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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
How much weight loss is normal after birth for Neonate?
<7% (during first 5 d)
26
Pink stains or brick dust in neonate’s diaper
Uric acid crystals | Common during the first week, or in later months with the morning void after infant begins to sleep through the night
27
When can infants have plain water?
After 6mo of age
28
Indications of laparotomy in penetrating abdominal injury
Hemodynamic instability Peritonitis (rebound tenderness, guarding) Evisceration Blood from NGT or rectal exam
29
If no indications of laparotomy in penetrating abdominal injury
Local wound exploration | Extended ultrasound examination
30
Indication of DPL
Unstable patients with blunt abdominal trauma and no available CT or FAST or inconclusive GAST
31
Diaphragm location range
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
32
Development of object permanence in an infant
6-12mo
33
Age of separation anxiety
9-18 mo
34
Contraindications to Nasotracheal intubation
Apneic/hypopneic pts | Basilar skull fracture
35
Diagnosis of coma is via:
Impaired brainstem activity Motor dysfunction Level of consciousness
36
ALL markers
Peroxidase - PAS + TdT + (preB, preT)
37
Anemia of chronic disease
``` 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 ```
38
Tx of warfarin necrosis
Cessation of warfarin | Administration of protein C concentrate
39
How long in advance should warfarin be discontinued before measurement of protein S levels?
2 wk
40
Fanconi anemia
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
41
Diamond-Blackfan anemia
``` 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 ```
42
Defect in Fanconi anemia
DNA repair Chromosomal breaks on genetic analysis Tx: BMT
43
Infection prophylaxis for splenectomy
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)
44
Howell-Jolly bodies
Single round blue RBC inclusion on Wright stain Remnant of nucleus Indicate physical/functional absence of spleen: Splenectomy, autoimfarction, infiltration, congestion
45
Intravascular hemolysis lab
Markedly reduced serum haptoglobin (undetectable) Elevated indirect Bil Raised LDH levels
46
Extravascular hemolysis lab
Less intravascular Hb release Nl/slightly low haptoglobin Slightly elevated LDH Elevated indirect Bil
47
Intravascular hemolysis DDx
``` MAHA (DIC...) Transfusion reaction Infection (clostridial sepsis...) PNH IV Rho(D) Ig infusion ```
48
Extravascular hemolysis DDx
``` RBC enzyme deficiencies Hemoglobinopathy Membrane defects Hypersplenism IVIg Warm/cold-agglutinin AI hemolytic anemia Bartonella Malaria ```
49
Indications of washed RBC
IgA deficiency Complement-dependent AI hemolytic anemia Allergic reaction with RBC despite antihistamine treatment
50
Indications for leukoreduced RBC
Chronically transfused pts CMV seronegative at-risk pts (AIDS, transplant) Potential transplant recipients Previous febrile non-hemolytic transfusion reaction
51
Indications for irradiated RBC transfusion
BMT recipients Acquired/congenital cellular immunodeficiency Blood components donated by first or second degree relatives
52
Timing of transfusion reactions
``` 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 ```
53
Rx of febrile non-hemolytic transfusion reaction
Stop transfusion Antipyretics Use leukocyte depleted RBC
54
Tx of hypercalcemia due to malignancy
Bisphosphonate
55
Tx of hypercalcemia related to granulomatous diseases
CS
56
The most common sites of osteonecrosis in SCA patients
Humoral and femoral heads
57
Soap bubble appearance on bone xray
Giant cell tumor
58
Giant cell tumor of bone
``` 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 ```
59
Osteitis fibrosa cystica
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
60
Osteosarcoma lab
Increased: ESR, ALP, LDH No systemic symptoms Soft tissue mass on examination
61
Parinaud (dorsal midbrain) syndrome
Limited upward gaze Upper eyelid retraction (collier sign) Pupils non-reactive to light but reactive to accomodation (light-near dissociation)
62
Features of pineal gland tumor
Pressure on pretectal region of the midbrain Parinaud syndrome Obstructive hydrocephalus
63
Neuroblastoma origin
Sympathetic nervous system
64
Intracranial neuroblastoma features
Opsoclonus myoclonus syndrome | Ab-mediated dancing eyes and feet
65
Trilateral neuroblastoma
``` Bilateral neuroblastoma (leukocoria) And pineal gland tumor ```
66
Symptoms of cerebellar vermis dysfunction
Truncal/gait instability
67
Symptoms if cerebellar hemispheres dysfunction
Dysmetria Intention tremor Dysdiadochokinesia
68
Tx of cancer-related anorexia/cachexia
``` Progesterone analogues (megestrol acetate) CS ``` If longer life expectancy, progesterone analogues preferred
69
Tx of advanced HIV cachexia
Synthetic cannabinoids (dronabinol)
70
Tx of chemotherapy-induced nausea
Serotonin 5HT3 receptor antagonist: Ondansetron +/- CS Both for treatment and prophylaxis
71
Tx of nausea secondary to gastroparesis
Motilin receptor agonists: erythromycin | D2 antagonist. Dompridone
72
Tx if opioid induced constipation
Methylnaltrexone (GI-specific opioid antagonist)
73
A form of treatment for a disease when a standard treatment fails
Salvage therapy
74
Treatment given in addition to standard therapy
Adjuvant therapy
75
