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Mix2 Flashcards

1
Q

Hearing impairment signs in children

A 
Inattentiveness
Poor language development
Poor social skills development
Difficulty following directions
Refusal to listen
Low self-esteem
Social isolation
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2
Q

Inspiratory stridor, worse when supine

A

Laryngomalacia

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3
Q

Surgical debridement in Tx of malignant otitis externa

A

If fails to response to antibiotics

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4
Q

The most common middle ear pathology in patients with HIV

A

Serous otitis media

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5
Q

The most specific sign of eardrum inflammation

A

Bulging

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6
Q

Indication of observation in children with AOM

A

If >2y
Mild, unilateral symptoms
Normal immune system

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7
Q

Peritonsillar abscess Tx

A

Drainage + IV AB (GAS, respiratory anaerobes)

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8
Q

Clues to the diagnosis of peritonsillar abscess (quinsy)

A 
Deviated uvula 
Muffled (hot potato) sound
Unilateral cervical LAP
Trismus
Pooling of saliva
Asymmetrically enlarged tonsills
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9
Q

Sialadenosis

A 
Nontender enlargement of submandibular glands
In pts with: 
Advanced liver disease (cirrhosis)
Altered dietary pattern
Malnutrition (DM, bulimia)
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10
Q

TMJ dysfunction

A 
Nocturnal teeth grinding
pain feels like coming from ear
Pain worsened with chewing
Audible click/crepitus with jaw movement
Tx: coservative: nighttime bite gaurd
Sometimes surgery necessary
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11
Q

Blunt abd trauma
Unstable pt
next step?

A

FAST

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12
Q

Blunt abd trauma
Unstable pt
Positive FAST
Next step?

A

Laparotomy

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13
Q

Blunt abd trauma
Unstable pt
Negative FAST
Next step?

A

Signs of extra-abdominal hemorrhage( pelvic/long-bone fx)?
Yes: stabilize, angio, splint
No: stabilize then CT of abd

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14
Q

Blunt abd trauma
Unstable pt
Inconclusive FAST
Next step?

A

DPL

If positive: Laparotomy
If negative: proceed as with negative FAST

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15
Q

Bronchial rupture features

A

Persistent pneumothorax despite chest tube
Pneumomediastinum
Subcutaneous emphysema
Mostly the right main bronchus is injured
Confirmation with: CT, bronchiscopy, surgical exploration
Tx: operative repair

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16
Q

The most important initial diagnostic study in all stabilized patients following blunt chest trauma

A

CXR

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17
Q

Esophageal rupture features

A

Mostly iatrogenic or following esophagitis
Pneumomediastinum
Pleural effusion

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18
Q

Disappearance of Babinski reflex in healthy child

A

Before 2 y of age

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19
Q

Disappearance of monro, grasp, tongue protrusion

A

By age 4 mo

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20
Q

Weight and height at 12 months of eight

A

Weight should triple and height should increase by 50%

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21
Q

Age of beginning and completing toilet training

A

2y

5y

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22
Q

Age of performing evaluations and interventions for children with urinary incontinence

A

5 y/o and higher

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23
Q

Contraindications to I/O access

A

Infection overlying the access site
Bone fracture
Previous I/O attempts in the chosen extremity
Bone fragility

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24
Q

Stemmer sign

A

Inability to lift the skin on the dorsum of the second toe

Highly specific for lymphedema

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25
Q

How much weight loss is normal after birth for Neonate?

A

<7% (during first 5 d)

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26
Q

Pink stains or brick dust in neonate’s diaper

A

Uric acid crystals

Common during the first week, or in later months with the morning void after infant begins to sleep through the night

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27
Q

When can infants have plain water?

A

After 6mo of age

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28
Q

Indications of laparotomy in penetrating abdominal injury

A

Hemodynamic instability
Peritonitis (rebound tenderness, guarding)
Evisceration
Blood from NGT or rectal exam

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29
Q

If no indications of laparotomy in penetrating abdominal injury

A

Local wound exploration

Extended ultrasound examination

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30
Q

Indication of DPL

A

Unstable patients with blunt abdominal trauma and no available CT or FAST or inconclusive GAST

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31
Q

Diaphragm location range

A

4th thoracic dermatome on the right and 5th on the left
Down to the 12th thoracic dermatome on both sides
Any penetrating injury at the thorax below the level of the nipples has potential to also involve the abdomen through the diaphragm, And is assumed to involve .both compartments until proven otherwise

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32
Q

Development of object permanence in an infant

A

6-12mo

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33
Q

Age of separation anxiety

A

9-18 mo

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34
Q

Contraindications to Nasotracheal intubation

A

Apneic/hypopneic pts

Basilar skull fracture

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35
Q

Diagnosis of coma is via:

A

Impaired brainstem activity
Motor dysfunction
Level of consciousness

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36
Q

ALL markers

A

Peroxidase -
PAS +
TdT + (preB, preT)

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37
Q

Anemia of chronic disease

A 
Iron trapping within macrophages
Low serum iron
Low TIBC
Low iron/TIBC
Low retic count relative to anemia
Nl/high ferritin
Tx: treatment of underlying disorder
If unresponsive, EPO
If all failed transfusion
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38
Q

Tx of warfarin necrosis

A

Cessation of warfarin

Administration of protein C concentrate

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39
Q

How long in advance should warfarin be discontinued before measurement of protein S levels?

A

2 wk

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40
Q

Fanconi anemia

A

The most common congenital cause of aplastic anemia. Macrocytic
AR or X-linked
Pancytopenia presents between 4-12 years of age.
Initial manifestation of CBC: thrombocytopenia, then neutropenia, then anemia
Hyperpigmentations
Cafe au lait
Skeletal anomalies, microcephaly
Upper limb anomalies, absent thumbs
Short stature
Eye/eyelid changes, middle ear abnormalities
Hypogonadism

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41
Q

Diamond-Blackfan anemia

A 
Presents within 3 mo of birth
Pure red cell anemia
Congenital anomalies: webbed neck, cleft lip, shielded chest, triphalangeal thumb
Macrocytic anemia
Elevated fetal Hb
Nl chromosomes
Tx: CS, transfusion
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42
Q

Defect in Fanconi anemia

A

DNA repair
Chromosomal breaks on genetic analysis
Tx: BMT

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43
Q

Infection prophylaxis for splenectomy

A

Vaccines against pneumococcus, meningococcus and hemophilis influenza B (several weeks before the procedure)
+
Daily oral penicillin for 3-5 years or until adulthood for children or AB available at home to begin with any significant fever
(After the procedure)

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44
Q

Howell-Jolly bodies

A

Single round blue RBC inclusion on Wright stain
Remnant of nucleus
Indicate physical/functional absence of spleen:
Splenectomy, autoimfarction, infiltration, congestion

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45
Q

Intravascular hemolysis lab

A

Markedly reduced serum haptoglobin (undetectable)
Elevated indirect Bil
Raised LDH levels

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46
Q

Extravascular hemolysis lab

A

Less intravascular Hb release
Nl/slightly low haptoglobin
Slightly elevated LDH
Elevated indirect Bil

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47
Q

Intravascular hemolysis DDx

A 
MAHA (DIC...)
Transfusion reaction
Infection (clostridial sepsis...)
PNH
IV Rho(D) Ig infusion
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48
Q

Extravascular hemolysis DDx

A 
RBC enzyme deficiencies
Hemoglobinopathy
Membrane defects
Hypersplenism 
IVIg
Warm/cold-agglutinin AI hemolytic anemia
Bartonella
Malaria
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49
Q

Indications of washed RBC

A

IgA deficiency
Complement-dependent AI hemolytic anemia
Allergic reaction with RBC despite antihistamine treatment

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50
Q

Indications for leukoreduced RBC

A

Chronically transfused pts
CMV seronegative at-risk pts (AIDS, transplant)
Potential transplant recipients
Previous febrile non-hemolytic transfusion reaction

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51
Q

Indications for irradiated RBC transfusion

A

BMT recipients
Acquired/congenital cellular immunodeficiency
Blood components donated by first or second degree relatives

