common, decreased hearing and fever can also occur
108
most sensitive physical finding for otitis media
immobility, full mobility will exclude otitis media
109
what is always the wrong answer for otitis
radiology
110
diagnostic test for otitis media
tympanocentesis for a sample of gluid for culture is the most accurate diagnostic test. choose tympanocentesis if there ar emutliple recurrences or if there is no response to multiple abs
111
treatment for otitis media
amox is best initial, if no response or recently treated with amox go with:
augmentin
azithromycin, clarithromycin
cefuroxime,loracarbef
levfofloxacin, gemifloxacin, moxifloxacin
112
quinolones are relatively ci in
children
113
culture of nasal discharge is always the wrong answer for
sinusitis
114
use of sinus biopsy, aspirate, or endoscopy
only needed if:
infection frequently recurs
there is no response to diff empiric therapies
115
first line therapy for otitis and sinusitis
augmentin
doxycycline
Bactrim
decongestant is used in all cases to promote sinus drainage
116
erythromycin had poor coverage for? in sinusitis
strep pneumo
117
linezolid does not cover? in sinusitis
haemophilus, but excellent in resistant gram pos organisms
118
Pharyngitis presents with
pain on swallowing
enlarged lymph node in the neck
exudate in the pharynx
fever
no cough or hoarseness
>90% If all these are present
119
pharyngitis diagnostic tests
initial test is the rapid strep test - group a beta hemolytic trep, neg cannot exclude disease.
small vesicles or ulcers: HSV or hepangina
membranous exudates: diphtheria, Vincent angina, or EBV
120
Pharyngitis treatment
penicillin or amox is best initial
if allergic to above then cephaliexin if the rxn is only a rash if anaphylaxis use clindamycin or a mcarolide
121
erythromycin has ae like
nausea vomiting and diarrhea
122
Influenza presents with
athralgias/myalgias
cough
fever
ha and sore throat
nausea vomiting or diarrhea especially in kids
123
Most appropriate next step in the flue
if w/in 48 hours then perform a naopharyngeal swab or wash in order to rapidly detect the ag associated with influenza
124
influenza treatment
less than 48 hours since symptoms: oseltamivir, zanamivir. neuraminidase inhibitor shorten the duration of symptoms. treat both a and b
greater than 48 hours: symptomatic treatment only, analgesics, rest, antipyretics, hydration
125
oseltamivir and zanamivir do not treat complications of influenza like
pneumonia
126
Infectious Diarrhea
Blood and WBC in stool
salmonella - poultry
campylobacter - most common cause, assoc with gbs
ecoli o157:h7 - hemolytic uremic syndrome
shigella - 2nd most common hus
vibrio parahaemolyticus - shellfish and cruise ships
vibrio vulnificus - shellfish, history or liver disease, skin lesions
Yersinia - high affinity for iron, hemochromatosis, blood transfusions
cdiff - white and red cells in stool
127
best test for infectious diarrhea blood and wbcs in stool
initial test is blood and fecal leukocytes
lactoferrin is a better answer than leukocytes if it is there
most accurate is stool culture
mos
128
Infectious Diarrhea
no blood or wbcs in stool
viral
giardia - camping/hiking and unfiltered fresh water
cryptosporidiosis - aids with less than 100 cd4 cells, detect with modified acid fast stain
bacillus cereus - vomiting
staphylococcus - vomiting
129
Infectious diarrhea
Scombroid
most rapid onset
wheezing flushing and rash
treat with antihistamine
130
Indectious diarrhea treatment
Mild - oral fluid replacement
severe - fluid replacement and oral antibiotics such as cipro
131
what is the most accurate in determining the etiology of infectious diarrhea?
blood in the stool (invasive like salmonella shigella Yersinia or ecoli) other things are what food was eaten, bowel frequency, and smell are useless
132
Severe infectious diarrhea means
```
hypotension
tachycardia
fever
abdominal pain
bloody diarrhea
metabolic acidosis
```
133
Giardia treatment
metronidazole, tinidazole
134
cryptosporidiosis treatment
treat underlying AIDS, nitazoxanide
135
Viral diarrhea treatment
fluid support as needed
136
B cereus and staphylococci diarrhea treatment
fluid support prn
137
Acute hepatitis definition/etiology
infection or inflammation of the liver
most cases for hep a or b
hep c rarely causes acute infection
hep d only exists in people with hep b
138
hep e
worse in pregnancy esp east Asians
139
hep from sex, blood and perinatal (parenteral):
b c d
140
hep from food and water:
a and e
141
hepatitis presentation
jaundice
fever, weight loss, fatigue
dark urine
hepatosplenomegaly
nausea, vomiting and abdominal pain
142
acute hepatitis diagnostic tests
increased direct bilirubin
increase alt to ast
increased alk phos
143
aplastic anemia is a rare complication of
acute hepatitis
144
elevated pt
fulminant hepatic failure and death
145
best initial diagnostic test for acute viral hep
igm for acute
igg for resolution
hep c activity is with pcr for rna level
hep b and c pcr levels are firt thing to chang as an indication of improvement with treatment and they rise if treatment fails
146
acute or chronic hep b infection tests
surface ag - pos
e ag - pos
core ab - positive igm or igg
147
resolved, old, or past hep b infection tests
core ab - pos igg
| surface ab - pos
148
hep b vaccination tests
surface ab - pos
149
hep b window period test
core ab - pos igm then igg
150
what becomes abnormal first after acquiring hep b infection?