An initial dose of treatment to rapidly kill tumor cells and send a patient into remission (<5% tumor burden)
Induction therapy
76
A treatment given after induction therapy with multi drug regiment to further reduce tumor burden
Consolidation
77
A treatment given after induction and consolidation therapies to kill any residual tumor cells and keep the patient in remission
Maintenance
78
Treatment given before the standard therapy for a particular disease
Neoadjuvant
79
Indication of EPO in CRF (after ruling out iron deficiency)
Hct<30% Pts on hemodialysis with symptoms attributed to anemia Target: Hct:30-35%
80
Side-effects of EPO
HTN (IV>SC), the most common side effect. Headache Flu-like (IV>SC) Red cell aplasia
81
Anemia in CRF vs IDA
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
82
Worse prognosis of CLL with
Anemia Thrombocytopenia Multiple chain LAP HSM
83
Classic presentation of hairy cell leukemia
``` Splenomegaly Pancytopenia B cell Age>50 Bone marrow fibrosis Typically no LAP, Hepatomegaly orB symptoms ```
84
Hodgkin usual presentation
Painless LAP and B symptoms | Nl CBC, PBS
85
CLL usual presentation
Dramatic lymphocytosis LAP HSM thrombocytopenia, anemia
86
Dx of CLL
CBC, PBS, FCM (clonality of mature Bcells) Elderly+ dramatic lymphocytosis+ mild anemia/thrombocytopenia + LAP + HSM = CLL Bx usually not required (LN, BM...)
87
Leukocyte alkaline phosphatase score in CML vs leukemoid reaction
Low LAP in CML
88
Dx of CML
``` Dramatic granulocytosis Absolute basophilia Immature neutrophil precursors low ALP score (alkaline phosphatase) BCR-ABL Thrombocytosis Anemia Splenomegaly ```
89
Intracranial tumor with calcification
Craniopharyngioma
90
The earliest vaso-occlusion manifestation in SCA
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
91
Best time for retesting G6PD after an episode of hemolysis
3 mo later
92
Pyruvate kinase deficiency manifestations
Chronic hemolysis Pigmented gallstones HSM Skin ulcers
93
Pathophysiology of wiskott-Aldrich syndrome
Impaired cytoskeleton in plt and WBC
94
Hemochromatosis increases susceptibility to which infectious organisms?
Vibrio vulnificus Listeria Yersinia enterocolitica
95
Tx of HUS
Supportive Dialysis Blood transfusion Fluid/electrolyte
96
HUS vs DIC
PT and PTT normal in HUS
97
How long after diarrhea does HUS develop ?
5-10 d
98
Hematuria in hemophilia
Common but no renal impairment. | Normal Cr
99
Hemophilic arthropathy
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
100
Type 2 HIT
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
101
Warfarin in HIT
Started after another anticoagulant has been received and plt>150,000
102
PTT in HIT
Prolonged due to heparin!!
103
Type 1 vs Type 2 HIT
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.
104
Effect of enoxaparin on aPTT
None
105
Osler-Weber-Rendu
HHT AVMs in: skin, mucous membranes, GI, Lung, liver In lung, AVMs cause: chronic hypoxia, clubbing, polycytemia. Also massive hemoptysis
106
Hereditary spherocytosis
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
107
Absent CD55
PNH
108
Increased HbF
Beta Thalassemia SCA Congenital aplastic anemia Hereditary persistence of fetal Hb
109
Time of splenic autoinfarct in SCA
By 18-36 mo
110
Helmet cells
MAHA (HUS, DIC, TTP)
111
Effect of hydroxyurea in SCA
Decreases: Pain crises Acute chest syndrome Need for transfusion
112
Risks of homocysteinuria
VTE | Atherosclerosis
113
Tx of homocysteinuria
B6 + folate + B12 (if reduced levels)
114
Pica specific for iron deficiency
Pagophagia (ice)
115
The first finding of IDA on PBS
anisocytosis (increased RDW) | >20% in suggestive
116
Cow’s milk in infants
Not before 12 mo of age | Not mire than 24 oz daily
117
Target cells
Alpha/beta thalassemia
118
Hb electrophoresis in alpha and beta thalassemia
Alpha thalassemia: Nl | Beta thalassemia: increased HbA2
119
Tx of ITP in children
Only skin manifestations: observe | Bleeding: IVIg, CS
120
Tx of ITP in adults
Plt 30,000 or higher and no bleeding: observe Plt<30,000 or bleeding, IVIg, CS
121
Tests required for ITP
CBC PBS HIV/HCV (if Hx suggestive)
122
Manifestations of acute lead poisoning
Abdominal pain | Constipation
123
Manifestations of chronic lead exposure
``` Fatigue Irritability Insomnia HTN motor/sensory neuropathies (paresis...) Neuropsychiatric disturbance Nephropathy (raised Cr) ```
124
Lead absorption route in children and adults
Children: GI Adults: respiratory
125
Dx of lead toxicity
``` CBC, PBS Microcytic anemia Basophilic stippling Blood lead levels Xray fluorescence (measure bone lead concentration) ```
126
Occupations with lead exposure
``` Battery manufacturing Plumbing Mining painting paper hanging auto repair ```
127
Location of lead in the body
99% Bound to erythrocytes
128
Serum protein gap
Protein - albumin > 4 Indicates: Poly/monoclonal gammopathy
129
Rouleaux formation indicates
Elevated serum protein
130
Eculizumab
PNH Tx | Inhibits complement activation
131
PNH Tx
Eculizumab Folate Iron
132
Age of presentation in PNH
4th decade of life
133
Abdominal pain + dark urine DDx
``` Hemolysis PNH Cholangitis Acute intermittent porphyria SCA ```
134
Prophylaxis in children with asplenia
Conjugated pneumococcal vaccine Twice daily penicillin up to 5 y of age Other routine vaccines
135
How long after reduced dietary intake does clinical folate deficiency appear?