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52
Q

Timing of transfusion reactions

A 
Anaphylaxis: seconds to minutes
Acute hemolytic: minutes to 1 h
Febrile non-hemolytic: 1-6 h
Transfusion-related acute lung injury: 1-6 h
Urticaria/allergic: 2-3 h
Delayed hemolytic: 2-10 d
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53
Q

Rx of febrile non-hemolytic transfusion reaction

A

Stop transfusion
Antipyretics
Use leukocyte depleted RBC

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54
Q

Tx of hypercalcemia due to malignancy

A

Bisphosphonate

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55
Q

Tx of hypercalcemia related to granulomatous diseases

A

CS

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56
Q

The most common sites of osteonecrosis in SCA patients

A

Humoral and femoral heads

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57
Q

Soap bubble appearance on bone xray

A

Giant cell tumor

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58
Q

Giant cell tumor of bone

A 
Expansile eccentric lytic area
Soap bubble appearance
Benign
Locally aggressive
Young adults
Pain, swelling, decreased range of motion at the involved site
Pathologic Fx
Epiphysial region of long bones
Distal femur, proximal tibia
MRI: Cystic and hemorrhagic regions
Tx: surgical curettage +/- bone grafting
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59
Q

Osteitis fibrosa cystica

A

Due to hyperpara from parathyroid carcinoma
Brown tumor (fibrous tissue) of long bones
Osteolytic resorption of bones
Bone pain
Salt-and-pepper skull
Subperiosteal bone resorption on radial aspect of middle phalanges
Distal clavicle tapering

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60
Q

Osteosarcoma lab

A

Increased: ESR, ALP, LDH
No systemic symptoms
Soft tissue mass on examination

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61
Q

Parinaud (dorsal midbrain) syndrome

A

Limited upward gaze
Upper eyelid retraction (collier sign)
Pupils non-reactive to light but reactive to accomodation (light-near dissociation)

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62
Q

Features of pineal gland tumor

A

Pressure on pretectal region of the midbrain
Parinaud syndrome
Obstructive hydrocephalus

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63
Q

Neuroblastoma origin

A

Sympathetic nervous system

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64
Q

Intracranial neuroblastoma features

A

Opsoclonus myoclonus syndrome

Ab-mediated dancing eyes and feet

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65
Q

Trilateral neuroblastoma

A 
Bilateral neuroblastoma (leukocoria)
And pineal gland tumor
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66
Q

Symptoms of cerebellar vermis dysfunction

A

Truncal/gait instability

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67
Q

Symptoms if cerebellar hemispheres dysfunction

A

Dysmetria
Intention tremor
Dysdiadochokinesia

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68
Q

Tx of cancer-related anorexia/cachexia

A 
Progesterone analogues (megestrol acetate)
CS

If longer life expectancy, progesterone analogues preferred

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69
Q

Tx of advanced HIV cachexia

A

Synthetic cannabinoids (dronabinol)

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70
Q

Tx of chemotherapy-induced nausea

A

Serotonin 5HT3 receptor antagonist:
Ondansetron
+/- CS

Both for treatment and prophylaxis

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71
Q

Tx of nausea secondary to gastroparesis

A

Motilin receptor agonists: erythromycin

D2 antagonist. Dompridone

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72
Q

Tx if opioid induced constipation

A

Methylnaltrexone (GI-specific opioid antagonist)

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73
Q

A form of treatment for a disease when a standard treatment fails

A

Salvage therapy

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74
Q

Treatment given in addition to standard therapy

A

Adjuvant therapy

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75
Q

An initial dose of treatment to rapidly kill tumor cells and send a patient into remission (<5% tumor burden)

A

Induction therapy

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76
Q

A treatment given after induction therapy with multi drug regiment to further reduce tumor burden

A

Consolidation

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77
Q

A treatment given after induction and consolidation therapies to kill any residual tumor cells and keep the patient in remission

A

Maintenance

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78
Q

Treatment given before the standard therapy for a particular disease

A

Neoadjuvant

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79
Q

Indication of EPO in CRF (after ruling out iron deficiency)

A

Hct<30%
Pts on hemodialysis with symptoms attributed to anemia
Target: Hct:30-35%

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80
Q

Side-effects of EPO

A

HTN (IV>SC), the most common side effect.
Headache
Flu-like (IV>SC)
Red cell aplasia

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81
Q

Anemia in CRF vs IDA

A

CRF: normo, normo, hypoproliferative
IDA: micro, hypo

Must evaluate pts with CRF for iron deficiency before starting EPO

If iron deficiency concurrent with CRF anemia, therapeutic choice is: IV iron preparation

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82
Q

Worse prognosis of CLL with

A

Anemia
Thrombocytopenia
Multiple chain LAP
HSM

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83
Q

Classic presentation of hairy cell leukemia

A 
Splenomegaly
Pancytopenia
B cell
Age>50
Bone marrow fibrosis
Typically no LAP, Hepatomegaly orB symptoms
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84
Q

Hodgkin usual presentation

A

Painless LAP and B symptoms

Nl CBC, PBS

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85
Q

CLL usual presentation

A

Dramatic lymphocytosis
LAP
HSM
thrombocytopenia, anemia

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86
Q

Dx of CLL

A

CBC, PBS, FCM (clonality of mature Bcells)

Elderly+ dramatic lymphocytosis+ mild anemia/thrombocytopenia + LAP + HSM = CLL

Bx usually not required (LN, BM…)

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87
Q

Leukocyte alkaline phosphatase score in CML vs leukemoid reaction

A

Low LAP in CML

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88
Q

Dx of CML

A 
Dramatic granulocytosis
Absolute basophilia
Immature neutrophil precursors
low ALP score (alkaline phosphatase)
BCR-ABL
Thrombocytosis
Anemia
Splenomegaly
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89
Q

Intracranial tumor with calcification

A

Craniopharyngioma

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90
Q

The earliest vaso-occlusion manifestation in SCA

A

Hand-foot syndrome or dactylitis
6mo-2y
Acute onset of pain and symmetrical swelling of hands and feet
+/- fever
vascular necrosis of metacarpals and metatarsals
There may be osteolytic lesions lesions

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91
Q

Best time for retesting G6PD after an episode of hemolysis

A

3 mo later

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92
Q

Pyruvate kinase deficiency manifestations

A

Chronic hemolysis
Pigmented gallstones
HSM
Skin ulcers

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93
Q

Pathophysiology of wiskott-Aldrich syndrome

A

Impaired cytoskeleton in plt and WBC

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94
Q

Hemochromatosis increases susceptibility to which infectious organisms?

A

Vibrio vulnificus
Listeria
Yersinia enterocolitica

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95
Q

Tx of HUS

A

Supportive
Dialysis
Blood transfusion
Fluid/electrolyte

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96
Q

HUS vs DIC

A

PT and PTT normal in HUS

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97
Q

How long after diarrhea does HUS develop ?

A

5-10 d

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98
Q

Hematuria in hemophilia

A

Common but no renal impairment.

Normal Cr

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99
Q

Hemophilic arthropathy

A

Hemosiderin deposition and arthritis and fibrosis
Chronic worsening pain and swelling
Contracture
Limited ROM
Early detection with MRI
Advanced disease visible on Xray
Early preventive treatment can significantly reduce the risk

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100
Q

Type 2 HIT

A

Plt reduction > 50% of baseline
Low risk of bleeding
But 50% risk if new arterial/venous thrombosis if untreated
Tx: D/C all heparin products. Start non-heparin medication (argatroban, fondaparinux)
Plt transfusion not required unless over bleeding
Normalization of plt count: 2-7 d after D/C
Dx: serotonin release assay (gold std), high-titer immunoassay

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101
Q

Warfarin in HIT

A

Started after another anticoagulant has been received and plt>150,000

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102
Q

PTT in HIT

A

Prolonged due to heparin!!

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103
Q

Type 1 vs Type 2 HIT

A

Type1: non immune mediated plt aggregation. Within 2d of heparin exposure. Plt rarely <100,000. No intervention required. No ill effect. Resolves w/o heparin cessation.