surface ab
151
what most directly correlates with the amount of virus or quantity of hep b replication?
e ag, correlates with dna polymerase, these pts will most likely need antiviral medications in chronic disease also if e ag is present
152
when do you know that a pt is no longer going to pass hep b?
surface ag is present
153
Viral load testing in hepatitis
b and c you track the level of viral particles, pcr is used for this, measure response to therapy also
154
what is the best indicator that a pregnant woman will transmit infection to her child?
e ag
qualitative test
dna polymerase is a quantitative test
90% of children with mother e ag pos will be infected at birth
155
what is the most common transmission of hep b worldwide?
perinatal
156
hepatitis b viral load is more precise than
e ag
157
hep a and e resolve
spontaneously, takes a few weeks and almost always benign
158
hep b becomes chronic in?
10%, treatment doesn't change this
159
acute hep c treatment
interferon, ribavirin and wither boceprivir or telaprevir
this decrease the likelihood of developing a chronic infection
160
only acute hep c get
medical therapy
161
sofosbuvir and ribavirin alone can be oral therapy for
hep c for genotypes 2 and 3
162
chronicity for hep bi is defined as
persistence of surface ag for more than 6 months
163
chronic hep b treatment
if positive for e ag with elevated level of dna polymerase, use one of the following: entecavir, adefovir, lamivudine, telbivudine, interferon, or tenofovir
interferon is injection and has the most adverse effects so it is no the best first choice
164
adverse effects of interferon
arthralgia/myalgia
leukopenia and thrombocytopenia
depression and flu like symptoms
165
goal of chronic hep therapy is
reduce dna polymerase to undetectable levels
convert hose pts with e ag to having antihepatitis e ab
166
hep c genotype 1 treat with
ledipasvir and sofosbuvir
167
role of liver biopsy in hep
presence of fibrosis with b or c - treat right away
if there is active viral replication, fibrosis will progress to cirrhosis
cirrhosis is not reversible
168
alt levels are not a good indication of the activity of
chronic hep, you can have significant infection with normal transaminase levels
169
ribavirin causes
anemia
170
treatment of chronic hep c
treat if pcrrna viral load is elevated
genotype 1 is treated with ledipasvir and sofosbuvir orally for 12 weeks
other genotypes are treated with sofosbuvir and ribavirin orally
interferon is used in treatment failure
telaprevir and boceprevir are less effective and should never be the first choice
if there is fibrosis on biopsy treatment is urgent
the goal of therapy is to cahive an undetectable viral load
171
key points of hep c treatment
acute hep c I streated
hep ci si the only form of acute hep to be treated
everyone born between 45 and 65 is tested for hep c regardless of risk factors
cure rates are exceeding 90%
hopefully prevent the need for liver transplant
172
interferon is rarely used as first line in
hep
173
hep c can be effectively cured in the majority of cases, be concerned with the following
do not test base only on risk factors (needle use)
anyone with a high pcr rna viral load needs treatment
genotype predicts the response to therapy
viral load assesses the effect of therapy. viral load answers the question has there been an effect
liver bipsy determines how much damage there has been to the liver. if you are going to treat anyone bc the viral load is high there is very little point in doing a liver biopsy.
