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67 Cards in this Set
- Front
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ebola contributing factors to scale of epidemic in west africa (6) |
1. shared borders 2. cultural practices around death and burial 3. recent histories of civil war and conflict have impaired infrastructure 4. distrust in government 5. deforestation related to mining 6. slow international response
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ebola patho |
1. cell and tissue damage: early preferred sites macrophages & dendritic cells, liver, spleen, adrenal glands & other lymphoid tissues 2. GI dysfunction: N/V/D & impairment of endothelium 3. systemic inflammatory response (release of cytokines, chemokines, and proinflammatory mediators >> widespread inflammation) 4. coagulation defects: release of tissue factor from infected cells 5. impaired adaptive immunity |
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ebola risk factors |
1. contact with meat or body fluids of an infected animal (reservoir is not yet well defined) 2. direct contact with blood, body fluids, and skin of a person with EVD 3. groups at risk: - healthcare profession - funerary/burial profession - family member/ close contact with person with EVD - breast fed infants- limited evidence |
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clinical presentation, signs and symptoms |
- fatigue/ weakness - diarrhea/vomiting - fever - headache - muscle pain - abdominal pain - unexplained bruising/bleeding - lack of appetitie |
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pertinent history questions |
1. have you traveled to an area known to be ebola- affected? 2. have you had contact with someone exhibiting symptoms of ebola? 3. are you experiencing any of the signs and symptoms of the ebola virus? |
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ebola physical exam |
- normal physical exam with labs CBC, CMP, PTT, PT/INR, LFT - determine risk of exposure - indications for initial testing for ebola virus infection - lab dx |
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ebola differential diagnoses |
- flu (fever, fatigue, muscle aches, loss of appetite) - malaria - thyphoid fever - marburg hemorrhagic fever - meningococcal disease |
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diagnostic tests & interpreation |
- detected in blood after onset of symptoms - diagnostic tests vary depending n timeline of infection 1) RT-PCR (polymerase chain reaction), rapid diagnostic tests for ebola virus infection are most commonly used tests for diagnosis, rapid blood tests, 2) ELISA 3) IgM, IgG antibodies 4) virus isolation |
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ebola nonpharmacological |
1. supportive care: preventing intravascular volume depletion, maintenance of blood pressure, detect and prvent electrolyte abnormalities, avoid shock complications, assessment of urine frequency, ovlume, color and skin turgor and mucous membranes 2. respiratory care: intubuation for patients with progressive respiratory failure 3. additional support: symptomatic management of fever, pain, nausea, vomiting, nutritional support, blood products for bleeding, renal replacement 4. convalescent plasma and whole blood |
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ebola pharmacological |
1. antimicrobial therapy 2. antiviral therapy (favipiravir, brincidofovir) 3. ebola specific agents: ZMapp, TKM- Ebola, Phosphorodiamide morpholino oligomers (PMO), BCX4430 4. vaccines: ChAD3- ZEBOV, rVSV- ZEBOV |
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ebola patient education and prevention |
1. avoid areas of known outbreak 2. wash your hands frequently 3. avoid contact with infected people 4. follow infection control procedures 5.don't handle remains 6. precautions during the convalescent period (shouldn't have oral, vaginal or anal sex for 3 months after recovery) |
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patient monitoring 1. active 2. direct active 3. other
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1. daily reporting of measured temps 2x/day & symptoms of ebola by a public health authority 2. public health authority directly observes the individual daily to review symptoms and monitor temperature; second daily follow up may be by phone call - discussion of plans to work, travel, take public transport or be in public places 3. other - controlled movement - isolation - quarantine |
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referrals |
transferring pts with confirmed EVD to an ebola treatment center - north shoresystem LIG - monte - NYP allen - Bellevue - Mt. Sinai |
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considerations for pregnancy |
no evidence to suggest that pregnant women are more susceptible
- limited evidence suggests pregnant women are at increased risk for severe illness and death when infected with EVD, more likely to have hemorrhagic complications, esp vaginal and uterine bleeding - breastfeeding safety for mothers with suspected or confirmed EVD is complicated, may not be an alternative - risk of body fluid exposure during childbirth >> employ additional protection shoe covers, double glove, leg covers - clinical management for pregnant women is same as non-pregnant adults |
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define 1) diarrhea 2) infectious diarrhea 3) acute diarrhea |
1) alteration in a normal bowel movement characterized by an increase in the water content, volume, or frequency of stools.
