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251 Cards in this Set
- Front
- Back
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Drug Abuse has multiple definitions. What characteristics are common hallmarks of drug abuse?
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() drug is used in excess and for non-medical purposes
() abusers may display drug seeking behavior () drugs abused have CNS effects |
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Is it necessary to have a pre-existing emotional or psychiatric problem to become drug dependent?
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No
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Cross-dependence and Cross-tolerance usually exist btw drugs in the same class but not different classes, what is the exception to this rule?
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Sedative hypnotics <--> volatile intoxicants
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What is the general mechanism for opioid action?
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Opioids bind the mu receptors that selectively exist on GABAergic neurons, inhibiting the release of GABA --> disinhibition of DA. This stimulates the reward center in the nucleus accumbens and VTA.
These mu receptors are part of a GPCR complex. |
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Which class of drugs of abuse has the most severe withdrawal, however not life threatening?
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Opioids/Narcotics
- no convulsions - no delirium - no disorientation |
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This drug is used to treat opioid overdose but is not used for detoxification?
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Naloxone
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Naltrexone vs Methadone for opioid detoxification
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Naltrexone - causes early, severe, but short withdrawal sxs
Methadone - causes late, prolonged, but moderate withdrawal sxs |
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Where is the main difference btw cocaine and amphetamines?
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In the pharmacokinetics - cocaine has a shorter half-life
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Although cocaine is a CNS stimulant, it has what effect in the brain?
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decreased glucose metabolism
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What is significant about low dose vs high dose administration of nicotine?
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Low dose - stimulates nicotinic a4b2 receptors
High dose - blocks nicotinic a4b2 receptors |
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What are the 2 main pathways for THC action?
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() inhibits adenylate cyclase --> decreased cAMP [metabotropic]
() inhibits N type Ca channels [ionotropic] |
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An absence of physiological dependence but psychological addiction is seen with use of these substances
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Solvents/Inhalants
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These are in some aerosol propellants and cleaning solutions and are known to cause cardiac arrest
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Halogenated hydrocarbons
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Most common cause of CAP
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streptococcus pneumoniae
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Most common causes of HAP
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gram (-) bacilli and staph aureus
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Mycoplasma pneumoniae is common in...
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young ppl
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Presents with sub-acute to chronic pneumonia
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mycobacterium tuberculosis
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Causes Q fever that manifests as pneumonia
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Coxiella burnetti
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Causes Rocky Mt Spotted Fever which presents with HA, bacterial vasculitis, and pneumonia
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Rickettsia rickettsiae
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This virus is known to cause pneumonia and may be obtained by inhalation from rodent urine or feces
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Hantavirus
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Causes PCP in HIV pts with a CD4 < 200
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Pneumocystis jirovecii
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A common cause of CAP, this organism is not visible via gram stain, generates a (+) cold agglutinin test, and displays IgM/IgG specific Ab by EIA. Its presentation is also often accompanied by other signs and sxs, including hemolytic anemia.
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Mycoplasma pneumoniae
Tx w/ Azythromycin, Erythromycin, or Doxycycline |
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Bronchial breath sounds suggest
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consolidation - equal on inspiration and expiration
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HAP most often caused by:
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() gram - rods
-enterobacter, P aeruginosa, Klebsiella () staph aureus |
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What is the predominant flora of the normal oropharynx that may cause aspiration pneumonia and what is used to treat it?
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oral anaerobes tx w/ clindamycin
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When diagnosing CAP and awaiting the culture and sensitivity results, what should you administer as an empirical tx against possible resistant or atypical pneumonia?
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vancomycin for resistant staph aureus as well as a macrolide (azithromycin, erythromycin, clarithromycin) for atypical causes
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What are the most common bacterial causes of pneumonia secondary to an influenza infection?
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() strep pneumoniae
() staph aureus () haemophilus influenza |
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High dose steroids greatly increase risk of which types of pneumonia?
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() Legionnaire's disease
() mycobacterial () nocardia |
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Ceftriaxone is prescribed to cover:
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H flu and M cat
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What test can be done to rapidly diagnose Legionella?
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Legionella urinary Ag test
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Tuberculated macroconidia and microconidia are used to for diagnosis of what fungal infection?
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Histoplasmosis
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What findings would you expect on the CXR of a pt w/ histoplasmosis?
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coin lesions
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Histoplasmosis is a pathology that primarily infects the macrophages. What virulence mechanism protects the organism from being broken down?
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H capsulatum prevents the formation of phagolysosomes, allowing the macrophages to serve as an indolent host.
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What are the 2 tests for histoplasmosis and which is better?
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() serology measures CF (complement fixation) which detects humoral immunity which is non-protective. humoral immunity decreases in pts who have a strong, protective cellular immunity.
() Exoantigen is also used via a urine sample sent to RIA. This test is preferred and indicates a primary vs secondary histoplasmosis. If exoantigen remains high then the prognosis is grave. |
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What is the tx for histoplasmosis?
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Primary = nothing
Secondary = Lip AmpB --> intraconazole |
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A dermatologist refers a pt to you who has what looks to be a disseminated cutaneous lesion. What is it likely to be?
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Blastomyces dermatitidis
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Of the dimorphic mycoses, which one is the most viscerally oriented?
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Paracoccidioidomycoses - found in S. America
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This fungus is not dimorphic and disseminates into the CNS via hematogenous spread
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Cryptococcus neoformans
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AIDS pts are particularly susceptible to opportunistic fungal infections. What fungal infections are indicative in this pt population?