174
Urethritis
what is the mostly likely diagnosis? if urethral discharge
urethritis and cystitis give dysuria with urinary frequency and burning but cystitis does not give urethral discharge
175
urethritis diagnostic tests
best initial test is a swab for gram stain
urin testing for nucleic acid amplification can detect gonorrhea and chlamydia
increased wbcs
intracellular gram neg diplococci is sufficient for Neisseria gonorrhea to initiate treatment
most accurate test is a urethral culture, dna probe, or nucleic acid amplification test (NAAT) for chlamydia and gonorrhea.
other causes can be mycoplasma genitalium and ureaplasma
176
urethritis treament
use a combination of one drug for gonorrhea and one for chlamydia
quinolones are not the best initial therapy bc of resistance
177
cefixime can no longer be used for
gonorrhea
178
Cervicitis
cervical discharge and an inflamed strawberry cervix
swab for nucleic acid amplification
treatment is ceftriaxone and azithromycin as a single dose, doxy is efficacious as azithromycin but harder to use
179
PID presents with
```
lower abdominal tenderness
lower abdominal pain
fever
cervical motion tenderness
leukocytosis
```
first step if these are present is to exclude pregnancy
180
pid diagnostic tests
cervical swab for culture, dna probe, or nucleic acid amplification
clarify need to treat the partner for an std and make treatment more precise
181
cervical testing is not the most accurate test in
pid
182
laparoscopy in pid
most accurate test
needed rarely, only if dx is unclear and symptoms persists or recur despite treatment
183
pid treatment
treat with combo for chlamydia and gonorrhea
inpatient - cefoxitin, or cefotetan combined with doxycycyline
outpatient - ceftriaxone and doxycycline (possibly with metronidazole)
pts with anaphylaxis to penicillin - levofloxacin and metronidazole as outpatient or clindamycin gentamicin and doxycycline as inpatient
184
it is often impossible to determine the specific diagnosis of genital ulcers by physical examination alone, but if this issue appear on step it means the question must
provide sufficient clues or evidence to give you the answer
185
all ulcerative genial disease can have
inguinal adenopathy
186
painless genital ulcer
syphilis
187
painful genital ulcer
chancroid (haemophilus ducreyi)
188
inguinal lymph nodes tender and suppurating
lymphogranuloma venereum
189
genital vesicles prior to ulcer and painful
herpes simplex
190
syphilis diagnostic tests
dark field
vdrl or rpr (75% sensitive in primary syphilis)
fta or mhatp (confirmatory)
191
chancroid diagnostic tests
stain and culture on specialized media
192
lymphogranuloma venereum diagnostic tests
complement fixation titers in blood
nucleic acid amplification testing on swab
193
herpes simplex diagnostic tests
tzanck prep is the best intiatl test
viral culture is the most accurate test
194
syphilis treatment
single dose of I'm benzathine penicillin
doxycycline if penicillin allergy
195
chancroid treatment
azithromycin single dose
196
lymphogranuloma venereum treatment
doxycyline
197
herpes simplex
acyclovier valaylovir famciclovir
foscarnet for acyclovir resistant herpes
198
If dark field is positive for spirochetes...
not further syphilis testing is needed
199
serology is worthless with herpes bc
it cannot distinguish between a current infection and a past oral infection
200
primary syphilis presentation
painless genital ulcer with heaped up indurated edges (it becomes painful if is becomes secondarily infected with bacteria)
painless adenopathy
201
secondary syphilis presentation
rash (palms and soles)
alopecia areata
mucous patches
condyloma lata
202
Tertiary syphilis presentation
neurosyphilis
meningovascular (stroke from vasculitis)
tabes dorsalis (loss of position and vibratory sense, incontinence, cranial nerve)
general paresis (memory and personality changes)
Argyll Robertson pupil ( reacts to accommodation but not light)
aortitis (aortic regurg or aneurysm)
gummas (skin and bone lesions)
203
syphilis chancres heal spontaneously even w/out treatment
penicillin prevents later stages
204
sensitivity of vdrl or rpr in syphilis
primary - 75-85%
secondary - 99%
tertiary - 95%
205
sensitivity of fta-abs in syphilis
primary - 95%
secondary - 100%
tertiary - 98%
206
a negative fta means
not neurosyphilis
207
if vdrl and rpr are negative it means what for neurosyphilis?