Type2: immunologic. More serious. Anti-PF4-Ab. Plt count usually 30-60,000. 5-10 d after heparin exposure (unless re-exposure). Limb ischemia, stroke.

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104
Q

Effect of enoxaparin on aPTT

A

None

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105
Q

Osler-Weber-Rendu

A

HHT
AVMs in: skin, mucous membranes, GI, Lung, liver
In lung, AVMs cause: chronic hypoxia, clubbing, polycytemia. Also massive hemoptysis

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106
Q

Hereditary spherocytosis

A

AD
Defect in ankyrin gene (spectrin scaffolding pr)
Increased MCHC (membrane loss, RBC dehydration)
Low MCV
Increased RDW
Splenomegaly
Increase osmotic fragility on acidified glycerol lysis test
Abn eosin-5-maleimide binding test
Tx: folic acid. Transfusion, splenectomy

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107
Q

Absent CD55

A

PNH

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108
Q

Increased HbF

A

Beta Thalassemia
SCA
Congenital aplastic anemia
Hereditary persistence of fetal Hb

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109
Q

Time of splenic autoinfarct in SCA

A

By 18-36 mo

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110
Q

Helmet cells

A

MAHA (HUS, DIC, TTP)

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111
Q

Effect of hydroxyurea in SCA

A

Decreases:
Pain crises
Acute chest syndrome
Need for transfusion

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112
Q

Risks of homocysteinuria

A

VTE

Atherosclerosis

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113
Q

Tx of homocysteinuria

A

B6
+ folate
+ B12 (if reduced levels)

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114
Q

Pica specific for iron deficiency

A

Pagophagia (ice)

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115
Q

The first finding of IDA on PBS

A

anisocytosis (increased RDW)

>20% in suggestive

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116
Q

Cow’s milk in infants

A

Not before 12 mo of age

Not mire than 24 oz daily

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117
Q

Target cells

A

Alpha/beta thalassemia

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118
Q

Hb electrophoresis in alpha and beta thalassemia

A

Alpha thalassemia: Nl

Beta thalassemia: increased HbA2

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119
Q

Tx of ITP in children

A

Only skin manifestations: observe

Bleeding: IVIg, CS

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120
Q

Tx of ITP in adults

A

Plt 30,000 or higher and no bleeding: observe

Plt<30,000 or bleeding, IVIg, CS

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121
Q

Tests required for ITP

A

CBC
PBS
HIV/HCV (if Hx suggestive)

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122
Q

Manifestations of acute lead poisoning

A

Abdominal pain

Constipation

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123
Q

Manifestations of chronic lead exposure

A 
Fatigue
Irritability
Insomnia
HTN
motor/sensory neuropathies (paresis...)
Neuropsychiatric disturbance 
Nephropathy (raised Cr)
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124
Q

Lead absorption route in children and adults

A

Children: GI
Adults: respiratory

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125
Q

Dx of lead toxicity

A 
CBC, PBS
Microcytic anemia
Basophilic stippling
Blood lead levels
Xray fluorescence (measure bone lead concentration)
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126
Q

Occupations with lead exposure

A 
Battery manufacturing
Plumbing
Mining
painting 
paper hanging 
auto repair
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127
Q

Location of lead in the body

A

99% Bound to erythrocytes

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128
Q

Serum protein gap

A

Protein - albumin > 4
Indicates:
Poly/monoclonal gammopathy

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129
Q

Rouleaux formation indicates

A

Elevated serum protein

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130
Q

Eculizumab

A

PNH Tx

Inhibits complement activation

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131
Q

PNH Tx

A

Eculizumab
Folate
Iron

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132
Q

Age of presentation in PNH

A

4th decade of life

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133
Q

Abdominal pain + dark urine DDx

A 
Hemolysis
PNH
Cholangitis
Acute intermittent porphyria 
SCA
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134
Q

Prophylaxis in children with asplenia

A

Conjugated pneumococcal vaccine
Twice daily penicillin up to 5 y of age
Other routine vaccines

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135
Q

How long after reduced dietary intake does clinical folate deficiency appear?

A

4-5 mo

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136
Q

MDS vs Pernicious anemia

A

Both: pancytopenia and macrocytosis

Distinction requires careful examination of BMB and PBS for dysplastic cells

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137
Q

Transient visual disturbance DDx

A

TIA
MS
PV
CRVO

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138
Q

PV associations

A 
Gout
HTN
erythromelalgia
Aquagenic pruritus
Thromboses
Bleeding
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139
Q

Indication of hydroxyurea in PV

A

High risk of thrombosis

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140
Q

Reason for transient visual disturbance in PV

A

Hyper-viscosity.

It is not due to thrombosis, and anticoagulation is not effective

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141
Q

O2 saturation in PV

A

Nl

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142
Q

ESR in PV

A

Low

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143
Q

CO poisoning Dx

A

Carboxyhemoglobin level
ECG in all pts
Cardiac enzymes in: elderly, cardiac RF, signs of ischemia
Pulse oximetry does not detect CO-Hb. Measurement by arterial blood gas cooximetry

Tx: 100% O2 with non-rebreathing face mask

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144
Q

CO-Hb level in normal vs smoker person

A

<3% vs 10%

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145
Q

Neonatal polycytemia

A

Hct>65%
Causes: intrauterine hypoxia, IUGR, twin-twin transfusion, delayed cord clumping

Presentations: hypoglycemia, hypocalcemia, respiratory distress, ruddy skin, cyanosis, apnea, irritability, jitteriness, abdominal distention

Tx: symptomatic: partial exchange transfusion.
If asymptomatic: only hydration by feeding or parenteral fluids

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146
Q

Anemia of prematurity etiology

A

Impaired EPO production
Short RBC life span
iatrogenic blood sampling

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147
Q

Anemia of prematurity symptoms

A 
Usually asymptomatic
Tachycardia
Apnea
Poor weight gain
Low Hb
Low retic
Normo-normo
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148
Q

Tx of anemia of prematurity

A

Minimize blood draws
Iron supplementation
Transfusion

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149
Q

The most common hereditary thrombophilia in whites

A

1st: Factor V Leiden (resistance to prC)
2nd: prothrombin mutation (increased levels)

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150
Q

Indications of hydroxyurea in SCA

A

Frequent acute painful episodes
Acute chest syndrome
Severe symptomatic anemia

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151
Q

Indication of periodic blood transfusion in SCA

A 
Acute stroke
Acute chest syndrome
Acute multiorgan failure
Acute symptomatic anemia
Aplastic crisis
Stroke prevention
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152
Q

Hypostenuria

A

Kidney’s inability to concentrate urine

e.g. SCA (disease and trait) red cell sickling in vasa recta of the inner medulla

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153
Q

Sickle cell trait features

A

Asymptomatic
At risk for renal issues
The most common: painless microscopic/gross hematuria
Others: isosthenuria, UTI
Splenic infarction uncommon but can occur in high altitudes

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154
Q

Anemia resulting from isoniazide

A

Sideroblastic
Decreased B6 -> decreased heme synthesis -> sideroblastic anemia
Dimorphic RBC population ( both normo and hypo)
Increased serum iron
Decreased TIBC

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155
Q

Spinal cord compression pain

A

Severe local back pain (pain is the first symptom, often present for 1-2 mo prior to additional symptoms)
Worse in recumbent position/ at night
Early signs: symmetric lower-extremity weakness, hypoactive/absent DTR
Late signs: Bilateral babinski reflex, decreased rectal sphincter tone, paraparesis/paraplegia, increased DTR, sensory loss

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156
Q

Spinal cord compression Tx

A

Emergency MRI
IV CS (given without delay)
Radiation/neurosurgery consultations

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157
Q

SVC syndrome etiologies

A

Malignancies (lung, Hodgkin)
Fibrosing mediastinitis (Histoplasmosis, TB)
Thrombosis due to CV line

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158
Q

Lab in APLS

A

Plt: mild decrease
PT: might be prolonged
PTT: prolonged (not corrected with dilution with normal plasma)