decrease in consistency and increase in frequency of more than 3 stools per day
2) diarrhea due to an infectious etiology, often accompanied by symptoms of nausea, vomiting, or abd cramps (second leading cause of morbidity and mortality worldwide
3) episode of diarrhea of <14 days in duration |
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what are the top 5 culprits for infectious diarrhea? |
- e. coli - salmonella - shigella - campylobacter - norovirus |
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infectious diarrhea etiology - non inflammatory cause: - inflammatory cause |
noninflammatory: usually viral, can be bacterial or parasitic
inflammatory: invasive or toxin- producting bacteria |
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infectious diarrhea patho |
noninflammatory: promote intestinal secretion without significant disruption in the intestinal mucosa
inflammatory: likely to disrupt integrity which may lead to tissue invasion and destruction |
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infectious diarrhea lab findings when are leukocytes present? |
noninflammatory: no fecal leukocytes present inflammatory: presence of fecal leukocytes |
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is inflammatory or non inflammatory infectious diarrhea more severe? |
generally inflammatory |
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infectious diarrhea risk factors |
specific to diarrhea - travel to a developing area - day care center attendance or employment - consumption of unsafe foods - swimming in/ drinking untreated surface water (lake or stream) - visiting a farm or petting zoo or having contact with reptiles or pets with iarrhea - contact with ill people - recent or regular meds - underlying medical conditions predisposing to infectious diarrhea - handling food - receptive and anal intercourse |
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infectious diarrhea differential diagnosis
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1) viral: rotavirus, enteric adenovirus, astrovirus, coronavirus, parechovirus, picobirnavirus, bocavirus, aichi virus 2) protozoal: giardia, cryptosporidium, cyclospora 3) bacterial: enterobacter infections, enterococcal, klebsiella, proteus, providencia, pseduomonas aeruginosa, serratia, shigella, strep group B, listeria, salmenolla |
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infectious diarrhea diagnostics: who should be tested?
evaluate severity & duration, history and PE, treat dehydration, report then determine which of these categories: A) B) C) |
A) community acquired or traveler's diarrhea, esp if accompanied by significant fever or blood in stool B) nosocomical diarrhea onset > 3 days in hospital C) persistent diarrhea ( >7 days) esp if immunocompromised |
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infectious diarrhea management 1) what's the treatment goal? 2) when is diagnostic testing indicated 3) what should be avoided? 4) antibiotic? 5) probiotic |
1) prevention and treatment of dehydration - oral rehydration with early refeeding is preferred treatment
2) patients with severe dehydration or illness, persistent fever, blood stool or immunosuppression, cases of suspected nosomical infection 3) antimotility agents in cases of blood diarrhea 4) effective when there's an appropriate cause 5) may shorten course of infection
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infectious diarrhea which drug for the following 1) - shigella - e. coli - aeromonas/ plesiomonas - isospora 2) - entamoeba histolytic - giardia - entamoeba histolytica 3) - campylobacter
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1) TMP- SMZ 2) metronidazole 3) erythromycin |
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infectious diarrhea complications (4) |
1) reactive arthritis 2) postinfectious irritable bowel syndrome 3) gullian barre syndrome 4) miller- fisher syndrome (MFS) |
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infectious diarrhea prevention |
- heat labile: make sure the thickest part of any poultry product reaches 165 F (74 degrees) - choose coolest part of care to transport meat and poultry home from the store - defrost meat and poultry in the frige or microwaves and make sure juices don't drip - use pasteurized milk and eggs - wash fruits and veggies - wash hands thoroughly after: contact with pets, farm animals, preparing food, changing diapers, dirty children |
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infectious diarrhea norovirus 1) prevalence 2) transmission 3) clinical presentation- when most contagious? 4) risk factors |