nothing, it has not been ruled out yet
208
vdrl and rpr titer levels
reliable when greater than 1:8
lower tier is more often falsely positive
high titer (greater than 1:32) are rarely false positive
209
false positive vdrl/rpr
```
infection
older age
ijection drug use and aids
malaria
antiphospholipid syndrome
endocarditis
```
210
syphilis treatment
primary and secondary syphilis - single I'm injection of penicillin. oral doxy if allergic
tertiary - iv penicillin. desensitive to penicillin if allergic
211
jarish-herxheimer rxn
fever and worse symptoms after syphilis treatment
give aspirin and antipyretics, it will pass
212
syphilis, desensitization is the answer for
allergies and pregnant women
213
Genital warts (condyloma Acuminata)
papillomavirus
diagnosed with visual appearance (wrong answer is biopsy serology stain smear or culture)
remove with cryotherapy liquid nitrogen, surgery laser or melting with podphyllin or trichloroacetic acid
imiiquimod is a locally immunostimulant that leads to sloughing off of the lesion. (also works for keratosis and basal cell cancer) it does not burn or damage the skin
214
Pediculosis (crabs)
found on hair bearing areas (askilla and pubis)
itching
sivislbe on surgace
permethrin, lindane is equal in efficacy but more toxic
215
scabies
web spaces between fingers and toes or at elbows or genitalia
nipples or near genitals
burrows visible but smaller than crabs
scrape and magnify
permethrin
widespread disease is crusted or hepyrkeratototic and responds to ivermectin, severe disease needs repeat dosing
216
Anatomic defects that lead to UTI
Stones
strictures
tumor or prostate hypertrophy
diabetes
any form of obstruction like a foley catherter or foreign body
neurogenic bladder is an obstruction
217
UTI presentation
all utis can present with dysuria (frequency, urgency, burning) and a fever
218
UTI urinalysis
increased WBC
e coli is the most common
219
quinolones are best initial therapy for
pyelonephritis
220
urinary frequency
multiple episodes of micturition
221
polyuria
increase in the volume of urine
222
Cystitis presentation
dysuria
suprapubic pain/discomfort
mild or no fever
223
men with utis have what more often then women
anatomic abnormalities
224
Best initial test for uti
urinalysis with more than 10 wbc
225
most accurate test for uti
urine culture
226
cystitis treatment
nitro (3 days worth if uncomplicated and 7 if anatomic abnormality) or fosfomycin
bactrim is local resistance is low
Cipro - don't use routinely so you don't get resistance
cefixime
227
all beta lactams are considered safe with
pregnancy
228
when do you do a urine culture or imaging with uti
frequent episodes or failure to respond to therapy
229
what is first for pyelonephritis treatement
ceftriaxone
230
Pyelonephritis presentation
flank or costovertebral angle tenderness
high fever
occasionally with abdominal pain from an inflamed kidney
wbcs on ua
ct or sonogram are done to determine anatomic abnormality
231
pyelonephritis treatment
ceftriaxone or ertapenem
ampicillin and gentamicin until culture results are known
ciprogloxacin (po for outpt)
232
any drugs for what are good for pyelo
gram neg bacilli
233
acute prostatitis
dysuria
perineal pain
tender prostate on exam
diagnostic yield of urin culture is increased with prostate massage
treat like pyelo
Cipro or bactrim for 6-8 weeks for chronic
234
prostatitis is usually caused by
ecoli
235
diff between cystitis and prostatitis treatment
still use Bactrim Cipro and other fluoros but with cystitis in a man you treat for 7 days and prostatitis treat for 2-6 weeks
236
perinephric abscess
pyelo that doesn't resolve with therapy
fever after 5-7 days of pyelo therapy
do imaging
drainage and collection of fluid is must
culture fluid
237
Endocarditis
infection of the valve heart leading to a fever and a murmur. diagnosed with vegetations seen on echo and positive blood cultures
238
endocarditis etiology
rare on normal heart valves unless injection drug user
risk is proportional to damaged of valve
regurg and stenosis increase risk
prosthetic valves have the highest risk
staph aureus on normal valves and iv drugs
dental procedures althought he risk is small
239
endocarditis presentation
```
fever
new murmur or change in murmur
splinter hemorrhages
janeway lesions (flat and painless)
osler nodes (raised and painful)
roth spots in the eyes
brain (mycotic aneurysm)
kidney (hematuria, glomerulonephritis)
conjunctival petechiae
splenomegaly
septic emboli to the lungs
```
240
endocarditis diagnostic tests
best initial test is:
blood culture (95-99% sensitive)
transthoracid echo (60% sensitive but 95-100% specific)
transesophageal echo (95% sensitive and specific)
ekg rarely shows and av block if there is dissection of the conduction system (less than 5-10%) sensitive