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() pneumocystis
() candida () cryptococcus () ~histoplasmosis AIDS pts are prophylactically tx w/ fluconazole to help with this |
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2 organisms capable of slow onset meningitis that will be required in a w/u are
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TB and Cryptococcus
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Aside from an India Ink stain, what is another test used for the diagnosis of cryptococcal meningitis?
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Latex Cryptococcal Ag Test (LCAT) - detects glucuronoxylomannan
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How does pneumocystis jirovecii cause severe hypoxemia --> death in AIDS pts?
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P jirovecii initiates a cascade of events that triggers cytokine dysregulation --> accumulation of excessive, dysfunctional pulmonary surfactant in the alveoli
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Used to tx PCP
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TMP-SMX
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Schizophrenia exhibits 3 different levels of sxs. What is the order for ease of tx of these?
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positive --> negative --> cognitive
(easiest --> hardest sxs to tx) |
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The 2nd generation antipsychotics are more effective than 1st generation on both negative and cognitive sxs. They also minimize acute extrapyramidal side effects (EPSs). What are the early onset and late onset EPSs?
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Early onset:
Acute dystonia Parkinsonism Akathisia - inability to sit still, restlessness Late onset: Perioral tremor - 'Rabbit Syndrome' Tardive dyskinesia - involuntary movement of mouth, tongue, ~limbs |
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Neuroleptic malignant syndrome is a life threatening condition associated with antipsychotic pharmacotherapy (more often with high potency). What are the sxs and tx for this adverse effect?
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Sxs: catatonia, stupor, fever, unstable BP, myoglobinemia
Tx: dantrolene or bromocriptine |
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This class of drugs may cause metabolic syndrome?
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2nd gen antipsychotics (atypical antipsychotics)
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Agranulocytosis is a life-threatening condition associated with this drug and should not be given to those with blood dyscrasias
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Clozapine
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This is a 2nd gen antipsychotic that may be used in mixed disorders (bipolar, depression,..) but is also known to cause QT elongation, a reason for using caution when giving to those with cardiac disease
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Ziprasidone
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A 2nd gen antipsychotic that may also be used for tx of acute manic episodes but has been found to cause a higher incidence of akathisia
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Aripiprazole
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What is the best medium to test for drugs of abuse?
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Urine is the better sample as drugs are metabolized and removed quickly from the blood
*exception = EtOH, which is better measured in the blood |
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What tools are used to test for drugs?
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() Immunoassays - for screening
drug-enzyme Ab conjugate is inactive (no NADH produced) unless free drug is present to compete with Ab binding () GC-MS - for confirmation |
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Federal guidelines (NIDA) mandate testing for 5 classes of drugs, what are they?
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Amphetamines
Cannabinoids Cocaine Opiates Phencyclidine (PCP) |
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What immune cells are indicated in asthma?
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() TH2 lymphocytes, mast cells (IgE mediated), respiratory macrophages, and eosinophils
() Neutrophils may be seen in severe asthma |
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Common respiratory sx triad seen in asthma
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cough, wheezing, dyspnea
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What are the risk factors that predispose children and young adults to dust mites?
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() high humiditiy
() moderate temperatures () food source (human skin scales) () energy efficient housing |
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A broncho-provocation study is used to dx the presence of asthma in those w/ normal peak flows, spirometry, but typical sxs of asthma. What are criteria for this test and what other conditions may exhibit a (+) test?
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() dx of asthma if 20% drop in FEV1 w/ std doses of Histamine or Methacholine (methacholine challenge test)
() (+) tests may also be seen in those with CHF, smokers, and allergic rhinitis, among other conditions |
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What immune cells are indicated in COPD?
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() Neutrophils macrophages, TH1 lymphocytes
() TNFa and IL8 are impt cytokines in COPD that cause structural damage alongwith recruiting more neutrophils |
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Oxidative stress and the imbalance of proteinases vs anti-proteinases in the lung are 2 impt mechanisms of
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COPD
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What virulence factors does TB have?
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() complex cell wall - resists phagocytosis, disinfectants, drying, abx
() is IC - hides from humoral immune response () siderophores - iron acquisition () resistance to many abx - through chr mutations and genes for resistance () inhibition of phagosome-lysosome fusion () RD1 --> ESAT6/CFP10 - may prevent phagosome-lysosome fusion. *a potential vaccine candidate |
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Caseous lesions formed in response to TB are known as
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Ghon complexes
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Signs and sxs of an active TB infection include
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() Fever
() Weight Loss () Night sweats () Cough () Bloody sputum () Fatigue () Decreased appetite () Abnormal CXR |
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Miliary and extra-pulmonary tuberculosis is better known as ____ and has a poor prognosis
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Disseminated tuberculosis, may see:
renal necrosis and scarring damage to reproductive organs degeneration of spine meningitis |
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Dx of ACTIVE TB requires more testing than that for LATENT TB. What tests are run to dx ACTIVE TB?
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1) TST
2) CXR 3) 3 lavage/sputum samples over 3 consecutive days then either acid fast stain or a fluorescent dye 4) cultivation of bacteria using fluorometric detection --> isolation of bacteria --> drug susceptibility Altogether takes ~2wks to get a definitive dx |
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When is a 5mm induration following a PPD TST considered (+)?
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() HIV infected persons
() Those w/ close contacts to an infectious TB case () Persons w/ chest radiographs consistent w/ prior untreated TB () Organ transplant recipients () Other immunosuppressed pts (on corticosteroids or TNFa antagonists) |
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When is a 10mm induration following a PPD TST considered (+)?