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159
Q

Microcytosis in IDA vs Thalassemia

A

IDA becomes microcytic when Hb<10
Thalassemia becomes microcytic with Hb>10

Mentzer index (MCV/RBC):
<13 in thalassemia
>13 in IDA

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160
Q

Screening for thalassemia trait in prenatal consultations

A

CBC

If reduced Hb and MCV, additional testing

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161
Q

Tested infections in thrombocytopenia

162
Q

Fragmented RBCs on PBS

A 
TTP
HUS
DIC
HELLP
Mechanical/ calcific heart valves
163
Q

Prophylaxis of tumor lysis syndrome

A

IV fluids

Allopurinol or raspuricase

164
Q

Tumor lysis syndrome damage to kidneys due to:

A

Renal tubule deposition of uric acid and Ca/P

165
Q

Tx of stroke in SCA

A

Exchange transfusion

166
Q

Prevention of stroke in SCA

A

Hydroxyurea

167
Q

Indications of hypercoagulable state in VTE pts

A 
Age<45
FHx of VTE
multiple thromboses
Unusual sites for thrombosis
Recurrent DVT
168
Q

Appropriate investigations in pts with VTE without clear provoking factors

A

Age-appropriate cancer screening and CXR

more extensive w/u if any concerns for occult cancer

169
Q

Modified wells criteria for pretest probability of DVT

A

if 1 or less: DVT unlikely
If >1 and clinical evidence of PE: compression US+ anticoagulation
If>1 and no evidence of PE: compression sono

170
Q

Indications of thrombolysis/thrombectomy in VTE pts

A

PE+ hemodynamic instability
Or
Massive proximal DVT with severe swelling or limb-threatening ischemia

171
Q

Benefits of Factor X inhibitors over warfarin in VTE

A 
Onset of action in 2-4 h (vs 5-7 d)
No need for overlap heparin
No need for dietary restriction
No lab monitoring needed
No increase in risk of bleeding
Same efficacy as warfarin

Drawbacks: Not for RF, not for VTE in cancer pts

172
Q

How long after surgery can anticoagulation therapy begin?

173
Q

What is the preferred long-term oral anti-hypercoagulation therapy in ESRD patients?

174
Q

Duration of anticoagulation therapy in a person with provoked DVT

A

At least three months

175
Q

Basophilic stippling

A

B12/folate deficiency
Lead poisoning
Thalassemia
alcoholism

176
Q

The most common cause of megaloblastic anemia in alcoholic patients

A

Folate deficiency
Mechanism: inhibiting folate absorption and impairing its enterohepatic cycle.
Can develop within 5 to 10 weeks

177
Q

Hematological manifestations of alcohol abuse

A 
Folate deficiency
Iron deficiency
Anemia of chronic disease
Thrombocytopenia
Macrocytosis even before development of anemia
178
Q

Antiepileptic drugs causing impaired absorption of folate in intestine

A 
Phenytoin
Phenobarbital
Primidone
Other drugs decreasing folate:
Trimethoprim 
MTX
179
Q

The most common cause of folate deficiency

A

Nutritional due to poor diet and/or alcoholism

180
Q

Nutritional deficiencies causing glossitis

A

B2, B3, B12, folate, iron

181
Q

Role of folate and B12

A

Both:
Conversion of homocysteine to methionin

B12 also:
Methylmalonyl-CoA to succinyl-CoA

MMA level can differentiate between folate and B12 deficiencies

182
Q

Normal supply of vitamin K in the liver

A

30 d

An acutely ill person with underlying liver disease can become deficient in 7-10 d

183
Q

DIC vs Vit K deficiency

A

DIC: increased PT, PTT, BT, decreased plt, decreased fibrinogen, schistocytes, acute liver and kidney injury, hypotension, tachycardia

VitK: prolonged PT, PTT

184
Q

Cervicofacial actinomycosis Dx/Tx

A

Dx: FNA, culture>14 d
Tx:penicillin 2-6 mo, surgery

185
Q

Prevention of acute bacterial parotitis after surgery

A

Adequate hydration
Oral hygiene

Bacteria: staph A
Painful swelling of parotid gland, aggravated by chewing

186
Q

Indications of CT in pyelonephritis

A

No improvement after 48-72h
Hx of nephrolithiasis
Gross hematuria
Suspicion for urinary obstruction

187
Q

Waterhouse-Friderichsen syndrome

A

Sudden vasomotor collapse and purpuric skin rash in infants with meningococcemia due to adrenal hemorrhage.

10-20% of Fulminant meningococcemia

Almost 100% mortality

188
Q

Human bite wound treatment

A

Debridement
Amoxicillin-clavulanate
Secondary intention healing
Tetanus prophylaxis

189
Q

Cat bite wound management

A

Copious irrigation and cleaning
Prophylactic amoxicillin/clavulanate
Tetanus prophylaxis
Avoid closure unless thee is a major cosmetic implication

190
Q

Pasturella multocida

A

G- coccobacilli

Cat bite

191
Q

Which bite has more risk of infection?

Cat, dog, human

A

Cat bite

Needs prophylactic antibiotic

192
Q

Which bites could be followed without prophylactic antibiotic?

A

Immunocompetent individuals with minor human or dog bites that are not located on hands and feet or genitalia

193
Q

The most common cause of viral meningitis

A

Non polio enterovirused

194
Q

Location of aspiration pneumonia

A

In supine pts: posterior segments of the upper lobes and superior segments of the lower lobes

In erect pts: the bases of the lower lobes and right middle lobe

195
Q

The most common cause of sepsis in post-splenectomy pts

A

Strep pneumoniae

196
Q

Vaccination of adults after splenectomy

A 
All vaccines should be given either 14d or more before splenectomy or >14 d after splenectomy
PCV13 
PPSV23, 8 wk later
PPSV23, 5 y later
PPSV23, at 65 y/o
Influenza, yearly
HIb, 1 dose
Meningococcal quadrivalent, every 5 y
HAV
HBV
Td, every 10 years (once Tdap)
197
Q

Tx of asymptomatic bacteriuria in pregnancy

A

Cephalexin
Amoxicillin-clavulanate
Nitrofurantoin
Fosfomycin

198
Q

Trimethoprim-sulfamethoxazole during pregnancy

A

Contraindicated during 1st T: interference with folic acid metabolism
Safe during T2
Contraindicated during T3: increased risk of neonatal kernicterus

199
Q

Babesiosis

A 
Protozoal illness
Northern US
Tick bite (ixodes scapularis), 48-72 h after attachment
Flu-like stmptoms
If severe:ARDS, CHF, DIC,splenic rupture
Anemia (intravascular hemolysis)
Thrombocytopenia
Increased:Bil, LDH, LFT
Dx: Thin blood smear (intraerythrocytic rings, maltese cross)
Tx: Atovaquone+ azithro
Or Quinin+ clinda
200
Q

Erlichiosis

A

Tick bite
Flu-like
Leukopenia
Thrombocytopenia

201
Q

Tourniquet test

A

Dx if dengue fever

202
Q

The most common cause of bloody diarrhea in the absence of fever

203
Q

Bacterial meningitis in age 2-50 y/o

Organism, Tx

A

Strep pneumoniae, Neisseria meningitis

Tx: vanco+ 3rd cephalo + dexa

204
Q

Bacterial meningitis in age >50 y/o

Organism, Tx

A

Strep pneumoniae, Neisseria meningitis, Listeria

Tx: vanco+ 3rd cephalo + ampicillin + dexa

205
Q

Bacterial meningitis in immunocompromised

Organism, Tx

A

Strep pneumoniae, Neisseria meningitis, Listeria, G-rods

Tx: vanco+ cefepime + ampicillin
+ dexa

206
Q

Bacterial meningitis in neurosurgery/penetrating skull trauma
Organism, Tx

A

G-rods, MRSA, coagulase - staph

Tx: vancomycin+ cefepime

207
Q

Alternative to cefepime

A

Ceftazidime

Meropenem

208
Q

Alternative to ampicillin for listeria

209
Q

Dexa in meningitis

A

For bacterial meningitis

Discontinued when pneumococcal meningitis ruled out

210
Q

Features of meningococcal meningitis

A 
Sudden onset
Rapid progress
Petechial/purpuric rash
Severe myalgias
Shock
211
Q

Suspecting meningitis

A 
If 2 or more of:
Fever
Headache
Nuchal rigidity
Altered mental status
212
Q

When to give AB prior to LP in infants with suspicious meningitis?