241
fever + murmur =
endocarditis
242
clostridium septicum and strep bovis endocarditis
think colonoscopy
243
Establishing a diagnosis of culture negative endocarditis
oscillating vegetation on echo
minor criteria:
fever>100.3 or 38
risk such as injection drug use or prosthetic valve
signs of embolic phenomena
244
endocarditis treatment
initial empiric therapy
best initial empiric therapy is vanco and gentamicin
245
Endocarditis treatment
viridans strep
ceftriaxone for 4 weeks
246
Endocarditis treatment
staph aureus (sensitive)
oxacillin nafcillin or cefazolin
247
Endocarditis treatment
fungal
amphotericin and valve replacement
248
Endocarditis treatment
staph epi or resistant staph
vanco
249
Endocarditis treatment
enterococci
ampicillin and gentamicin
250
endocarditis treatment of resistant organisms
add an aminoglycoside and extend duration of treatment
251
when do you do surgery with endocarditis
chf from ruptured valve
prosthetic valves
fungal endocarditis
abscess
av block
recurrent emboli while on antibiotics
252
add what for prosthetic valve endocarditis with staph
rifampin
253
the single stongetst indication for surgery with endocarditis is
acute valve rupture and chf
254
treatment of culture negative endocarditis
coxiella is most common cause and bartonella
```
hacek
h aphrphilus
h parainfluenzae
actinobacillus
cardiobacterium
eikenella
kingella
```
use ceftriaxone for hacek
255
what do you need in order to receive endocarditis prophylaxis
```
significant heart defect
prosthetic valve
previous endocarditis
cardiac transplant recipient with valvulopathy
unrepaired cyanotic heart disease
```
and
risk of bacteremia
dental work with blood
respiratory tract surgery that produces bacteremia
use amox unless allergic use clindamycin azithromycin or clarithromycin
256
procedures or conditions that do no need endocarditis prophylaxis
mvp even with a murmur
mitral regurg and stenosis
aortic regurg and stenosis
hocm
asd
257
Lyme disease
definition
arthropod borne disease from spirochete borrelia burgdorferi
fever and rash
untreated you get joint pain cardiac disease or neurological disease
258
lyme disease etiology
ixodes scapularis (deer tick)
20% of pts recall the tick bite
been hiking or camping
tick must be on for 24 hours to transmit organism
northeast
259
lyme disease rash
85-90% of pts
5-14 days after bite
fever
round lesion with pale area in middle (buls eye)
erythema migrans
260
lyme diseas joint pain
most common long tem manifestation
60% w/o treatment
few joints are affected (oligoarthritis)
joint fluid will have 25000 wbc
261
lyme disease neuro
10-15% of pts
menignits encephalitis or cn palsy
262
lyme disease cardiac
4-10% of pts
damage to any part of the myocardium or pericardium such as the myocarditis or ventricular arrhythmia
263
what joint is most commonly affected in lyme disease
knee
264
what is the most common neuro manifestation of lyme
7th nerve or bells palsy
265
what is the most common cardiac symptom of lyme
transient av block
266
lyme diagnostic tests
if rash is typical you are done
serology is essential if any of the other symptoms are present,do igm igg elisa western blot and pcr testing
267
lyme treatment
asymptomatic tick bite
no routine treatment, but a single dose of doxy is indicated withing 72 hours of bite when:
ixodes scapularis is clearly the tick
attached for longer than 24-48 hours
engorged nymph-stage tick
endemic area
268
lyme treatment
rash
doxycycline
amox or cefuroxime
269
lyme treatment
joint or bells palsy
doxy
amox or cefuroxime
270
lyme treatment
cardiac and other neuro besides bells palsy
iv ceftriaxone
271
HIV/AIDS
definition
retrovirus that infects the cd4 t helper cell
cd4 drops at a rate of 50-100 if untreated
5-10 years to deplete cd4 cell and before you get any clinical manifestation
272
HIV/AIDS
etiology
```
transmitted through
injection drug use with contaminated needles
sex, men who have sex with men
perinatal
needle stick or blood sharp injury
transfusion (rare since 1985)
```
kissing does not transmit it
273
HIV/AIDS
vaginal transmission
1 in 3 to 10000 for insertive intercourse
1 in 1000 for receptive intercourse
274
HIV/AIDS
oral sex
1 in 1000 for receptive fellatio with ejaculation
unclear for insertive fellatio or cunnilinjus
275
HIV/AIDS
needle stick injury
1:3000
276
HIV/AIDS
anal sex
1:1000 for receptive anal intercourse
277
HIV/AIDS
mother to chld
25-30% perinatal transmission w/o meds
278
HIV/AIDS
presentation
infection occurs with progound immunosuppression when cd4 count frops below 50/ul
pcp occurs at 200/ul or below or under 14%
when cd4 is above 200 few infection occur
279
HIV/AIDS
infection with hiv that occur with higher frequency but cd4 above 200