1) most common cause of gastroenterititis in US 2) fecal- oral route when person consumes contaminated food, touching surfaces or objects then in mouth 3) nausea, acute onset vomiting, watery, non-bloody diarrhea with abd cramps, fever, headache, myalgias. symptoms improve 24-72 hours. most contagious when sick and during first few days 4) day care centers, nursing homes, schools, cruise ships Nov - April |
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infectious diarrhea norovirus 1) eval 2) diagnostic testing 3) treatment 4) pt education |
1) dehydration, dry mucous membranes, increased HR, increased respiratory rate, oliguria, sunken eyes 2) can dx on clinical presentation alone - PCR assays (RT- qPCR) detects genetic material of virus or EIA usually for outbreaks 3) replenish fluids, viral so NO antibiotics 4) hand washing, signs and symptoms of dehydration |
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infectious diarrhea norovirus 1) pregnancy considerations 2) prevention |
1) dehydration which can lead to preterm labor or UTIs (which can also lead to preterm labor) - oral rehydration solution (pedialyte), IV fluids - do not use immodium and pepto-bismol
2) hand washing, be clean, wash fruits and veggies, cook seafood thoroughly, don't prep food when sick |
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infectious diarrhea e. coli 1) where does e. coli come from? 2) transmission 3) clinical presentation 4) risk factors
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1) shiga toxin makes ______ 2) contaminated raw dairy products, produce and water 3) abd cramps, diarrhea, fever. onset 3-4 days but can be 1- 10 days 4) age, weakened immune system, June - September, decreased stomach acid levels
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infectious diarrhea e. coli 1) evaluation 2) diagnostic tests 3) pharm & non pharm |
1) physical presentation, history, CBC w/ diff, may be blood, urine, sputum or other fluids ie cerebrospinal, biliary, abcess, & peritoneal 2) confirmed by bacteria in stool specimen, may be cultured to confirm diagnosis and specific toxins 3) symptoms last a week then resolve w/o any long term problem, hydrate. antibiotics do not help |
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infectious diarrhea e. coli 1) patient education 2) considerations for pregnancy 3) prevention |
1) symptoms are self limiting, dehydration, hand hygiene 2) dehydration 3) handwashing, clean & sanitize all fruits or veggies, careful of cross contamination |
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infectious diarrhea shigella 1) patho 2) prevalence 3) transmission 4) risk factors |
1) bacteria that invades the epithelium of the colon & makes ______ toxin causing ulceration and sloughing of bowel wall tissue 2) 500,000 cases year 3) fecal- oral, bacteria is in stool then passed via direct contact with stool, improper hand washing, contaminated food or water, sex, houseflies. incubation 12-72 hours 4) ages 2-4, travelers to developing countries, men who have sex with men, prisoners, patients in long term care facilities
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infectious diarrhea shigella 1) clinical presentation 2) treatment |
1) usually lasts 4-7 days, diarrhea with blood, frequent and large volume, tenesmus (straining and pain associated with feeling that another bowel movement even though bowels are empty), n/v, seizures in kids 2) hydration, ciproflaxin, zinc supplementation |
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infectious diarrhea campylobacter 1) patho 2) prevalance 3) transmission 4) risk factors |
1) gram negative that cause inflammatory diarrhea, heat-labile that create bloody diarrhea 2) summer disease of 1.3 million people, self limiting 3) fecal- oral, person to person sexual contact, unpasteurized raw milk and poultry ingestion, waterborne, incubation period 2-5 days 4) consumption of unpasteurized or undercooked poultry, milk or eggs, day care, drinking from rivers, lakes or streams |
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infectious diarrhea campylobacter 1) clinical presentation 2) diagnostics 3) treatment |
1) brief prodrome of fever, headache, myalgias lasting up to 24 hours followed by crampy abdominal pain, fever, watery, and frequently bloody stool. tenesmus, symptoms 5-7 days 2) ELISA or PCR, fecal leukocytes or erythrocytes 3) azythromycin 500 mg, resistance to fluoroquinolones if pt has high fever, bloody diarrhea, excessive bowel movements >8 per day, worsening symptoms, failure of symptoms to improve, pregnancy |
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infectious diarrhea salmonella 1) prevalence 2) clinical presentation 3) transmission 4) tests and diagnosis |