4-5 mo
136
MDS vs Pernicious anemia
Both: pancytopenia and macrocytosis | Distinction requires careful examination of BMB and PBS for dysplastic cells
137
Transient visual disturbance DDx
TIA MS PV CRVO
138
PV associations
``` Gout HTN erythromelalgia Aquagenic pruritus Thromboses Bleeding ```
139
Indication of hydroxyurea in PV
High risk of thrombosis
140
Reason for transient visual disturbance in PV
Hyper-viscosity. | It is not due to thrombosis, and anticoagulation is not effective
141
O2 saturation in PV
Nl
142
ESR in PV
Low
143
CO poisoning Dx
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
144
CO-Hb level in normal vs smoker person
<3% vs 10%
145
Neonatal polycytemia
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
146
Anemia of prematurity etiology
Impaired EPO production Short RBC life span iatrogenic blood sampling
147
Anemia of prematurity symptoms
``` Usually asymptomatic Tachycardia Apnea Poor weight gain Low Hb Low retic Normo-normo ```
148
Tx of anemia of prematurity
Minimize blood draws Iron supplementation Transfusion
149
The most common hereditary thrombophilia in whites
1st: Factor V Leiden (resistance to prC) 2nd: prothrombin mutation (increased levels)
150
Indications of hydroxyurea in SCA
Frequent acute painful episodes Acute chest syndrome Severe symptomatic anemia
151
Indication of periodic blood transfusion in SCA
``` Acute stroke Acute chest syndrome Acute multiorgan failure Acute symptomatic anemia Aplastic crisis Stroke prevention ```
152
Hypostenuria
Kidney’s inability to concentrate urine | e.g. SCA (disease and trait) red cell sickling in vasa recta of the inner medulla
153
Sickle cell trait features
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
154
Anemia resulting from isoniazide
Sideroblastic Decreased B6 -> decreased heme synthesis -> sideroblastic anemia Dimorphic RBC population ( both normo and hypo) Increased serum iron Decreased TIBC
155
Spinal cord compression pain
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
156
Spinal cord compression Tx
Emergency MRI IV CS (given without delay) Radiation/neurosurgery consultations
157
SVC syndrome etiologies
Malignancies (lung, Hodgkin) Fibrosing mediastinitis (Histoplasmosis, TB) Thrombosis due to CV line
158
Lab in APLS
Plt: mild decrease PT: might be prolonged PTT: prolonged (not corrected with dilution with normal plasma)
159
Microcytosis in IDA vs Thalassemia
IDA becomes microcytic when Hb<10 Thalassemia becomes microcytic with Hb>10 Mentzer index (MCV/RBC): <13 in thalassemia >13 in IDA
160
Screening for thalassemia trait in prenatal consultations
CBC | If reduced Hb and MCV, additional testing
161
Tested infections in thrombocytopenia
HIV | HCV
162
Fragmented RBCs on PBS
``` TTP HUS DIC HELLP Mechanical/ calcific heart valves ```
163
Prophylaxis of tumor lysis syndrome
IV fluids | Allopurinol or raspuricase
164
Tumor lysis syndrome damage to kidneys due to:
Renal tubule deposition of uric acid and Ca/P
165
Tx of stroke in SCA
Exchange transfusion
166
Prevention of stroke in SCA
Hydroxyurea
167
Indications of hypercoagulable state in VTE pts
``` Age<45 FHx of VTE multiple thromboses Unusual sites for thrombosis Recurrent DVT ```
168
Appropriate investigations in pts with VTE without clear provoking factors
Age-appropriate cancer screening and CXR | more extensive w/u if any concerns for occult cancer
169
Modified wells criteria for pretest probability of DVT
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
Indications of thrombolysis/thrombectomy in VTE pts
PE+ hemodynamic instability Or Massive proximal DVT with severe swelling or limb-threatening ischemia
171
Benefits of Factor X inhibitors over warfarin in VTE
``` 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
How long after surgery can anticoagulation therapy begin?