A

If:
Critically ill ( status epilepticus, hypotension)
Immediate LP not possible

213
Q

Tx of bacterial meningitis in infants>1mo

A

Ceftriaxone (covers meningococ and most strains of pneumococ)
+ vanco (covers cephalosporin-resistant pneumococ)
+ Dexa (for HIb)

214
Q

The most common cause of early and late-onset sepsis in neonatal period.

A 
GBS (term)
E coli (preterm)
215
Q

If sepsis in preterm neonate

A

Entrococcus

216
Q

If sepsis with indwelling IV cath in neonate

A

Coagulase negative staph

217
Q

Late-onset sepsis in neonates in NICU

A

Gram negatives

218
Q

Sepsis associated with skin, bone, joint infection

219
Q

Evaluation of neonatal sepsis

A

CBC (neutrophilia with bands>700 or band/total > 0.16)
B/C
CSF culture
Ampicillin+gentamycin

220
Q

AB of choice in bacillary angiomatosis

A

Oral erythromycin
Also: doxy
+ ART (2-4 w later)

221
Q

CD4 count in bacillary angiomatosis

222
Q

Features of bacillary ang

A

Fever, fatigue, night sweats

Rarely: liver, bone, CNS involvement

223
Q

Bartonella transmission

A

Intracellular, gram negative
Via cat scratch, flea (hensella)
Head lice bite (quintana)

224
Q

Tx of cat scratch disease

A

Azithromycin

225
Q

Dx of cat-scratch disease

A

Clinical

+/- serology

226
Q

Blastomycosis features

A 
Wart-like lesions, violaceous nodules, skin ulcers, microabscess 
Acute/chronic osteomyelitis
prostatitis, epididymo-orchitis
Osteomyelitis, lytic bone lesions
Meningitis, epidural/brain abscesses
Even in immunocompetents
227
Q

Dx of blastomycosis

A

Culture (blood, sputum, tissue)
Microscopy (body fluids, sputum, tissue)
Antigen testing(urine, blood)

228
Q

Tx of blastomycosis

A 
Mild pulmonary, immunocompetent: non
Mild-moderate pulmonary: oral itra
Mild disseminated: oral itra
Severe pulmonary: iv ampho
Mod-severe disseminated: iv ampho
Immunocompromised: iv ampho
229
Q

Coccidioidomycosis cutaneous manifestations

A

Erythema nodosum
Erythema multiform
Prediminantly pulmonary disease (lasting >1wk) with arthralgia

Valley fever
Dx: serology, culture

Tx
If mild-mod in healthy pts: non
If severe or immunocompromised: antifungal: keto, fluco

230
Q

Histoplasmosis

A

Asymptomatic or mild pulmonary edema

If immunocompromised: disseminated disease with papular crusted skin lesions

231
Q

Nocardia

A

Subacute pneumonia mimicking TB

232
Q

Cellulitis vs erysipelas and external ear involvement

A

Involvement is suggestive of erysipelas rather than cellulitis

233
Q

Chikungunya fever

A 
Mosquito
Fever
Polyarthralgia
Maculopapular rash
Myalgia
Conjunctivitis
Decreased: plt, WBC
increased: liver enzymes 
Tx: supportive
Dx: clinical, serology
234
Q

Etiology of neonatal conjunctivitis

A

<24h: chemical
2-5d: gonococcal
5-14d: chlamydial

235
Q

Chemical conjunctivitis

A

Mild irritation, injection, tearing
Due to silver nitrate
Tx: eye lubricant

236
Q

Gonococcal conjunctivitis in neonates

A

Marked eyelid swelling, profuse purulent discharge, corneal edema/ulceration
IV/IM ceftriaxone or cefotaxime

237
Q

Chlamydial conjunctivitis in newborn

A 
Eyelid swelling
Chemosis
Watery/bloody/mucopurulent discharge
Oral erythromycin
Blood stained discharge is highly characteristic
238
Q

The AB that increases the risk of pyloric stenosis

A

Erythromycin

239
Q

The most common organism causing pneumonia in HIV pts

A

S. Pneumoniae

240
Q

CA-MRSA pneumonia

A 
Young people with secondary bacterial pneumonia after influenza.
Necrotizing pneumonia.
Rapidly progressive and fatal.
High fever
Productive cough
Hemoptysis
Leukopenia
Multilobar cavitary infiltrates
241
Q

The most common complication of influenza

A

Bacterial pneumonia

Organisms: strep pneumoniae, staph aureus

242
Q

Pneumonia with high fever and prominent gastrointestinal symptoms

A

Legionella

243
Q

The best method to prevent neonatal chlamydial infection

A

Screening and treatment of maternal chlamydia

244
Q

Cryptococcal meningoencephalitis

A 
Subacute
CD4<100
CSF: elevated opening pressure, WBC<50(mononuclear) , low glucose, elevated protein. transparent capsule (seen with India ink stain), cryptococcal Ag positive. Culture in Sabouraud agar.
Tx:
Induction: AmB + flucytosine, 2wk
Consolidation: fluconazole, 8wk
Maintenance: fluconazole >1 y
Salvage: intrathecal AmB
\+/- serial LP to reduce increased ICP
No ART until 2-8 wk after completing induction therapy
245
Q

Clinical features of cryptococcal meningoencephalitis

A 
Headache
Fever
Supple neck
Subacute
Can be acute and severe
246
Q

JC virus

A

Progressive multifocal leukoencephalopathy in HIV

Dx: PCR of CSF

247
Q

Traveller diarrhea organisms

A

Most cases: viral, bacterial

If prolonged/profuse/watery: cryptospordium, cyclospora, giardia

248
Q

Cryptospordium parvum

A

Intracellular protozoan
Ingestion of contaminated water
Alter villous architecture
Mild to profuse watery diarrhea
+/- malaise, nausea, crampy abdominal pain, low-grade fever
Not identified in routine stool ova/parasite exam (requires modified acid fast stains)
Spontaneous resolution in healthy adults in 10-14d
Severe/chronic in HIV

249
Q

Cutaneous larva migrans

A

Hookworm larvae (cat and dog)
Human:incidental host. Unable to penetrate cutaneous BM
Normal eos
Tx: ivermectin

250
Q

The irritant component of poison ivy, poison oak, poison sumac

251
Q

The most common pathogen isolated from sputum in CF

A

Before 20 y/o: staph aureus

After 20: pseudomonas aeroginosa (contributes to life-threatening decline of pulmonary function)

252
Q

CMV vs EBV

A

CMV:
Mild/absent pharyngitis, LAP, splenomegaly
Negative heterophil Ab

253
Q

Odyniphagia/dysphagia DDx in HIV pts

A

White plaques: candida, fluconazole
Large linear ulcers: CMV, gancyclovir
Vesicles, round/ovoid ulcers: HSV, acyclovir
Aphtous ulcers: symptomatic therapy

The most common cause: candida

HSV has intranuclear inclusions
CMV has intranuclear and intracytoplasmic inclusions

254
Q

Approach to HIV pt with dysphagia/odynophagia

A

If mild symptoms, oral thrush, treat for candida

If severe symptoms, no thrush or no response to above treatment, endoscopy

255
Q

Tissue-invasive CMV disease

A

Pneumonitis
Gastroenteritis
Meningoencephalitis
Hepatitis

In immunocompromised individuals

Dx: PCR in blood

Tx: D/C antimetabolites, initiate antivirals (gancyclovir iv if severe, oral if mild)

256
Q

Diarrhea in HIV pts

A

cryptospordium, CD4 <180, severe, watery, low-grade fever

Microspordium/isospora: CD4<100, watery, crampy abdominal pain

MAC: CD4<50, watery, high fever>39

CMV: CD4< 50, frequent, small volume, hematochezia, abdominal pain, low-grade fever, Dx: colonoscopy and Bx. Tx: gancyclovir+ART, ocular exam required

257
Q

HIV pt with colitis symptoms and CD4 <50 next step?