1) one of most common and widely distributed food -borne diseases 2) n/v, abd cramps, diarrhea, fever, chills, headache, blood stool, symptoms last 4- 7 days 3) foods: raw or undercooked meat, poultry, seafood, raw eggs, improper hand washing, pets 4) stool sample but people recover before results return |
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infectious diarrhea salmonella 1) treatment 2) consideration for pregnancy 3) patient education |
1) replace fluids and electrolytes lost during severe diarrhea and vomiting via IV or pedialyte. anti diarrheals relieve cramping but can prolong diarrhea associated with infection. antibiotics may be given in complicated cases if provider suspects bacteria 2) crosses placenta and produce severe fetal disease or death, even if maternal symptoms are mild. extra care of undercooked foods and wash hands carefully. if infected protocol is the same but watch fetus 3) hand washing, changing diapers, handling raw meat or poultry, touching birds. prevent crosscontamination, avoid eating raw, unpasteurized eggs |
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osteomyelitis list three types and where they come from |
1) hematogenous (infection enters bone from blood) 2) contiguous focus (caused by trauma like a puncture wound or open fracture, infection of adjacent tissue, ie oral mucosa infected by dental carries) 3) associated with peripheral vascular disease (diabetic foot wounds and venous stasis ulcers seen in chronic venous insufficiency) |
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osteomyelitis 3 most common infectious organisms |
1) s. aureus 2) pseudomanas aeruginos 3) staphylococcus pogenes |
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osteomyelitis 1) clinical presentation 2) risk factors 3) physical exam a. chronic b. verebral |
1) fever, decreased ROM, pain, swelling, draining sinus tract, erythema, soft tissue cellulitis, bone tenderness 2) children, elderly, diabetics 3) local inflammation, constitutional symptoms, bone tenderness, decreased joint ROM, draining sinus tract, ulceration a. exposed bone, draining sinus tract, tissue necrosis overlying bone, chronic wound overlying surgical hardware or fracture, etc b. local tenderness to spinal percussion, reduced back ROM, protective spasm of nearby muscles, rarely visible mass, abscess or spinal deformity |
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osteomyelitis 1) diabetic foot tests, describe what to look for and the following a. PBT b. ulcer size c. doppler
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1) assess for inflammation, ulcer, neurologic and vascular status of foot. a. probe to bone test: positive result is probe contacts bone, suggesting osteomyelitis. b. ulcer size > 2 cm2 + elevated ESR c. doppler study: highlights hyperemia around peristeum & surrounding abscess |
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osteomyelitis 1) differential diagnosis 2) diagnostic tests and interpretation - gold standard? 3) imaging |
1) differential - septic arthritis - gout - post traumatic periosteal reaction - bursitis - abscess - ulcer - tumor - subacte bacterial endocarditis 2) bone biopsy with histopathologic exam & tissue culture, CBC with diff, blood culture, increased ESR and CRP, needle aspiration 3) x- ray, bone scan, MRI, CT, ultrasound, gallium/indium scan |
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osteomyelitis 1) pharm/ nonpharm a. acute hematogenous b. continguous focus c. nonpharm 2) patient education |
1) a. nafcillin, cefazolin b. ampicillin-sulbactam, piperacillin- tazobactam c. debridement, surgical, bone removal, rod, dead space management 2) daily foot inspection, explain everything that's going on |
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osteomyelitis 1) patient monitoring what can chronic osteomyelitis cause? 2) long term antibiotics associated with 3) referral |
1) relapse is common in diabetic, vascular insufficient and immunocompromised patients if s. aureus is involved, look for cellulitis, sepsis, and metastatic foci. chronic: amputation but rare 2) line infections, thrombosis, ADE, resistant organisms 3) physical therapy, prosthetics, psychiatric counseling, podiatrist, |
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osteomyelitis considerations for pregnancy |
drugs to treat for osteomyelitis are category C so risk cannot be ruled out - cipro - levofloxacin
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lyme disease 1) cause - include how long it takes to get it 2) what does it require 3) hosts 4) where are the most common outbreaks?