48-72 h
173
What is the preferred long-term oral anti-hypercoagulation therapy in ESRD patients?
Warfarin
174
Duration of anticoagulation therapy in a person with provoked DVT
At least three months
175
Basophilic stippling
B12/folate deficiency Lead poisoning Thalassemia alcoholism
176
The most common cause of megaloblastic anemia in alcoholic patients
Folate deficiency Mechanism: inhibiting folate absorption and impairing its enterohepatic cycle. Can develop within 5 to 10 weeks
177
Hematological manifestations of alcohol abuse
``` Folate deficiency Iron deficiency Anemia of chronic disease Thrombocytopenia Macrocytosis even before development of anemia ```
178
Antiepileptic drugs causing impaired absorption of folate in intestine
``` Phenytoin Phenobarbital Primidone Other drugs decreasing folate: Trimethoprim MTX ```
179
The most common cause of folate deficiency
Nutritional due to poor diet and/or alcoholism
180
Nutritional deficiencies causing glossitis
B2, B3, B12, folate, iron
181
Role of folate and B12
Both: Conversion of homocysteine to methionin B12 also: Methylmalonyl-CoA to succinyl-CoA MMA level can differentiate between folate and B12 deficiencies
182
Normal supply of vitamin K in the liver
30 d | An acutely ill person with underlying liver disease can become deficient in 7-10 d
183
DIC vs Vit K deficiency
DIC: increased PT, PTT, BT, decreased plt, decreased fibrinogen, schistocytes, acute liver and kidney injury, hypotension, tachycardia VitK: prolonged PT, PTT
184
Cervicofacial actinomycosis Dx/Tx
Dx: FNA, culture>14 d Tx:penicillin 2-6 mo, surgery
185
Prevention of acute bacterial parotitis after surgery
Adequate hydration Oral hygiene Bacteria: staph A Painful swelling of parotid gland, aggravated by chewing
186
Indications of CT in pyelonephritis
No improvement after 48-72h Hx of nephrolithiasis Gross hematuria Suspicion for urinary obstruction
187
Waterhouse-Friderichsen syndrome
Sudden vasomotor collapse and purpuric skin rash in infants with meningococcemia due to adrenal hemorrhage. 10-20% of Fulminant meningococcemia Almost 100% mortality
188
Human bite wound treatment
Debridement Amoxicillin-clavulanate Secondary intention healing Tetanus prophylaxis
189
Cat bite wound management
Copious irrigation and cleaning Prophylactic amoxicillin/clavulanate Tetanus prophylaxis Avoid closure unless thee is a major cosmetic implication
190
Pasturella multocida
G- coccobacilli | Cat bite
191
Which bite has more risk of infection? | Cat, dog, human
Cat bite | Needs prophylactic antibiotic
192
Which bites could be followed without prophylactic antibiotic?
Immunocompetent individuals with minor human or dog bites that are not located on hands and feet or genitalia
193
The most common cause of viral meningitis
Non polio enterovirused
194
Location of aspiration pneumonia
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
The most common cause of sepsis in post-splenectomy pts
Strep pneumoniae
196
Vaccination of adults after splenectomy
``` 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
Tx of asymptomatic bacteriuria in pregnancy
Cephalexin Amoxicillin-clavulanate Nitrofurantoin Fosfomycin
198
Trimethoprim-sulfamethoxazole during pregnancy
Contraindicated during 1st T: interference with folic acid metabolism Safe during T2 Contraindicated during T3: increased risk of neonatal kernicterus
199
Babesiosis
``` 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
Erlichiosis
Tick bite Flu-like Leukopenia Thrombocytopenia
201
Tourniquet test
Dx if dengue fever
202
The most common cause of bloody diarrhea in the absence of fever
E-coli
203
Bacterial meningitis in age 2-50 y/o | Organism, Tx
Strep pneumoniae, Neisseria meningitis Tx: vanco+ 3rd cephalo + dexa
204
Bacterial meningitis in age >50 y/o | Organism, Tx
Strep pneumoniae, Neisseria meningitis, Listeria Tx: vanco+ 3rd cephalo + ampicillin + dexa
205
Bacterial meningitis in immunocompromised | Organism, Tx
Strep pneumoniae, Neisseria meningitis, Listeria, G-rods Tx: vanco+ cefepime + ampicillin + dexa
206
Bacterial meningitis in neurosurgery/penetrating skull trauma Organism, Tx
G-rods, MRSA, coagulase - staph Tx: vancomycin+ cefepime
207
Alternative to cefepime
Ceftazidime | Meropenem
208
Alternative to ampicillin for listeria
TMP-SMX
209
Dexa in meningitis
For bacterial meningitis Discontinued when pneumococcal meningitis ruled out
210
Features of meningococcal meningitis
``` Sudden onset Rapid progress Petechial/purpuric rash Severe myalgias Shock ```
211
Suspecting meningitis
``` If 2 or more of: Fever Headache Nuchal rigidity Altered mental status ```
212
When to give AB prior to LP in infants with suspicious meningitis?