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() Persons w/ clinical conditions placing them at high risk
() Children < 4yo, and adolescents exposed to adults at high risk |
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When is a 15mm induration following a PPD TST considered (+)?
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() Persons w/ no known risk factors for TB
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Skin tests are used to assess what type of immunity?
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() Cell-mediated immunity
the result of a Type IV Delayed Hypersensitivity response (Ag specific T cells) |
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Does an (+) PPD TST mean that person has an active infection?
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No - just that you have had a primary infection w/in the last year
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Before drug sensitivity is known, what 4 drugs are administered for an active TB infection?
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RIPE
Rifampin, Isoniazid, Pyrazinamide, Ethambutol |
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Active against IC (macrophages) TB
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INH, RIF + PZA, quinolones
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Active against EC (rapidly dividing) TB
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INH, RIF + ~ETH, streptomycin, quinolones
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Active against lg populations of tubercle bacilli in cavities
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INH, RIF + Ethambutol
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Only those individuals w/ TB in their ____ are contagious
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lungs
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This anti-TB drug is bactericidal via inhibition of synthesis of mycolic acids and is the primary tx for preventive therapy
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Isoniazid
Side Fx: hepatotoxic, neurotoxic (co-administer pyridoxine), CNS toxicity |
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This anti-TB drug is bactericidal against actively dividing organisms AND IC slowly dividing bacilli but has many drug reactions
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Rifampin
Side Fx: hepatotoxic, turns secretions red-orange, many drug interactions (oral contraceptives, HIV drugs, warfarin...) |
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This anti-TB drug may shorten the tx course to 6mo in conjuction with INH and RIF
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Pyrazinamide
Side Fx: hepatotoxic, increased uric acid concentrations (may precipitate gout) |
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This is the only injectable (IM) of the first line drugs for TB
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Streptomycin - an AG
Side Fx: vestibular and auditory toxicity, nephrotoxicity |
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This anti-TB drug is bacteriostatic and is known to cause ocular toxicity/optic neuritis
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Ethambutol
Side Fx: ocular toxicity/optic neuritis, increased uric acid concentrations (may precipitate gout) |
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What resistances do MDR-TB and XDR-TB have?
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MDR = INH and RIF
XDR = INH, RIF, quinolones, plus injectable drugs |
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Are cavitary TB lesions more or less contagious?
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More
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When should you place a pt in airborne isolation?
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when you suspect pulmonary TB
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Who will more easily become intoxicated, women or men, and why?
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Women - they have a higher peak concentration b/c of a lower TBW and gastric ADH
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What is the Mellanby Effect?
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It says that the effects of EtOH are greater during the rising compared to the falling limb of the BAC curve. This is b/c of the concentration is higher in the arterial side until a steady state is reached.
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Which enzyme is responsible for the rate limiting step in ethanol metabolism?
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ADH
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This metabolic condition is sometimes misdiagnosed as acute EtOH intoxication
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diabetic coma
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What is infused in tx of methanol poisoning?
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() sodium bicarbonate
() large doses of EtOH - if signs of toxicity then too late |
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Ethanol abuse can result in delirium tremens. What are the characteristics of this disorder?
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() insomnia, REM rebound, sweating, agitation
() delirium, hallucinations, convulsions/seizures () disorientation, paranoid delusions, cv collapse () risk of death |
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What is typically used to tx EtOH w/drawal?
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benzodiazepines
not prescribed more than 2wks or administered for more than 3 nights/wk |
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These 2 drugs are used for tx of alcoholism
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Disulfiram (ALDHI) and Naltrexone (opioid antagonist)
Acamprosate has also been approved (decreases glutamatergic transmission and modulates hyperexcitability during w/drawal) |
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What is the most frequent form of extrapulmonary TB?
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cervical lymphadenitis - scrofula
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TB can spread hematogenously. What route makes a systemic spread capable?
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spread via pulmonary vein can lead to TB in: bone marrow, spleen, fallopian tubes, adrenals (Addison's), epididymis, kidneys
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Pulmonary lesions of secondary TB are almost invariably found
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in the apical region of the upper lobe
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Mycobacterium Avian Complex (MAC) is similar to TB but is very uncommon. What pt population is it frequently seen in and how does it get there?
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Seen in AIDS pts w/ CD4 lymphocytes <60.
Best portal of entry is the GI tract then respiratory. |
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Leprosy, caused by M Leprae, infects what tissues?
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skin and peripheral nerves
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The more severe form of leprosy
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Lepromatous Leprosy - defective T cell response and a failure to make granulomas
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The most common reason for antibiotic tx in children
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otitis media
usually caused by: s pneumo, h flu, m cat tx: abx < 2yrs < wait and see |
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What are the diagnostic signs of sinusitis?
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() > 14d w/ URI sxs (facial pain, cough, nasal congestion)
() Water's view on xray () CT scan |
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Which phase of pertussis is most contagious?
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Catarrhal
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Elevated WBCs w/ lymphocytosis and a frequent 'whooping' cough suggest
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Pertussis
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The most common clinical illness
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Streptococcal pharyngitis
- diagnosed via Rapid Ag Swab - caused by GAS |
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What are the 3 most common causes of fever + abdominal pain + vomiting?
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() viral gastroenteritis
() pneumonia () GAS tonsillitis/pharyngitis |
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What are the non-suppurative complications complications of streptococcal pharyngitis?