A

Colonoscopy and Bx

258
Q

HIV pt with profuse non bloody diarrhea, next step?

A

Stool exam for ova and parasites, acid fast stain, clostridium difficile antigen

259
Q

Tx of cryptospordiosis in HIV

A

Supportive

ART

260
Q

Eggshell calcification of a hepatic cyst on CT

A

Hydatid cyst

261
Q

Dx of hydatid cyst

A

Imaging

IgG serology

262
Q

Tx of hydatid cysts

A

If < 5cm: albendazole

If > 5cm or complex or ruptured: percutaneous treatment, surgery

263
Q

Ehrlichiosis

A 
Tick
Flu-like
Neurologic symptoms
Leukopenia
Thrombocytopenia
Elevated liver enzymes and LDH
Dx: Morulae in monocytes, PCR
Tx: empiric doxy while awaiting confirmatory testing
264
Q

Empiric AB in native valve endocarditis

A

Vancomycin

Covers staph, sterp, entrococci

265
Q

Pts susceptible to Staph A endocarditis

A

Prosthetic valves
IV cath
Implanted devices
IDU

266
Q

Strep viridans endocarditis

A

Gingival manipulation

Respiratory tract incision and biopsy

267
Q

Staph epidermidis endocarditis

A

Prosthetic valve
IV cath
Implanted devices

268
Q

Enterococci endocarditis

A

Nosicomial urinary tract infections

269
Q

Strep bovis endocarditis

A

Colon cancer

IBD

270
Q

Fungal endocarditis

A

Immunocompromised
IV cath
Prolonged AB

271
Q

Strep viridans group

A

Strep mutans, mitis, oralis, sanguinis

272
Q

The most common valvular abnormalities in patients with infective endocarditis

A

Mitral Valve prolapse with regurgitation

273
Q

IE in IDU

A 
HIV increases the risk if IE in IDUs
Tricuspid
Often no audible heart murmur
Septic pulmonary emboli common
Staph A
Fewer peripheral manifestation
Heart failure rare
274
Q

Splenic abscess

A 
Fever, leukocytosis, left upper quadrant abdominal pain
Left sided pleuritic chest pain
Left pleural effusion
\+/- splenomegaly
Staph, strep, salmonella
Dx:CT

Tx: broad spectrum AB+ splenomegaly
If poor surgical candidate, cutaneous drainage

275
Q

RFs for splenic abscess

A

IE, SCA, trauma, HIV, IDU, ImSup

276
Q

If IE with penicillin resistant strep

A 
Change vanco to either:
IV aqueous penicillin G
Or
IV ceftriaxone once daily
X 4 wk
277
Q

Food poisoning with predominant diarrhea

A 
Staph A (mayonnaise) 
Bacillus cereus (starch)
Noroviruses (e.g. norwalk)
278
Q

Features of disseminated gonococcal infection

A

Purulent artgritis w/o skin lesions
Or
Tenosynovitis+ migratory asymmetric polyarthralgia (non purulent) + dermatitis

+ high fever, chills

279
Q

Dx of disseminated gonococcal infection

A

Blood culture (mostly negative)
Synovial fluid analysis
Urethral/cervical/pharyngeal/rectal cultures
HIV/Syphilis
Terminal complement activity (if recurrent)

280
Q

Exposure to HBV with unknown immunity

A

HBIG + vaccine

281
Q

Ventillator acquired pneumonia

A

After 48 h or more of intubation
Aerobic gram negatives, gram positive cocci
Fever, leukocytosis, purulent discharge, difficulty with ventilator

282
Q

The 1st step in VAP

A

CXR

If positive findings on CXR: lower respiratory tract sampling for gram and culture + empiric AB

283
Q

Hepatitis C in pregnancy

A

Increased risk of GDM, cholestasis, PTL
Ribavirin: teratogenic
Barrier protection: no indication
Hepatitis A & B vaccination (all pts including pregnants)
Cesarian: not protective
Scalp electrode: avoid
Breastfeeding: encourage unless maternal blood at nipple
Association between maternal viral load and risk of vertical transmission
Risk of vertical transmission: 2-5%

284
Q

The most common route of HCV transmission

A

Exposure to infected blood

285
Q

Definition if post herpetic neuralgio

A

Pain persisting > 4 mo

286
Q

Ways of acquiring immunity agains varicella

A

Prior infection

Receiving 2 doses of vaccine (usually at 12-15 mo and 4-6 y)

287
Q

Post prophylaxis exposure for varicella in non immune

A

VZV vaccine.
If immunocompromised or pregnant or neonate: VZIG within 10 d
If <1 y but older than 1 mo: prophylaxis not required

288
Q

Histoplasmosis

A

Soil, bird/bat droppings

Closely mimics sarcoidosis (but deteriorates with CS)

Pulmonary symptoms +
Mediastinal/hilar lymph nodes or masses
Or arthralgia and erythema nodosum

If ImmSup
LAP, HSM, pancytopenia
Increased AST, ALT, LDH, ferritin

Caseating and non-caseating granuloma

Dx: fungal tissue culture (4-6wk) and stain, Histoplasma urinary/serum Ag testing

Tx:AmB (mod-sev), itra (mild, maintenance)

289
Q

Blastomycosis

A 
Soil, rotting wood
Skin lesions
Osteolytic bone lesions
Prostate involvement
Can disseminate in ImmSup
290
Q

Fungal infection with prominent pulmonary, mucocutaneous, reticuloendothelial involvement

A

Histoplasmosis

291
Q

Diagnostic method of choice for histoplasmosis

A

Urinary/serum Ag

292
Q

Dx of PCP

A

Induced sputum sample
If negative
BAL

293
Q

Disseminated MAC

A

Fever, cough, diarrhea, night sweats, wt loss
Splenomegaly, increased ALP
CD4< 50

Dx: blood culture, LN/BM biopsy

Tx: clarithro or azithro
Prophylaxis: azithro when CD4<50

294
Q

Post-exposure HIV prophylaxis

A

Draw blood for HIV serology and start ART with 3 drug immediately (within hours)
Continue for 28 d
Test HIV again at 6w, 3mo, 6mo

295
Q

Risk of HIV seroconversion after needle exposure

296
Q

Prrimary pophylactic AB for HIV pts

A 
CD4 < :
200, TMP-SMX for PCP
100, TMP-SMX for toxo
50, Azithro/clarithro for MAV
150, Itra, histoplasmosis (endemic regions)
297
Q

Prophylaxis with fluconazole for candidiasis/cryptococcal disease in HIV

A

Effective but not recommended

298
Q

Live virus vaccines in HIV

A

Should not receive if CD4 < 200
If CD4 >200, should receive varicella and MMR vaccine if low titers

Also:
Pneumococcal vaccine, hepatitis B

Also:
Tdap, influenza as general population

299
Q

Pneumococcal vaccine in HIV

A

PCV13
After 8w, PPSV23
After 5y, PPSV23
At age 65, PPSV23

300
Q

Preferred HIV screening method

A

HIV p24 Ag + HIV Abs

If positive:
Confirm with HIV1/HIV2 ab differentiation immunoassay

If negative, but high clinical suspicion:
HIV RNA

301
Q

Prenatal management of HIV

A

Viral load: monthly until undetectable, then q 3mo
CD4 count q 3 mo
Resistance testing if not previously obtained
3 drug HAART
prophylaxis against opportunistic infections if CD4< 200
Avoid AC until viral load undetectable

302
Q

Intrapartum HIV care

A 
Rapid HIV testing if not performed
Avoid artificial ROM
Avoid fetal scalp electrode
Avoid instrumentation
If not on HAART: Zidovudine
If viral load > 1000: Zidovudine and C-section
303
Q

Post natal HIV Mx

A

Maternal: continue HAART
Infant: Zidovudine for at least 6 wk + serial HIV PCR

304
Q

Dx of HIV infection in infants

A

DNA PCR
Or
Persistence of HIV Ab after 18 mo

305
Q

Hx of genital HSV infection in pregnant woman

A

Start prophylaxis with acyclovir/valacyclovir at 36 GA

306
Q

Pneumococcal vaccine in adults age > 65

A

PCV13, then PPSV23 after 6-12 mo

307
Q

Pneumococcal vaccine in adults under 65

A

If chronic heart/lung/liver disease, or DM, smoker, alcoholic: one time PPSV23

If CRF, ImSup, asplenic, CSF leakage, cochlear implant: PCV13, then PPSV23

308
Q

Indications gor meningococcal vaccine in age > 18y

A 
Complement deficiency
Asplenia
College students in residential housing
Military recruits
Travel to endemic areas
Exposure to community outbreaks
309
Q

Regular schedule for meningococcal vaccine

A

Primary dose at age 11-12

Booster at age 16-21 (if primary at age <16)

310
Q

The safety of live-attenuated/vaccines in the those receiving tumor necrosis factor antagonist

A

Should be avoided

311
Q

Duration of contact sport avoidance in infectious mononucleosis

A

At least 3 weaks

312
Q

Pts with strep pharyngitis are not contagious after?