If: Critically ill ( status epilepticus, hypotension) Immediate LP not possible
213
Tx of bacterial meningitis in infants>1mo
Ceftriaxone (covers meningococ and most strains of pneumococ) + vanco (covers cephalosporin-resistant pneumococ) + Dexa (for HIb)
214
The most common cause of early and late-onset sepsis in neonatal period.
``` GBS (term) E coli (preterm) ```
215
If sepsis in preterm neonate
Entrococcus
216
If sepsis with indwelling IV cath in neonate
Coagulase negative staph
217
Late-onset sepsis in neonates in NICU
Gram negatives
218
Sepsis associated with skin, bone, joint infection
Staph A
219
Evaluation of neonatal sepsis
CBC (neutrophilia with bands>700 or band/total > 0.16) B/C CSF culture Ampicillin+gentamycin
220
AB of choice in bacillary angiomatosis
Oral erythromycin Also: doxy + ART (2-4 w later)
221
CD4 count in bacillary angiomatosis
<100
222
Features of bacillary ang
Fever, fatigue, night sweats | Rarely: liver, bone, CNS involvement
223
Bartonella transmission
Intracellular, gram negative Via cat scratch, flea (hensella) Head lice bite (quintana)
224
Tx of cat scratch disease
Azithromycin
225
Dx of cat-scratch disease
Clinical | +/- serology
226
Blastomycosis features
``` 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
Dx of blastomycosis
Culture (blood, sputum, tissue) Microscopy (body fluids, sputum, tissue) Antigen testing(urine, blood)
228
Tx of blastomycosis
``` 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
Coccidioidomycosis cutaneous manifestations
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
Histoplasmosis
Asymptomatic or mild pulmonary edema If immunocompromised: disseminated disease with papular crusted skin lesions
231
Nocardia
Subacute pneumonia mimicking TB
232
Cellulitis vs erysipelas and external ear involvement
Involvement is suggestive of erysipelas rather than cellulitis
233
Chikungunya fever
``` Mosquito Fever Polyarthralgia Maculopapular rash Myalgia Conjunctivitis Decreased: plt, WBC increased: liver enzymes Tx: supportive Dx: clinical, serology ```
234
Etiology of neonatal conjunctivitis
<24h: chemical 2-5d: gonococcal 5-14d: chlamydial
235
Chemical conjunctivitis
Mild irritation, injection, tearing Due to silver nitrate Tx: eye lubricant
236
Gonococcal conjunctivitis in neonates
Marked eyelid swelling, profuse purulent discharge, corneal edema/ulceration IV/IM ceftriaxone or cefotaxime
237
Chlamydial conjunctivitis in newborn
``` Eyelid swelling Chemosis Watery/bloody/mucopurulent discharge Oral erythromycin Blood stained discharge is highly characteristic ```
238
The AB that increases the risk of pyloric stenosis
Erythromycin
239
The most common organism causing pneumonia in HIV pts
S. Pneumoniae
240
CA-MRSA pneumonia
``` Young people with secondary bacterial pneumonia after influenza. Necrotizing pneumonia. Rapidly progressive and fatal. High fever Productive cough Hemoptysis Leukopenia Multilobar cavitary infiltrates ```
241
The most common complication of influenza
Bacterial pneumonia | Organisms: strep pneumoniae, staph aureus
242
Pneumonia with high fever and prominent gastrointestinal symptoms
Legionella
243
The best method to prevent neonatal chlamydial infection
Screening and treatment of maternal chlamydia
244
Cryptococcal meningoencephalitis
``` 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
Clinical features of cryptococcal meningoencephalitis
``` Headache Fever Supple neck Subacute Can be acute and severe ```
246
JC virus
Progressive multifocal leukoencephalopathy in HIV Dx: PCR of CSF
247
Traveller diarrhea organisms
Most cases: viral, bacterial If prolonged/profuse/watery: cryptospordium, cyclospora, giardia
248
Cryptospordium parvum
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
Cutaneous larva migrans
Hookworm larvae (cat and dog) Human:incidental host. Unable to penetrate cutaneous BM Normal eos Tx: ivermectin
250
The irritant component of poison ivy, poison oak, poison sumac
Urushiol
251
The most common pathogen isolated from sputum in CF
Before 20 y/o: staph aureus | After 20: pseudomonas aeroginosa (contributes to life-threatening decline of pulmonary function)
252
CMV vs EBV
CMV: Mild/absent pharyngitis, LAP, splenomegaly Negative heterophil Ab
253
Odyniphagia/dysphagia DDx in HIV pts
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
Approach to HIV pt with dysphagia/odynophagia
If mild symptoms, oral thrush, treat for candida If severe symptoms, no thrush or no response to above treatment, endoscopy
255
Tissue-invasive CMV disease
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
Diarrhea in HIV pts
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
HIV pt with colitis symptoms and CD4 <50 next step?