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() Rheumatic fever
() Acute glomerulonephritis |
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Pastia lines are pathognomonic for
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Scarlet Fever
- associated w/ streptococcal pharyngitis and s aureus - exanthum produces erythrogenic toxin - accentuation of rash at skin folds |
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Impetigo
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yellow crusts caused by GAS or S aureus that are highly contagious but benign
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Rheumatic fever is a non-suppurative complication of GAS caused by an immunologic rxn by cross-reactive antigens. How is it treated?
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() PO/IM Pen G for 10d
- ASA for arthritis and chorea - Corticosteroids + ASA for carditis |
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What is most responsible for an increase in infectious disease mortality in the past 2 decades?
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Antimicrobial resistance
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Antibiotic vs Antimicrobial
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Antibiotic = a product of nature
Antimicrobial = a synthetically altered antibiotic |
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What 2 factors are principally described to be the reason for the development of antimicrobial resistance?
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() Prevalence of resistance genes - the antibiotic existed in nature so there must be an organism resistant to it out there
() Extent of abx use - with excessive use, we have selected for the resistance gene |
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Where, in the hospital setting, are the antimicrobial resistance rates highest?
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ICU
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What are the 4 fundamental mechanisms for how antimicrobial resistance develops?
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() Stop entry of the drug (b-lactams, pseudomonas)
() Efflux pumps (tetracyclines, quinolones) () Destroy drug (b-lactamases) () Modify drug target (VRE) Microbes may utilize any number or combination of these |
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Highlighted control strategies against antimicrobial resistance
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() selective removal, control, or restriction of antimicrobial agents or classes that are more likely to become refractory
() rotation of antimicrobial agents () use of combination therapy |
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Sepsis
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a systemic inflammatory response syndrome as a consequence of an infectious process, with low BP
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What 2 organisms, with no effective abx, are commonly seen in the nosocomial setting?
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Pseudomonas and Acinitobacter
- both are gram (-) bacilli |
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A patient has diarrhea, an elevated WBC, but is afebrile. What organism should you think of first?
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C difficile
- tx w/ vancomycin (PO) |
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Central venous catheters can be placed in multiple locations but come with different risks for infection. What is the order, highest to lowest, for the risk associated with a central venous catheter?
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Femoral > jugular > subclavian
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Markers of severe antimicrobial 'pressure'
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Fungemia and VRE line sepsis
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Lack of the transcription factor T-bet is thought to possibly be a player in the mechanism for atopy in asthamatics. What is T-bet's fxn?
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T-bet is a T cell transcription factor required for Th1 cell production of IFN-gamma, an inhibitor of Th2. Without this inhibition Th2 cells may become active, producing an allergic inflammation - one of the mechanisms for atopy.
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An asthmatic response has both immediate and late phase reactions. What are the characteristics of each?
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Immediate - initiated by the cross-linking of IgE on mast cells, leading to the release and formation of inflammatory mediators, cytokines, and chemokines, causing increased vascular permeability and edema, smooth muscle contraction, and mucous production.
Late phase - mainly involving basophils, neutrophils, and eosinophils, causing an inflamed response which may damage the airway |
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Chronic changes in asthma
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() increased mucus secretion and goblet cell hyperplasia
() thickening of the BM and subepithelial fibrosis () hypertrophy/hyperplasia of bronchial smooth muscle () eosinophilic and lymphocytic inflammation |
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What is the mechanism behind Aspirin-Induced Asthma?
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Aspirin blocks COX and shunts Arachidonic Acid down the LOX pathway, generating more leukotrienes that may act in bronchoconstriction --> the induction of asthma
ASA-sensitive ppl often have nasal polyps and sinus disease alongwith their asthma |
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What 3 points should be determined to establish the dx of asthma?
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() episodic sxs of airflow obstruction or airway hyperresponsiveness
() airflow obstruction that is at least partially reversible () exclusion of alternative diagnoses |
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Name 2 markers used to assess airway inflammation?
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Exhaled Gas - nitric oxide
Expectorated sputum - cells or soluble contents |
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What unique structures may be seen in an asthmatic sputum sample?
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() Charcot-Leyden Crystals - needle-like eosinophilic crystals
() Creola Body - clusters of desquamated columnar epithelial cells () Curschmann's Spirals - basophilic mucus plugs |
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Associated with an increase in deaths in asthmatics when not paired with an ICS
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LABA
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Theory on the MoA of methyl xanthines: theophylline and aminophylline
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increase histone deacetylase activity which allows winding of the DNA around the histone --> decreased cytokine gene transcription
narrow margin of safety and may cause arrhythmias as well as seizures |
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An anticholinergic drug used to block muscarinic receptors in asthma
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Ipratropium
- blocks bronchoconstriction (M3) and mucus secretion (M1) - may cause dry mouth and cough but has little CNS effect |
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What drugs are administered for status asthmaticus?
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Oral or IV glucocorticoids : hydrocortisone, prednisone, prednisolone, methylprednisolone
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What are the 2 mechanisms by which glucocorticoids are thought to act in inhibiting airway inflammation in asthmatics?
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() prevents cytokine synthesis by increasing histone deacetylase
() prevents down-regulation of beta receptors (thought to be decreased in asthmatic airways) |
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These drugs fxn by stabilizing mast cells
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Cromolyn sodium and nedocromil
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What drugs should be used with caution in patients with Churg-Strauss syndrome?