A

24 h after initiation of AB

313
Q

EBV heterophil Abs

A

Arise within one weak
Peak: 2-6 wk after infection
Remains positive up to 1 year

314
Q

Anemia and thrombocytopenia due to EBV

A

IgM cold-agglutinin
Complement-mediated destruction of RBCs
Usually coombs positive
2-3 wk after the onset of symptoms

315
Q

Pharyngitis with complication if dilated CMP

A

Corynebacterium with pseudomembrane

316
Q

CD4 count in HIV with KS

317
Q

Legionella pneumonia

A 
High fever (>39)
Relative bradycardia
Atypical pneumonia with Bilateral interstitial lung infiltrates
Headache, confusion, ataxia (neurologic)
Watery diarrhea, hepatic dysfunction (GI)
Hyponatremia
Hematuria, proteinuria 
MOF

Sputum gram stain: many PMN, few/no organism (gram negative, intracellular)

Travel-associated:due to aerosols/droplets from contaminated water supplies

Dx: culture + Legionella urine Ag

Tx: respiratory quinolone (especially inpatient) , newer macrolides

318
Q

Dx and Tx of entamoeba histolytica

A

Stool O & P, stool Ag testing (colitis)
Serology (liver abscess)

Tx: Metro, paromomycin

319
Q

Tx of amoebic liver abscess:

A

Metro
+ paromomycin to eradicate luminal organism
Drainage: not recommended (unless there is mass effect, imminent risk of rupture, uncertain diagnosis, no improvement)

320
Q

Tx for influenza considered when:

A

RF for complications (>65, pregnancy, chronic disease…) or pts who come within 48 h of symptom initiation

Osrltamivir

321
Q

Ludwig angina Dx, Tx

A

Dx: CT
Tx: IV AB (ampicillin-sulbactam, clinda)
Mechanical ventilation if respiratory compromise

322
Q

Lyme carditis Dx

A

If no classic rash: serology

323
Q

Lyme carditis Tx:

A

Ceftriaxone IV

324
Q

When does erythema migrans develop?

A

1-2 wk after tick bite

At least 36h attachment

325
Q

Tx for acute unilateral cervical lymphadenitis

A

Clindamycin

Staph A, strep pyogen

326
Q

The most common cause of unilateral subacute lymphadenitis

A

Atypical mycobacterium (avium)

327
Q

Malaria chemoprophylaxis

A

Atovaquone-proguanil
Doxycycline
Mefloquine: 2wk or more prior to travel, continued up to 4 wk after returning

Change to an alternate if neuropsychiatric side effects (anxiety, depression, restlessness)

+ protective clothing, insect repellent, insecticide-treated bed netting

328
Q

Dengue fever

A 
Mosquito
Within 4-7 d (never after 2wk)
Marked muscle and joint pain
Retroorbital pain
Rash
Leukopenia
329
Q

Human African trypanosomiasis

A

Tsetse fly
Acute febrile illness + trypanosomal chancre
Myocarditis
CNS involvement

330
Q

Measles Tx

A

Supportive
Vit A if deficient or hospitalized
(Reduces mortality and morbidity)

331
Q

Measles virus transmission

A

Airborne precautions: N95 mask for personnel, negative pressure room

Vaccine (2 doses) generate immunity in > 95%

332
Q

Tx of rhino-orbito-cerebral mucormycosis

A

Surgical debridement
Liposomal AmB
Elimination of risk factors (increased glucose, acidosis)

333
Q

Pts with significant immunecompromise and sinositis, next step?

A

Sinus endoscopy with culture and biopsy to evaluate for mucormycosis

334
Q

The most common complication of mumps

A

Aseptic meningitis

335
Q

Orchitis in mumps

A

Primarily post-pubertal males

Can impair fertility

336
Q

Necrotizing fasciitis Tx

A

Surgical debridement (most important)
Broad spectrum AB
Tight glycemic control
Hydration

337
Q

Neurocysticercosis Tx

A

Antiepileptics
Albendazole
CS

338
Q

Typical presentation of neurocysticercosis in adults

A

Seizure

Less common: increased ICP

339
Q

Nocardiosis

A

Gram + rods
Filamentous, beaded, branching
Partially acid-fast
Aerobic
Endemic in soil
Transmission: inhalation, traumatic inoculation into skin (gardening)
Pts: ImmSup (defense dependent on cell-mediated immunity), elderly
Features: pneumonia (TB-like), CNS (brain abscess), cutaneous involvement

Tx: TMP-SMX +/- amika or +carbapenem (if CNS involvement), surgical drainage of abscess

340
Q

The most common form of nokardiosis

A

Pulmonary
Fever, wt loss, malaise, dyspnea, cough, pleurisy
Imaging: nodular, cavitary lesions in the upper lobes

Dx: BAL : sample for smear/stain and culture (>4wk)

Susceptibility testing required

341
Q

Aztreonam

A

Monobactam

Gram negative coverage, pseudomonas

342
Q

Actinomyces

A

Gram +, filamentous
Non acid-fast
Anaerobic
Tx: penicillin

343
Q

Cavernous sinus thrombosis

A

Headache is the most common early symptom
Periorbital edema, chemosis, papilledema, exophthalmous, dilated tortuous retinal veins
Begins unilaterally. Becomes bilateral within 24-48 h
Dysfunction of III, IV, V, VI cranial nerves

344
Q

If suspicion about vertebral osteomyelitis,

A

Plain Xray (might be nl in first 2-3 wk)
CBC, ESR, CRP, blood culture
Modality of choice: MRI
If MRI not possible: radionuclide bone scan using gallium
CT guided aspiration and culture of infected disc or bone is needed to confirm diagnosis

345
Q

Tx of infectious diabetic foot ulcer

A

Piperacillin-tazobactam + vancomycin

346
Q

Increased risk of deep infection in diabetic foot ulcer if:

A 
Long standing (>1-2 wk)
Systemic symptoms: fever, chills
Large ulcer size (>2cm)
Elevated ESR
Palpation if bone in the ulcer base

Polymicrobial, direct extension

347
Q

Organisms most responsible for deep infection following puncture wound

A

Staph A

Pseudomonas (especially through dole of the shoe)

348
Q

The most common organism of osteomyelitis in IDUs

A

Staph A&raquo_space; gram -

349
Q

The most reliable sign of spinal osteomyelitis

A

Tenderness to gentle percussion over the spinous process

High index of suspicion for vertebral osteomyelitis if IDU pt or recent distant site infection

350
Q

The most common organism responsible for osteomyelitis in infants and children

A

Staph A in both

Others:
Infants: GBS, Ecoli
Children: strep pyogen

351
Q

Parvo B19 arthritis

A

Resembles RA
Acute, symmetrical arthralgia/arthritis in hands, wrists, knees and feet
Transient aplastic anemia if hematologic disease
Flu-like symptoms
Fever, diarrhea, nausea

352
Q

Dx of parvovirus infection

A

B19 IgM in immunocompetent
NAAT in immunocompromised
If reactivation of previous infection: NAAT to detect DNA