Colonoscopy and Bx
258
HIV pt with profuse non bloody diarrhea, next step?
Stool exam for ova and parasites, acid fast stain, clostridium difficile antigen
259
Tx of cryptospordiosis in HIV
Supportive | ART
260
Eggshell calcification of a hepatic cyst on CT
Hydatid cyst
261
Dx of hydatid cyst
Imaging | IgG serology
262
Tx of hydatid cysts
If < 5cm: albendazole | If > 5cm or complex or ruptured: percutaneous treatment, surgery
263
Ehrlichiosis
``` 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
Empiric AB in native valve endocarditis
Vancomycin | Covers staph, sterp, entrococci
265
Pts susceptible to Staph A endocarditis
Prosthetic valves IV cath Implanted devices IDU
266
Strep viridans endocarditis
Gingival manipulation | Respiratory tract incision and biopsy
267
Staph epidermidis endocarditis
Prosthetic valve IV cath Implanted devices
268
Enterococci endocarditis
Nosicomial urinary tract infections
269
Strep bovis endocarditis
Colon cancer | IBD
270
Fungal endocarditis
Immunocompromised IV cath Prolonged AB
271
Strep viridans group
Strep mutans, mitis, oralis, sanguinis
272
The most common valvular abnormalities in patients with infective endocarditis
Mitral Valve prolapse with regurgitation
273
IE in IDU
``` 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
Splenic abscess
``` 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
RFs for splenic abscess
IE, SCA, trauma, HIV, IDU, ImSup
276
If IE with penicillin resistant strep
``` Change vanco to either: IV aqueous penicillin G Or IV ceftriaxone once daily X 4 wk ```
277
Food poisoning with predominant diarrhea
``` Staph A (mayonnaise) Bacillus cereus (starch) Noroviruses (e.g. norwalk) ```
278
Features of disseminated gonococcal infection
Purulent artgritis w/o skin lesions Or Tenosynovitis+ migratory asymmetric polyarthralgia (non purulent) + dermatitis + high fever, chills
279
Dx of disseminated gonococcal infection
Blood culture (mostly negative) Synovial fluid analysis Urethral/cervical/pharyngeal/rectal cultures HIV/Syphilis Terminal complement activity (if recurrent)
280
Exposure to HBV with unknown immunity
HBIG + vaccine
281
Ventillator acquired pneumonia
After 48 h or more of intubation Aerobic gram negatives, gram positive cocci Fever, leukocytosis, purulent discharge, difficulty with ventilator
282
The 1st step in VAP
CXR | If positive findings on CXR: lower respiratory tract sampling for gram and culture + empiric AB
283
Hepatitis C in pregnancy
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
The most common route of HCV transmission
Exposure to infected blood
285
Definition if post herpetic neuralgio
Pain persisting > 4 mo
286
Ways of acquiring immunity agains varicella
Prior infection | Receiving 2 doses of vaccine (usually at 12-15 mo and 4-6 y)
287
Post prophylaxis exposure for varicella in non immune
VZV vaccine. If immunocompromised or pregnant or neonate: VZIG within 10 d If <1 y but older than 1 mo: prophylaxis not required
288
Histoplasmosis
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
Blastomycosis
``` Soil, rotting wood Skin lesions Osteolytic bone lesions Prostate involvement Can disseminate in ImmSup ```
290
Fungal infection with prominent pulmonary, mucocutaneous, reticuloendothelial involvement
Histoplasmosis
291
Diagnostic method of choice for histoplasmosis
Urinary/serum Ag
292
Dx of PCP
Induced sputum sample If negative BAL
293
Disseminated MAC
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
Post-exposure HIV prophylaxis
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
Risk of HIV seroconversion after needle exposure
< 0.5 %
296
Prrimary pophylactic AB for HIV pts
``` CD4 < : 200, TMP-SMX for PCP 100, TMP-SMX for toxo 50, Azithro/clarithro for MAV 150, Itra, histoplasmosis (endemic regions) ```
297
Prophylaxis with fluconazole for candidiasis/cryptococcal disease in HIV
Effective but not recommended
298
Live virus vaccines in HIV
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
Pneumococcal vaccine in HIV
PCV13 After 8w, PPSV23 After 5y, PPSV23 At age 65, PPSV23
300
Preferred HIV screening method
HIV p24 Ag + HIV Abs If positive: Confirm with HIV1/HIV2 ab differentiation immunoassay If negative, but high clinical suspicion: HIV RNA
301
Prenatal management of HIV
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
Intrapartum HIV care
``` 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
Post natal HIV Mx
Maternal: continue HAART Infant: Zidovudine for at least 6 wk + serial HIV PCR
304
Dx of HIV infection in infants
DNA PCR Or Persistence of HIV Ab after 18 mo
305
Hx of genital HSV infection in pregnant woman
Start prophylaxis with acyclovir/valacyclovir at 36 GA
306
Pneumococcal vaccine in adults age > 65
PCV13, then PPSV23 after 6-12 mo
307
Pneumococcal vaccine in adults under 65
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
Indications gor meningococcal vaccine in age > 18y
``` Complement deficiency Asplenia College students in residential housing Military recruits Travel to endemic areas Exposure to community outbreaks ```
309
Regular schedule for meningococcal vaccine
Primary dose at age 11-12 | Booster at age 16-21 (if primary at age <16)
310
The safety of live-attenuated/vaccines in the those receiving tumor necrosis factor antagonist
Should be avoided
311
Duration of contact sport avoidance in infectious mononucleosis
At least 3 weaks
312
Pts with strep pharyngitis are not contagious after?