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Zafir and Monte lukast and Zileuton
- these drugs are often used to reduce pt dependence on steroids, however, the steroids inhibit the sxs of Churg Strauss syndrome, so when taken off steroids, these sxs may be seen (necrotizing vasculitis, rash, eosinophilia, heart failure) |
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Blocks formation of both LTB4 (chemoattractant/proinflammatory) AND LTC4/LTD4/LTE4(bronchoconstrictors)
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Zileuton - LOX inhibitor
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IgE inhibitor
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omalizumab
- used if SABA/LABA and ICS tx is refractory due to expense |
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What is the role of eosinophils in late and chronic phase asthma?
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Eosinophils granules release toxic materials that damage to the bronchial epithelial cells --> desquamation and the presence of Creola bodies in sputum (think that eosinophils are routinely known to attack parasites, doing so by causing damage to them)
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Bronchoconstriction in both the Early and Late phase rxns of asthma, is tx with
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SABA
* tx of Early phase rxn w/ a SABA does NOT halt the progression to Late phase |
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What is the effect of administering ICS (glucocorticoid) during the Early phase rxn of asthma?
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Since glucocorticoids fxn by inhibiting gene transcription, their effects take time to develop. Administration during the Early phase will not have an effect on the associated bronchoconstriction, but will attenuate the Late phase.
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Therapy used to prevent onset of early phase, thus inhibiting the late phase rxn in asthma
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chronic use of glucocorticoids
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What sxs are associated with each phase of asthma?
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Early = bronchoconstriction (via histamine) and chemotaxis (via LTB)
Late = bronchoconstriction, submucosal edema, and airway hyperreactivity Chronic = epithelial cell damage, airway hyperreactivity, mucus hypersecretion |
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Neurogenic inflammation occurs in asthma and is not caused by inflammatory cells. In this case, what are the effects of the neurogenic inflammatory response?
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() Cholinergic - reflex bronchoconstriction
() Sensory nerves - increased vascular permeability, mucus secretion, and bronchoconstriction |
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Causes of ineffective cough:
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() Unconscious due to EtOH, drugs, or anasthesia
() Alteration in cough mechanics (muscles, nerves, ribs) () Thick mucous (rheology) () Immotile cilia |
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What is the differentiation btw Acute and Chronic cough?
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Acute < 3wks
3wks < Chronic < 8wks |
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When is the cough of chronic bronchitis most frequent?
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in the morning
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Top 3 causes of Chronic Cough:
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1) Post Nasal Drip (a product of sinusitis, allergic rhinitis)
2) Asthma 3) GERD |
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Failure of the respiratory system to provide adequate gas exchange to meet body's demand
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dyspnea
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Conditions in the CNS that stimulate increased breathing:
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acidosis, toxins, hypoxemia, hypercapnia, CVA, drugs (aspirin - causes metabolic acidosis)
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Most common non-pulmonary causes of dyspnea
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() Sepsis
() Hepatic failure () Intra-abdominal pathology () De-conditioning () Anxiety () Drugs: salicylate |
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Most common pulmonary causes of dyspnea
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() Airway obstruction or Bronchospasm - asthma, COPD, emphysema
() Parenchyma - pneumonia, pneumothorax, atelectasis, pleural effusion () Pulmonary edema, ARDS, Pulmonary hemorrhage () Chest trauma () Aspiration () Pulmonary embolism, Pulmonary HTN () Chest wall: trauma, weakness, pain () Diaphragm: ascites, weakness or paralysis () Neuromuscular disorders: myasthenia, GBS () Inhalation of toxic or irritant chemicals () Lung cancer |
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Causes of Acute dyspnea
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bronchospasm, pulmonary infection or embolism, airway obstruction, heart failure
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Causes of Chronic dyspnea
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COPD, interstitial lung disease, occupational exposure (dust common in WV)
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Platypnea
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Shortness of breath that is relieved when lying down (contrary to COPD)
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Dyspnea occurring only at night, roughly 2-4hrs after lying down. Of cardiac origin.
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Paroxysmal Nocturnal Dyspnea
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Dyspnea precipitated by lying down. Of cardiac origin.
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Orthopnea
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Which direction do you expect a tracheal shift with the following: pneumothorax, collapsed lung, pleural effusion
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Pneumothorax and pleural effusion = shift to opposite side, may be either hyperressonant or dull respectively
Collapsed lung = shift to same side, may be dull to percussion |
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Subcutaneous air located at the suprasternal notch or neck suggests
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mediastinal air leak
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What are the 3 requirements for an airborne isolation room?
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() Negative pressure
() At least 6 air changes per hour () Air that does not recirculate |
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Although you rightfully sent a pt with chicken pox (varicella zoster) into both contact and airborne isolation, what still may pose a problem?
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The transmission period for varicella zoster starts 1-2d before the rash appears and is highly contagious if not immune.
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4 most common sites of healthcare associated infections
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() Urinary tract* - the most common
() Blood stream () Lower respiratory tract (VAP) - leading cause of death () Surgical sites |
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Sterilization vs Disinfection
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Sterilization eliminates all microbial life + spore
Disinfection only eliminates microbial life |
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In limiting hospital acquired infection, is shaving better or worse in order to prevent infection?
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worse
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Expectorants act by
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hydrating the mucus making it easier to expel
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These 2 drugs stimulate the secretion of ions and water as well as help to initiate the cough reflex
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Guaifenesin and Guaiacolsulfonate
- expectorants - excessive doses may cause drug metabolite kidney stones |
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Most common lethal genetic disorder in the caucasian population
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Cystic Fibrosis - autosomal recessive
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A child comes in for a well child visit and you notice a nasal polyp. What test is a must to rule out CF?