353
Q

Acute mucopurulent cervical discharge with friable cervix is the classic presentation of:

A

acute cervicitis which is most commonly due to (Chlamydia & Gonorrhea)
Empiric treatment: ceftriaxone +
azithro

NAAT proven chlamydia: azithro
NAAT proven gonorrhea: ceftriaxone + azithro

354
Q

Tx of pertussis

A

Macrolides
Avoid antitussives in <6 y/o

Tx in catarrhal stage, may shorten disease duration
Tx in paroxysmal stage, may only reduce risk of transmission

355
Q

Dx of pertussis

A

clinical, but also:
Culture
PCR
Lymphocyte-predominant leukocytosis

356
Q

Post-exposure prophylaxis for pertussis

A

Prophylaxis recommended for all close contacts despite vaccination status:

Age <1 mo: azithro x 5d
Age >1mo: azithro 5d, clarithro 7d, erythro 14 d
+ immunization according to recommendations

Tx is also the same

357
Q

Pertussis vaccine in US

A 
5 doses during childhood
1 dose in adolescence
1 dose in adulthood
1 dose with every pregnancy
Macrolide with each close exposure
358
Q

Tx of entrobiosis

A

Albendazole
Or
Pyrantel pamoate (preferred if pregnant) for pts and all household contacts

359
Q

First line for treatment if strogyloides stercoralis

A

Ivermectin

360
Q

Tx of chagas

A

Benznidazole

361
Q

Tx of PCP

A

TMP-SMX x21 d
CS (if low O2: O2 sat <92%, PaO2 <70%, A-A gradient >35 on room air)

ART after 2 wk

362
Q

PCP clinical features

A

In setting of HIV: indolent

Other immune-suppression settings: fulminant

363
Q

Dx of PCP

A

Induced sputum with specialized stain

If unrevealing, BAL

364
Q

Pneumonia with increased LDH

365
Q

Infection prophylaxis in transplant pts

A

TMP-SMX: for PCP, listeria, toxo. Desensitization if sulfa allergy. Usually 6-12 mo

Pneumococci and HBV vaccination prior to transplant

IM influenza vaccine yearly

Gancyclovir/valgancyclovir depending on serostatus of pt and donor

Fungal prophylaxis for liver/lung but not for renal transplant

366
Q

Pneumonia with hypoxia out of proportion to CXR findings

367
Q

Healthcare workers, exposed to blood from a suspected or unknown hepatitis B pt, next step?

A

If previously vaccinated and known Ab response: require nothing (maybe HB booster)

If previously unvaccinated/without adequate response to vaccine: complete vaccines, the first dose within 12 h, also HBIG within 24 h

No lab!

368
Q

Post-operative fever

Immediate

A 
0-2h
Blood products
Inflammation due to surgery
Malignant hyperthermia
Prior trauma/infection
369
Q

Post-operative fever

acute

A

24h-1wk
Nosocomial infections
SSI (GAS, clostridium perfringens)
MI, PE, DVT

370
Q

Post-operative fever

Subacute

A 
1wk-1mo
SSI (organisms other than GAS/clostridium)
Cath site infection
Clostridium difficile
Drug fever
PE/DVT
371
Q

Post-operative fever

Delayed

A

> 1mo
Viral infections (due to blood products), infective endocarditis
SSI

372
Q

Post operative fever definition

A

> 38 C (100.4 F)

373
Q

Progressive multifocal leukoencephalopathy

A

JC virus reactivation (acquired during childhood, dormant in kidneys and lymphoid tissue)
Severe ImSup
Slowly progressive
Confusion, paresis, ataxia, seizures

Dx: CT: non-enhancing, hypo-dense lesions, no edema (therefore no mass effect). MRI: irregular white matter lesions with no enhancement/edema. LP (PCR for JC virus). Rarely brain Bx

Tx: often fatal. ART if HIV

374
Q

HIV dementia

A

Affects deep gray matter structures
Subacute
Cognitive, behavioral, motor deficit
Imaging: cerebral atrophy, enlarged ventricles

375
Q

Rabies following direct exposure to bats (uncertain of bite)

A

Receive rabies prophylaxis

376
Q

Tx of croup

A

Mild (no respiratory stridor at rest): dexa

Mod-sev (respiratory distress, stridor at rest): dexa+ nebulized epinephrine

377
Q

Retropharyngeal abscess

A

Inability to extend neck
Widened prevertebral space on lateral
Fever, odynophagia/dysphagia, drooling, muffled voice, trismusp
x-ray (on normal xray prevertebral soft tissue space should be narrower than the vertebral bodies)
polymicrobial

Next step: CT with contrast

378
Q

Tx of Acute Rheumatic Fever

A

Benzathine penicillin G
CS for chorea
NSAIDs for pericarditis, arthritis

379
Q

The most common organism responsible for pericarditis/myocarditis

A

Coxsackievirus

380
Q

Congenital rubella

A

SNHL
Leukocoria from cataracts, glaucoma
PDA

381
Q

Congenital toxo

A

Chorioretinitis
Hydrocephalus
Diffuse intracranial calcifications

382
Q

Congenital CMV

A

Chorioretinitis

Periventricular calcifications

383
Q

Congenital varicella

A

Limb hypoplasia
Cataract
Skin scarring

384
Q

Congenital syphilis

A 
Hepatomegaly
Snuffles (nasal discharge)
osteoarticular distruction
Maculopapular rash
SNHL as a late sequela
385
Q

Transplacental HSV infection

A

Brain destruction
Seizures
Vesicular rash

386
Q

Pristhetic joint infection organisms

A

<3mo: Staph A, Gram - rods, anaerobic

> 3mo: Staph epidermidis, propionibacterium species, enterococci

387
Q

The most common organism is SCA osteomyelitis

A

Salmonella

388
Q

The most common cause of sepsis in SCA

A

S pneumoniae (despite vaccination)

389
Q

Sporotrichosis Dx and Tx

A

Dx: culture of aspirated fluid, Biopsy

Tx: oral itra 3-6 mo

390
Q

Primary syphilis tests

A

Non-treponemal (higher false negative)

Treponemal (higher sensitivity, esp:FRA-ABS)

391
Q

Neurosyphilis and penicillin sensitivity

A

Desensitize

Also for ocular, pregnancy, multiple failures with non-penicillins

392
Q

How to make sure of syphilis treatment

A

RPR at the time of diagnosis and 6-12 mo later (a 4fold decrease required)

393
Q

Secondary syphilis rash starts on:

A

Trunk and spreads to extremities

394
Q

Features common to all TORCH agents

A

IUGR
HSM
Jaundice
Blueberry muffin spots

395
Q

Jarisch-herxheimer reaction

A

6-48 h after treatment of syphilis
Also with treatment of lyme, leptopirosis
Fever, chills, myalgia, rigor, sweating, hypotension
Rash progression in secondary syphilis

Tx: IV fluid, acetaminophen, NSAIDs
Self-limiting within 48h

396
Q

Neonatal tetanus

A 
Within 2 wk
Poor suckling, fatigue 
Rigidity, spasm, opisthotonus
Apnea
Septicemia
High mortality

Prevention: maternal vaccination, promoting hospital delivery, training non-medical birth attendants, clean cord handling practices

397
Q

Tx of toxo in HIV

A

Sufadiazine+Prymethamine+leucovorin

398
Q

Pts with hepatitis B to treat

A

Acute liver failure

Clinical complications of cirrhosis

Advanced cirrhosis with high serum HBV DNA

Pts without cirrhosis but with positive HBeAg, HBV DNA> 20,000 and ALT > 2x upper limit of normal

Prevent HBV reactivation during chemotherapy or ImSup

399
Q

Tx for hepatitis B

A

IFN: younger pts with compensated liver disease. Short-term treatment

Lamivudine: diminished role due to drug resistance. May have role in HIV

Entecavir: decompensated cirrhosis

Tenofovir: most potent. Preferred drug. Limited resistance.

400
Q

Purpose of treating chronic HBV infection

A

Prevent complications

Decrease transmission to others

Reduce progression to chronic liver disease

Med (25 decks)

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