```
shingles
herpes simplex
tb
oral and vaginal candidiasis
bacterial pneumonia
Kaposi sarcoma
```
280
HIV/AIDS
diagnostic tests
elisa is the best initial test
confirmed with western blot
infants are diagnosed with pcr or viral culture
elisa is unreliabele in infants bc they havce maternal hiv abs for up to 6 months after delivery
281
HIV/AIDS
viral load testing
pcr-rna level
measures response to therapy
detect treatment failure
diagnose hiv in babies
if viral load is undetectable (below 50/ul) then cd4 will rise and life expectancy is the same as uninfected person
282
HIV/AIDS
viral resistance testing (genotyping)
performed prior to initiating antiretroviral meds so you don't take a med that your virus is resistant to
also do if there is treatment failure
if treamtner failure select 3 drugs from 2 classes the virus is susceptible to
283
HIV/AIDS
treatment failure first manifests with
a rising pcr rna load
284
HIV/AIDS
treatement
initiated when:
cd4 drops below 500
or
viral load is very high (greater than 100,000/ul
or
opportunistic infection occurs
antiretroviral meds are ok even if cd4 is greater than 500
285
the strongest indication for antitretroviral med is
a cd4 below 500
286
HIV/AIDS
best initial drug choice
the best initial drug combo is emtricitabine, tenofovir, and efavirenz, combine in a single once a day pill called atripla
287
usmle step 2 ck does not test
dosing
288
changes in cd4 lag behind and are slower to occur than
changes in viral load testing
289
treating everyone no matter how high the cd4 is
acceptable
290
HIV/AIDS
alternate drug regimens
if emtricitabine/tenofivir/efavirenz cannot be used bc of resistance alternate regimesn are based on a combo or 3 drugs from at least 2 diff classes
the first choices are either atazanavir, darunavir, or raltegravir combined with emtricitabine/tenofovir.
abacavir is dangerous with hla b5701 mutation
ritonavir is used with other protease inhibitors to boos their levels
elvitagravir is an integrase inhibitor used with cobicistat which inhibits its metabolism
291
ritonavir in a small dose
is used to boost darunivir or atazanavir levels
292
nucleoside and nucleotide reverse transcriptase inhibitors (rtis)
```
zidovudine
didanosine
stavudine
lamivudine
emtricitabine
abacavir
tenofovir
```
293
non nucleoside rtis
efavirenz
etravirine
nevirapine
rilpivirine
294
protease inhibitors
-avirs
295
HIV/AIDS
addtl classes or second line agents
used for theose with drug resistance to multiple classes or first line agents
entry inhibitors - enfuvirtide and maraviroc
integrase inhibitors - raltegravir, dolutegravit and elvitegravir with cobicistat
296
cobicistat inhibits
elvitegravir metabolism which boosts its levels
297
HIV/AIDS
postexposure prophylaxis
all significant needle stick injuries and sexual exposures are given 4 weeks of therapy with combination therapy, choice of therapy is the same as the initial choice of antiretroviral med
exposure to urine and stool are not indicated for prophylaxis unless blood is in them
bites are indicated as needle stick and sex above
298
is postexposure prophylaxis indicated in a needle stick injury if the pts hiv status is unknown?
no
299
Zidovudine AE
anemia
300
stavudine and didanosine ae
peripheral neuropathy and pancreatitis
301
abacavir (if hlab5701) ae
hypersensitivity, stevens Johnson rxn
302
protease inhibitors ae
hyperlipidemia, hyperglycemia
303
indinavir ae
nephrolithiasis
304
tenofovir ae
renal insufficiency
305
HIV/AIDS
prevention of perinatal transmission
continue if pt is on effective treatment
if not on meds treat with same indications as if not pregnant
do not use efavirenz switch it to protease inhibitors they are ok to use
give no matter what cd4 levels are
baby receives zidovudine during deliver (interpartum) and for 6 weeks after to prevent transmission
306
Cesarean deliver for hiv positive mothers
prevents transmission of virus if load is high
if viral load is over 1000/ul do c section
intrapartum antiretrovirals with zidovudine are routinely given to every pregnant hiv positive pt
307
fully controlled hiv (viral load undetectable) give what percentage of transmission
less than 1%
308
anaphylaxis definition
worst from of allergic condition or acute event
synonymous with term: immediate hypersensitivity
must be presensitized to ag
ige binds to mast cells leading to the release of their granules (histamine prostaglandins and leukotrienes)
anaphylactoid rxns are not ige related but are clinically identical and are treated the same way, they are not presensitized though
resp and hemodynamic problems
309
anaphylaxis etiology
the same causes of any allergic event
insect bite and stings
medications: penicillin phenytoin lamotrigine quinidine rifampin and sulf