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sweat test
< 40 mmol/l normal > 60 mmol/l diagnostic |
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In what condition is the lovibond angle greater than 180 degrees?
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In clubbed fingers - may be a sign of CF
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Common organisms causing respiratory infections in CF pts
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() P aeruginosa, S. aureus, H. influenza, S. maltophilia, B. cepacia, and MRSA.
() Over time, the percent of patients colonized with Pseudomonas dramatically increases. |
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The 2 types of pseudomonas infection
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Mucoidy vs Biofilm (may produce alginate)
- when pseudomonas becomes mucoid, there is no longer any chance at clearing the infection |
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What is the mainstay tx for CF?
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() Nutrition w/ a high fat, high calorie diet
() Fat-soluble vitamins () Pancreatic enzyme replacement (NO generics) |
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Dermatophytes can be transmitted by a number of means: from others (anthro), animals (zoo), or soil (geo). What method of transmission causes the lowest inflammatory response?
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anthropophilic
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Onychomycosis
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a tinea infection involving the whole finger/toenail - requires systemic tx
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Primary tx for Candida albicans, the most common fungal infection
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() fluconazole
- need to distinguish btw C albicans and non-C albicans. tx non-C albicans with caspofungin (resistant to fluconazole) |
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You see an older pt being treated with steroids for a hip replacement who now complains of headaches and confusion, disabling her from feeding the pigeons in the park. The CSF is loaded with WBCs (lymphocytes). What is your presumed dx, test, and tx?
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Cryptococcal meningitis in an immunocompromised pt exposed to pigeon feces
- Do an India Ink stain and LCAT - tx with amp B and send home with fluconazole |
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A pt presents with an asthma-like bronchopulmonary syndrome. CXR reveals a mycetoma, a ball of filamentous fungus as well as an "air crescent sign". What is your assumed dx and tx?
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Aspergillosis infection that was transmitted via inhalation and caused a dysfxnal host immune response in the lungs.
Tx w/ steroids (do not tx w/ antifungals) |
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A diabetic pt you've been seeing for years is very worried about a gross, necrotic lesion on his cheek. He is very concerned about it spreading to his eye and seeks your advice. What is the assumed dx and tx?
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Zygomycosis (aka mucormycosis, rhizomucor, rhizopus) infection.
Needs aggressive surgery and possible removal of eye if infected b/c antimicrobials can't penetrate necrotic tissue. |
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After a spelunking trip, a pt of yours comes down with a flu-like pulmonary illness, arthralgia, and what you decide to be erythema nodosum. What test are you going to run in order to curb your dx suspicions? Also, would you give this man corticosteroids for his arthralgia?
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Run a Urine Histoplasma Ag test
- do not treat with steroids as immunocompromised individuals are at risk for disseminated disease |
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Used to tx the dimorphic fungal infections?
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intraconazole
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Although less common, this Enterococci sp is usually the one that is VR.
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E faecium is less common than E faecalis but more often VRE
- is so b/c it encodes for VanA/B/C genes which change D-Ala-D-Ala --> D-Ala-D-Lac, making vancomycin bind ineffectively - Abx used to tx: synercid, linezolid, daptomycin, tigecycline |
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What is the mechanism for MR in staphylococci (MRSE, MRSA)?
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These resistant strains have a mecA gene --> altered PBP (2' or 2a) which has little affinity for b-lactams
- Abx used to tx: vancomycin - community MRSA strains are different and tx w/ PO abx |
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Vancomycin Resistant Staph Aureus comes in 2 different flavors: fully resistant (VRSA) or heteroresistant (VISA/GISA). Which is more common?
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VISA/GISA is more common - has a thicker cell wall and vancomycin can't penetrate into the cell.
VRSA is very rare - has a VanA gene for resistance (changes D-Ala terminus) |
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Penicillin Resistant S Pneumo can be overcome by
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giving larger doses of penicillin
- these resistant organisms simply have an altered PBP, decreasing the affinity for penicillin |
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This newer antibiotic agent can cause Serotonin syndrome if used with SSRIs or Meperidine
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Linezolid - is a weak, rev MAOI
- also may cause blood dyscrasias, lactic acidosis, and peripheral neuropathies |
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Features nearly always present in SARS:
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Fever and Cough (non-productive)
Uncommon: coryza, sore throat |
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Dx of SARS
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() Acute and Convalescent serum Ab titers
() PCR () Viral cultures () Exclude other causes of atypical pneumonia |
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Mgmt of SARS:
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() supportive care
() strict isolation* |
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The 4 types of strabismus
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Exotropia - out
Esotropia - in, *most common form, aka cross eyes Hypertropia Hypotropia |
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Corectopia
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pertaining to abnormal shape/position of pupil
- coloboma is a type of corectopia, referring to a keyhole-shaped pupil. in this case the inside of the eye also needs examination |
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Anisocoria
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pertaining to an abnormally sized pupil
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Visual Development milestones:
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Birth - blink reflex
1mo - fixates on faces 2-3mo - follows objects of interest 4mo - intermittent eye crossing stops 5-6mo - visually directed grasp 9-10mo - attentive to distant objects (10-20ft) 1-2yrs - points to pictures in a book 2-3yrs - identifies shapes 3+yrs - adult-like visual acuity and color vision |
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Visual acuity in infants is measured using
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Teller acuity cards - have a square of lines of varying thickness
Lea Symbol chart - objects the child is able to interpret |
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Amblyopia
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is a problem of the developing visual cortex as a result of an abnormal eye(s), most commonly strabismus
*most impt disease that must be recognized by a pediatric opthalmologist - tx with glasses, tightening eye muscles, and/or a patch over the GOOD eye, allowing the visual cortex to 'catch up' (only works up to age 8/9) |
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Anisometropia
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unequal focusing btw the two eyes
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The Hirschberg test is otherwise known as the
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Corneal Light Reflex Test
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Tests used to assess ocular alignment
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Corneal Light Reflex Test
Cover testing Prism testing |
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Innervation of extraocular muscles
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LR6 SO4 AO3
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The more common name of the Bruckner Test
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Red Reflex Test
- view both eyes simultaneously at arms length - cataract will block red reflex from the retina |
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Most common PREVENTABLE cause of blindness in the world
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trachoma
*most common cause of blindness in the world is cataract |
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A specific chronic keratoconjunctivitis which infects bulbar and tarsal(lid) conjunctiva and cornea
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Trachoma
- is more often in children and woman b/c it is a cluster disease - sight lost in middle age |
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Trichiasis
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a condition where an inturned eyelid causes the eyelashes to touch the eye
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Most common type of orbital inflammation?