24 h after initiation of AB
313
EBV heterophil Abs
Arise within one weak Peak: 2-6 wk after infection Remains positive up to 1 year
314
Anemia and thrombocytopenia due to EBV
IgM cold-agglutinin Complement-mediated destruction of RBCs Usually coombs positive 2-3 wk after the onset of symptoms
315
Pharyngitis with complication if dilated CMP
Corynebacterium with pseudomembrane
316
CD4 count in HIV with KS
<200
317
Legionella pneumonia
``` 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
Dx and Tx of entamoeba histolytica
Stool O & P, stool Ag testing (colitis) Serology (liver abscess) Tx: Metro, paromomycin
319
Tx of amoebic liver abscess:
Metro + paromomycin to eradicate luminal organism Drainage: not recommended (unless there is mass effect, imminent risk of rupture, uncertain diagnosis, no improvement)
320
Tx for influenza considered when:
RF for complications (>65, pregnancy, chronic disease...) or pts who come within 48 h of symptom initiation Osrltamivir
321
Ludwig angina Dx, Tx
Dx: CT Tx: IV AB (ampicillin-sulbactam, clinda) Mechanical ventilation if respiratory compromise
322
Lyme carditis Dx
If no classic rash: serology
323
Lyme carditis Tx:
Ceftriaxone IV
324
When does erythema migrans develop?
1-2 wk after tick bite | At least 36h attachment
325
Tx for acute unilateral cervical lymphadenitis
Clindamycin | Staph A, strep pyogen
326
The most common cause of unilateral subacute lymphadenitis
Atypical mycobacterium (avium)
327
Malaria chemoprophylaxis
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
Dengue fever
``` Mosquito Within 4-7 d (never after 2wk) Marked muscle and joint pain Retroorbital pain Rash Leukopenia ```
329
Human African trypanosomiasis
Tsetse fly Acute febrile illness + trypanosomal chancre Myocarditis CNS involvement
330
Measles Tx
Supportive Vit A if deficient or hospitalized (Reduces mortality and morbidity)
331
Measles virus transmission
Airborne precautions: N95 mask for personnel, negative pressure room Vaccine (2 doses) generate immunity in > 95%
332
Tx of rhino-orbito-cerebral mucormycosis
Surgical debridement Liposomal AmB Elimination of risk factors (increased glucose, acidosis)
333
Pts with significant immunecompromise and sinositis, next step?