foods
310
anaphylaxis is identified by what
severity not the cause of the reaction
311
latex is a very important cause of anaphylaxis in who
healthcare
312
anayphylaxis presentation
rash (hives)
hypotension and tachycardia
Resp: sob wheeze swelling of lips tongue or face and stridor
can also have itching, constriction of airways, dyspnea, nausea, vomiting, diarrhea, dizziness or fainting
313
urticarial is considered part of anaphylaxis and not just an
allergy
314
anaphylaxis treatment
best initial therapy is:
epinephrine
antihistamines such as diphyenhydramine (h1blocker) and ranitidine (h2blocker)
glucocorticoids such as methylprednisolone or hydrocortisone
emergent airway protection if needed: intubation or cricothyroidotomy
315
there is no specific test to define
anaphylaxis
316
angioedema definition
sudden swelling of the face, tongue, eyes, or airway
this can be from deficiency of c1 esterase inhibitor
there is a characteristic association with the onset with minor physical trauma
often is idiopathic
317
look for ace inhibitor when pt has
angioedema
318
angioedema presentation
hereditary is characterized by sudden facial swelling and stridor with the absence of pruritus and urticarial. hereditary does not respond to glucocorticoids
319
angioedema diagnostic tests
best initial test is for dereased levels of c2 and c4 in the complement pathway as well as deficiency of c1esterase inhibitor
320
ecallantide is specific therapy for
angioedema
321
angioedema treatment
for acute therapy use ffp or ecallantide
for long-term management use androgens: danazol and stanazol
ensure airway protection first; can be a rapidly evolving process
322
urticaria
for of allergic reaction that causes sudden swelling of the superficial layers of the skin
```
can be caused by:
insects
medication
pressure
cold
vibration
```
323
urticaria treatment
antihistamines: hydroxyzine, diphenhydramine, fexofenadine, loratidine, or cetirizine: ranitidine
leukotriene receptor antagonists: montelukast or zafirlukast
324
allergic rhinitis
etiology
seasonal allergies like hay fever are common. this is an igedependent triggering of mast cells
325
allergic rhinitis
presentation
recurrent episodes of:
watery eyes, sneezing, itchy nose, itchy eyes
inflamed boggy nasal mucosa
pale or violaceous turbinates
nasal polyps
326
allergic rhinitis diagnostic tests
most often a clinical dx with recurrent episodes
skin testing and blood testing for reactions to ags may be sueful to identify a etiology
allergen specific ige levels may be elevated
nasal smear may show large number of eos
327
allergic rhinitis
treatment
prevention with avoidance of precipitating allergen
close windows and don't use ac to avoid pollen
get rid of animals to which the pt is allergic
cover mattresses and pillows
use air purifiers and dust filters
intranasal corticosteroid sprays
antihistamines: loratidine clemastine fexofenadine and bormpheniramine
intranasal anticholinergic medications: ipratropium
desensitization to allergens that cannot be avoided
328
common variable immunodeficiency
etiology
b cells are present in normal numbers but they do not make effective amounts of ig there is a decrease in all subtypes: igg igm and iga
329
common variable immunodeficiency
presentation
cvid presents with recurrent sinopulmonary infections in adults with an equal gender distribution. there are frequent episodes of bronchitis pneumonia sinusitis and otitis media
other manifestations are:
giardiasis
sprulike intestinal malabsorption
increase in autoimmune diseass such as pernicious anemia and seronegative rheumatic disease
330
common variable immunodeficiency give a marked increase in the risk of
lymphoma
331
Cvid basics
low b cell output
normal t cells
332
x linked agammaglobulinemia (brutons) basics
low b cells
normal t cells
young males
333
scid basics
low b cells and t cells
analogous to hiv
334
iga deficiency basics
atopic disorders
anaphylaxis
335
hyper ige syndrome basics
skin infections (staph)
336
wiskott-aldrich syndrome basics
normal t and b cells
low platelets
eczema
337
lymph nodes with purulent material basics
```
infections, combined with:
staphylococcus
burkholderia
nocardia
aspergillus
```
338
Coronary Artery Disease
definition
Coronary Artery Disease can be used interchangeably with atherosclerotic heart diease or ischemic heart disease
all of these terms imply insufficient pergusion of the coronoary arteries from an abnormal narrowing of the vessels, leading to insufficient oxygen delivery to the myocardial tissue
339
by the time a woman is 55-60 the protective effect of menstruation and naturally occurring estrogen have worn off and the rate of what will be the same in men and women
cad
340
menstruating women virtually never have?