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Idiopathic orbital inflammation - usually referred to as an orbital inflammatory pseudotumor and is commonly biopsied
- w/ time may see a combination of inflammatory cells and fibrosis |
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Chalazion vs Stye
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Chalazion - granulomatous rxn to lipid material released in blocked salivary glands
Stye (hordeolum) - staph infection of eyelash follicle (external) or meibomian glands (internal) |
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One of the most common sites of a sebaceous carcinoma
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Eyelid
- lesion mimics chalazion - Pagetoid spread (lateral spread) - vacuolization of the cytoplasm |
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Elementary bodies in a conjunctival smear may indicate
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Trachoma
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Types of Conjunctival-melanocytic lesions
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() Conjunctival nevi - benign, often compound and contain subepithelial cysts line by conjunctival epithelium
() Primary acquired melanosis - precursor to melanoma () Conjunctival melanoma - spreads to parotid or submandibular nodes and have a mortality rate of approx 25% |
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Keratoconus
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A common disorder of the cornea, characterized by progressive ectasia (expansion) of the cornea after puberty
- usually bilateral - may require corneal transplantation - Fleischer ring caused by Fe deposition at base of cone |
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Fuch's Endothelial Dystrophy
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Dystrophy of the cornea --> blurring and loss of vision in late middle age adults
- major indication for corneal transplantation - primary loss of endothelial cells --> fluid leak into cornea, stromal edema, and ~bullous keratopathy - Guttata, droplike deposits of abnormal basement membrane material |
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Types of ocular inflammation
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Endopthalmitis - inflammation affects 1+ coats of the eye
- can be exogenous or endogenous in origin Panopthalmitis - inflammation involving all three coats of the eye |
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Sympathetic opthalmia
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Development of bilateral autoimmune granulomatous uveitis secondary to a penetrating injury in one eye
- unique b/c trauma to one eye causes autuoimmne development and damage to both eyes |
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Most common primary intraocular neoplasm
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Uveal melanoma
- may arise from pre-existing nevi - common in fair skin pts and those w/ blue irises - tx w/ enucleation or radiation - more epitheliod cells (vs spindle cells) = worse prognosis |
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Most common cause of fungal retinitis
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Candida - disseminates hematogenously
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Most common primary intraocular tumor OF CHILDHOOD
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Retinoblastoma - most younger than 3yo
- a small round blue cell tumor - loss of Rb tumor suppressor gene on chr13 - will give white pupillary reflex - can spread to brain directly or metastasize hematogenously |
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Risk factors for Open Angle Glaucoma
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() increased intra-ocular pressure
() thin corneal thickenss () family hx () increase in age (lose ganglion cells w/ age) () race - AfAm more common Others: obstructive sleep apnea, migraine, vascular instability, myopia (near-sightedness), steroid use |
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What visual field is initially affected by glaucoma?
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Nasal visual field
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In what case should you refrain from dilating a pts pupils for direct opthalmoscopy?
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If the pt has narrow angles
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Visible laminal pores indicate
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neural and possibly glial loss
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Where is a hemorrhage associated with glaucoma usually present?
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on the edge of the rim extending onto adjacent retina
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|
Scotoma
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a blind spot
- ppl are usually not aware of a scotoma until it reaches the center area |
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Worldwide, what is the most common type of glaucoma (open or closed angle)?
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Angle Closure Glaucoma
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Risk factors for angle closure glaucoma?
|
() Hyperopia (far-sightedness)
() Asian, Native Americans () Advancing cataract - b/c will push iris anteriorly |
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This type of glaucoma is a medical emergency?
|
ACUTE angle closure glaucoma
- sudden onset of pain, red eye, blurred vision, N/V |
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Pre-Septal Cellulitis vs Orbital Cellulitis
|
Pre-septal cellulitis is characterized by inflammation of soft tissue anterior to the septum
Orbital cellulitis is characterized by inflammation of soft tissue posterior to the septum and is the more worrisome of the two. Aside from symptomatic sequelae, it usually requires hospitalization and an orbital CT scan |
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Common cause of nasolacrimal duct obstruction in adults
|
trauma
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A stringy, white mucoid discharge suggests conjunctivitis due to
|
allergies
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Presence of a palpable preauricular lymph node suggests
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viral conjunctivitis
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Why do you not want to patch an individual with exposure keratitis?