Sinus endoscopy with culture and biopsy to evaluate for mucormycosis
334
The most common complication of mumps
Aseptic meningitis
335
Orchitis in mumps
Primarily post-pubertal males | Can impair fertility
336
Necrotizing fasciitis Tx
Surgical debridement (most important) Broad spectrum AB Tight glycemic control Hydration
337
Neurocysticercosis Tx
Antiepileptics Albendazole CS
338
Typical presentation of neurocysticercosis in adults
Seizure Less common: increased ICP
339
Nocardiosis
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
The most common form of nokardiosis
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
Aztreonam
Monobactam | Gram negative coverage, pseudomonas
342
Actinomyces
Gram +, filamentous Non acid-fast Anaerobic Tx: penicillin
343
Cavernous sinus thrombosis
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
If suspicion about vertebral osteomyelitis,
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
Tx of infectious diabetic foot ulcer
Piperacillin-tazobactam + vancomycin
346
Increased risk of deep infection in diabetic foot ulcer if:
``` 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
Organisms most responsible for deep infection following puncture wound
Staph A | Pseudomonas (especially through dole of the shoe)
348
The most common organism of osteomyelitis in IDUs
Staph A >> gram -
349
The most reliable sign of spinal osteomyelitis
Tenderness to gentle percussion over the spinous process High index of suspicion for vertebral osteomyelitis if IDU pt or recent distant site infection
350
The most common organism responsible for osteomyelitis in infants and children
Staph A in both Others: Infants: GBS, Ecoli Children: strep pyogen
351
Parvo B19 arthritis
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
Dx of parvovirus infection
B19 IgM in immunocompetent NAAT in immunocompromised If reactivation of previous infection: NAAT to detect DNA
353
Acute mucopurulent cervical discharge with friable cervix is the classic presentation of:
acute cervicitis which is most commonly due to (Chlamydia & Gonorrhea) Empiric treatment: ceftriaxone + azithro NAAT proven chlamydia: azithro NAAT proven gonorrhea: ceftriaxone + azithro
354
Tx of pertussis
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
Dx of pertussis
clinical, but also: Culture PCR Lymphocyte-predominant leukocytosis
356
Post-exposure prophylaxis for pertussis
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
Pertussis vaccine in US
``` 5 doses during childhood 1 dose in adolescence 1 dose in adulthood 1 dose with every pregnancy Macrolide with each close exposure ```
358
Tx of entrobiosis
Albendazole Or Pyrantel pamoate (preferred if pregnant) for pts and all household contacts
359
First line for treatment if strogyloides stercoralis
Ivermectin
360
Tx of chagas
Benznidazole
361
Tx of PCP
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
PCP clinical features
In setting of HIV: indolent | Other immune-suppression settings: fulminant
363
Dx of PCP
Induced sputum with specialized stain | If unrevealing, BAL
364
Pneumonia with increased LDH
PCP
365
Infection prophylaxis in transplant pts
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
Pneumonia with hypoxia out of proportion to CXR findings
PCP
367
Healthcare workers, exposed to blood from a suspected or unknown hepatitis B pt, next step?
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
Post-operative fever | Immediate
``` 0-2h Blood products Inflammation due to surgery Malignant hyperthermia Prior trauma/infection ```
369
Post-operative fever | acute
24h-1wk Nosocomial infections SSI (GAS, clostridium perfringens) MI, PE, DVT
370
Post-operative fever | Subacute
``` 1wk-1mo SSI (organisms other than GAS/clostridium) Cath site infection Clostridium difficile Drug fever PE/DVT ```
371
Post-operative fever | Delayed
>1mo Viral infections (due to blood products), infective endocarditis SSI
372
Post operative fever definition
>38 C (100.4 F)
373
Progressive multifocal leukoencephalopathy
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
HIV dementia
Affects deep gray matter structures Subacute Cognitive, behavioral, motor deficit Imaging: cerebral atrophy, enlarged ventricles
375
Rabies following direct exposure to bats (uncertain of bite)
Receive rabies prophylaxis
376
Tx of croup
Mild (no respiratory stridor at rest): dexa | Mod-sev (respiratory distress, stridor at rest): dexa+ nebulized epinephrine
377
Retropharyngeal abscess
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
Tx of Acute Rheumatic Fever
Benzathine penicillin G CS for chorea NSAIDs for pericarditis, arthritis
379
The most common organism responsible for pericarditis/myocarditis
Coxsackievirus
380
Congenital rubella
SNHL Leukocoria from cataracts, glaucoma PDA
381
Congenital toxo
Chorioretinitis Hydrocephalus Diffuse intracranial calcifications
382
Congenital CMV
Chorioretinitis | Periventricular calcifications
383
Congenital varicella
Limb hypoplasia Cataract Skin scarring
384
Congenital syphilis
``` Hepatomegaly Snuffles (nasal discharge) osteoarticular distruction Maculopapular rash SNHL as a late sequela ```
385
Transplacental HSV infection
Brain destruction Seizures Vesicular rash
386
Pristhetic joint infection organisms
<3mo: Staph A, Gram - rods, anaerobic >3mo: Staph epidermidis, propionibacterium species, enterococci
387
The most common organism is SCA osteomyelitis
Salmonella
388
The most common cause of sepsis in SCA
S pneumoniae (despite vaccination)
389
Sporotrichosis Dx and Tx
Dx: culture of aspirated fluid, Biopsy Tx: oral itra 3-6 mo
390
Primary syphilis tests
Non-treponemal (higher false negative) | Treponemal (higher sensitivity, esp:FRA-ABS)
391
Neurosyphilis and penicillin sensitivity
Desensitize Also for ocular, pregnancy, multiple failures with non-penicillins
392
How to make sure of syphilis treatment
RPR at the time of diagnosis and 6-12 mo later (a 4fold decrease required)
393
Secondary syphilis rash starts on:
Trunk and spreads to extremities
394
Features common to all TORCH agents
IUGR HSM Jaundice Blueberry muffin spots
395
Jarisch-herxheimer reaction
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
Neonatal tetanus
``` 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
Tx of toxo in HIV
Sufadiazine+Prymethamine+leucovorin
398
Pts with hepatitis B to treat
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
Tx for hepatitis B
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
Purpose of treating chronic HBV infection
Prevent complications Decrease transmission to others Reduce progression to chronic liver disease

Med (25 decks)

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