MI
341
estrogen does not improve cad but can improve?
ldl
342
the worst risk factor for cad is?
diabetes
343
the most common risk factor for cad is?
hypertension
344
risk factor for coronary artery disease
dm
tobacco
htn
hyperlipidemia
family hx of premature cad
age above 45 in men and 55 in women
345
how many people in country suffer from htn?
20% or 60 million
half of them don't know they have htn
346
family hx and cad
this does not covey a risk for the pt if cad developed in elderly relatives or if the realtives were grandparens cousins or aunts and uncles
first degree relatives are sibling and parents
only first degree relatives matter and it must also be premature
347
premature cad is defined as being in a family member who is:
male under 55
female under 65
348
hyperlipidemia and cad
marked ldl elevation is by far the most dangerous portion of a lipid progile for a pt
a low hdl is also associated with a porr long term prognosis
elevatd tri levels are potentially dangerous but not as porr of an outcome as ldl, treating tris doesn't really show benefit
obesity, especially abdominal girth is associated with increased cardiac mortality
much of the danger of obesity is from its associations with hyperlipidemia diabetes and htn
349
less reliable but probably risk factors for cad
physical inactivity
excess alcohol ingestion
insufficient fruits and veggies
emotional stress
elevated cardiac ct scan calcium scores
positron emission tomography (PET) scanning
increased physical activity and exercise reliably lower all-cause mortality but physical inactivity is not as severe a risk for cad as diabetes and htn
calcium scores on a ct scan of the heart are still considered experimental. it is not clear what to do differently with this information in addition to standard risk factors
350
tako-tsubo cardiomyopathy
acute myocardial damage most often occurring in postmenopausal women immediately following an overwhelming, emotionally stressful event. (divorce financial issue earthquake lightning strike and hypoglycemia)
this lead to ballooning and left ventricular dyskinesis. as with ischemic disease manage with bblockers and acei, revascularization will not help bc arteries are fine
351
unreliable risk factors for cad
homocysteine levels
chlamydia infection
elevated c reactive protein
these levels have not been proven to be reliable and are the wrong answer
352
the most common wrong answer on cad risk factor questions
usually family hx: mistaking cad in elderly relative, even if they are the pts parents but their age is above the guidelines don't choose it
353
correcting what risk factor for cad results in the most immediate benefit for the pt
smoking cessation results in the greatest immediate improvement in pt outcomes for cad
withing 1 year of stopping smoking the risk of cad decreases by 50% withing 2 years of stopping smoking the risk is reduced by 90%
354
what is the most likely dx
chest pain
ischemic pain is described as:
dull or sore
squeezing or pressure like
qualities of pain that go against ischemia are:
sharp knife or poinlike
lasts for a few seconds
355
ischemic pain is not
tender
positional
pleuritic
356
the most common cause of chest pain that is not ischemic in nature is
gi disorders
357
for every 100 people presenting to the ed with chest pain how many have an mi and how many do not have any cardiac disease
10%
50%
358
stable angina lasts
>2 min but
359
ACS lasts
>10 to 30 min
360
provoking factors or ischemic chest pain
physical activity, cold, emotional stress
361
associated symptoms of ischemic chest pain
sob
nausea
diaphoresis
dizziness
lightheadedness
fatigue
362
quality of ischemic chest pain
Squeezing tightness heaviness pressure burning aching
not sharp pins stabbing knifelike
363
location of ischemic chest pain
substernal
364
alleviating factors of ischemic chest pain
rest
365
ischemic chest pain radiation
neck lower jaw and teeth arms and shoulders
366
Causes of chest pain
chest wall tenderess
most likely dx - costochondritis
most accurate test - pe
367
Causes of chest pain
radiation to back, unequal blood pressure between arms
most likely dx - aortic dissection
most accurate test - chest cray with widened mediastinum, chest ct, mri, or tee confirms the disease
368
Causes of chest pain
pain worse with lying flat, better when sitting up, young (
most likely dx - pericarditis
most accurate test - ekg with st elevation everywhere, pr depression
369
Causes of chest pain
epigastric discomfort, pain better when eating
most likely dx - duodenal ulcer disease
most accurate test - endoscopy
370
Causes of chest pain
bad taste, cough, hoarseness
most likely dx - gerd
most accurate test - response to ppis, aluminum hydroxide, and magnesium hydroxide, viscous lidocaine
371
Causes of chest pain
cough, sputum, hemoptysis
most likely dx - pneumonia
most accurate test - chest xray
372
Causes of chest pain
sudden-onset sob, tachycardia, hypoxia
most likely dx - pe
most accurate test - spiral ct or v/q scan
373
Causes of chest pain
sharp pleuritic pain tracheal deviation
most likely dx - pneumothorax
most accurate test - chest x ray