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This would cover up the cornea and hide any bacterial infection that may present
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|
How does the avascular cornea acquire the nutrients it needs?
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through pumps in the endothelium that deliver aqueous humor from the anterior chamber
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A family physician from the WVU clinic complains of moderate pain from a corneal abrasion and comes to you to see if he can borrow a topical anesthetic to get through the day. Is this is a safe tx?
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No. Topical anesthetics can dissolve the cornea. Oral analgesics may be prescribed but it usually resolves w/out tx.
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|
Suggests corneal edema
|
a scattered light reflection
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Which is worse, an acid or base chemical eye burn?
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base - more damaging, sticks around longer, emergency referral to opthalmologist
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Side effects of topical steroid use in the eye
|
() facilitates corneal penetration of herpes virus
() elevates IOP --> glaucoma () potentiates fungal corneal ulcers |
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Recurrent chalazion may suggest
|
sebaceous gland carcinoma
- need immediate referral to opthalmologist |
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Of particular concern in orbital cellulitis
|
cavernous sinus thrombosis
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|
|
Should be referred to an opthalmologist
|
Hythema, acute glaucoma, iritis
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|
Most common cause of blindness in the working age population of developed countries
|
Diabetes
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|
Stages of Diabetic eye disease
|
() Background - exudates, microaneurisms
() Pre-proliferative - CWS, hemorrhage, vascular tortuosity () Proliferative - neovascularization, pre-retinal hemorrhage () Advanced - pre-retinal fibrosis, tractional retinal detachment, rubeosis iridis End stage = phthisis |
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|
Cataract is a slow, painless decrease in vision that may prevent examination or tx of
|
Diabetic retinopathy
Glaucoma - b/c can't properly evaluate fundus through a cloudy lens |
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|
Why is glaucoma referred to as the 'thief of eyesight'?
|
b/c the sxs are insidious and silent
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|
Giant Cell (Temporal) Arteritis is an idiopathic vasculitis that needs to be treated as an ocular emergency. Why?
|
Without immediate identification and tx (steroids), it may cause central retinal artery occlusion and/or ischemic neuropathy, all leading to visual loss.
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|
Hyperthyroidism, as in the dominantly female Grave's disease, may present as a condition known as Thyroid Eye Disease. What is the pathology assoc w/ this disease?
|
() enlargement of extraocular muscles via fibroblast stimulation
() cellular infiltration of interstitial tissues like lymphocytes into the extraocular muscles, fat, and CT () proliferation of orbital fat and CT |
|
|
Clinical manifestation of Thyroid Eye Disease (TED)
|
* eyelid retraction
- proptosis - TED is most common cause of this in adults - optic neuropathy - fibrosed muscles - restricts movement and causes diplopia - soft tissue involvement - photophobia, lacrimation, periorbital/lid swelling |
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|
Both ___ and ___ cause sudden, painless visual field defects and loss of vision.
|
Retinal vein and retinal artery occlusion
- retinal artery occlusion can be tx w/ IA tPA w/in a 12hr window |
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|
Most common cause of TREATABLE visual loss in the elderly
|
macular disease
- deterioration of central visual acuity - normal pupil reflexes |
|
|
Dry vs Wet AMD
|
Dry AMD - 90% of cases, severe progressive vision loss, currently not treatable, caused by the accum of retinal cell by-products --> retinal scarring
Wet AMD - 10% of AMD, also severe progressive vision loss (but much more rapid onset than Dry AMD), new tx's are evolving, caused by breaks in the membrane and dysfxnal vessels --> bleeding under the retina, fibrosis, and scar formation |
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|
Visual side effect of topical beta blockers
|
hallucinations
|
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|
What effective combination is used to dilate the pupil?
|
Anticholinergics - blocks the light reflex, miosis, and cycloplegia (accomodation), which causes blurry near vision
Sympathetics - stimulate the dilator to cause mydriasis |
|
|
What is the effect of eye color on duration of dilating agents?
|
Blue eyes - quick action, short duration
Dark eyes - delayed action, longer duration |
|
|
How are topical anesthetics toxic to the cornea?
|
- acidic pH
- delay epithelial growth - slows blinking, a natural defense |
|
|
Alphagan side effects
|
* 30% of pts get allergic conjunctivits that develops months to years later
- very lipophilic (cross BBB) and may cause extreme somnolence - very dry mouth |
|
|
Side effects of systemic CAIs
|
nausea
tingling lips/fingers - due to metabolic acidosis aplastic anemia kidney stones |
|
|
Most commonly prescribed drugs for glaucoma
|
prostaglandin analogs
- enhance uveoscleral outflow by breaking bonds btw ciliar muscles allows flow into choroid - once a day dosing is better than twice daily - worried about abortion - side fx: superficial dilation of conjunctival vessels (only a cosmetic effect), increased pigmentation, increased lash growth |
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|
What is particular about abx usage in the eye compared to systemic use?
|
The worry over systemic side effects is diminished. The bacteria are now less likely to be resistant to the high dosage that is capable on the eye.
|
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|
While conjunctivitis is caused by a viral agent in a majority of the population, in children 2-3yo it is likely to be bacterial, esp H flu. What is the best tx against this?
|
Although chloramphenicol is a reasonable tx, Polytrim (polymixin/TMP) is most commonly used. It is well tolerated (unlike chloramphenicol) and covers H flu.
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|
|
The only antivirals helpful for the eye are limited to tx of
|
herpes virus
|