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1) borrelia burgdorgeri transmitted by tick bite with rodents like the white- footed mice and chipmunks serving as reservoir hosts extended contact of 36-72 hours 2) requires a blood meal at larval, nymphal, and adult stages of life 3) deer, mice, chimpmunks 4) North America, Europe, Asia, most common vector borne disease in US & Europe |
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lyme disease 1) pathophysiology 2) risk factors 3) history
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1) bacteria enters subcutaneous tissue, cluster, localize in neuronal tissue in sensory ganglia, endothelial cells, glial cells. spirochete produces specific toxin (neurotoxin) that disturbs cells & causes pain, paresthesias, and cognitive impairment 2) heavily wooded areas, exposed skin, not using insect repellant (esp DEET) 3) will not recall being bitten, assess based on history, lives works, recreational activities |
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lyme disease 1) clinical presentation a) early localized disease b) early disseminated disease (4 manifestations) c) late disseminated disease |
1 a) 1-30 days after tick bite, appearance of skin lesion, erythema migrans (EM), clearing as it enlarges, red center, warm to touch, not itchy or painful. may or may not have fever, fatigue, chills, headache, myalgias, althralgias, lymphadenoapthy b) 3-10 weeks after, neurologic manifestation (facial or bell's palsy, triad: meningitis, cranial neuropathy, motor/sensory radiculoneuropathy), cardiac manifestations (heart palpitations), ocular (pink eye), cutaneous manifestations (borrelial lymphocytoma) c) intermittent or persistent arthritis w/ severe pain and swelling in large joints, esp knee preceded by migratory arthralgias + neurologic manifestations |
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lyme disease physical exam, what are you looking for 1) integumentary 2) neuro (early and late) 3) cardiovascular 4) musculoskeletal |
- integumentary: characteristic erythema migrans (EM) lesions, may be singular or multiple, bull's eye pattern, area of clearing, warm to touch - neurological: a) early is unilateral or bilateral cranial nerve palsies, lymphocytic meningitis, radiculopathy, peripheral neuropathy, mononeuropathy late: ataxic, cognitive dysfunction 3) during late, carditis, fluctuating AV block, myopericarditis 4) late, migratory arthralgias, monoarticular or oligoarticular arthritis |
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lyme disease common differentials |
- contact dermatitis - cellulitis - rheumatoid arthritis - gout/ pseudogout - herpes zoster - cardiac arrhythmias - fibromyalgia |
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lyme disease diagnostic work up |
2 step testing 1. enzyme- linked immunosorbent assay (ELISA) if negative, r/o lyme positive, perform western blot 2. western blot confirms dx of lyme |
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lyme disease treatment 1) non pharm 2) pharm what's first line? if pt has neuro manifestations? arthritic manifestations? |
1) targets joint pain: acupuncture, electromagnetic therapy, ROM exercises, water exercises 2) doxy (contraindicated in kids and pregos) so amoxicillin (esp for kids and pregos) neuro manifestations 2-4 weeks ceftriaxone lyme carditis: oral/parenteral antibiotics: IV therapy, continous monitoring, temporary pace maker arthritis: re treatment with 4 wk course of oral antibiotics or 2-4 weeks ceftriaxone, 4 wk course of oral antibiotics, NSAIDs, intra articular injections, corticosteroids or DMARDS |
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lyme disease prophylactic antibiotics what are the 4 conditions to use it? |
only if all 4 have been met 1) attached tick can be reliably identified as an adult of nymphal I. scapularis tick and attached for > 36 hours 2) prophylaxis can be started within 72 hours of tick removal 3) ecologic info indicates local rate of infection of B. burgdorferi > 20% 4) no contraindication to doxy (no support for the use of amoxicillin) |
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lyme disease patient education and prevention monitoring |
- avoid tick infested areas - wear protective clothing - use insecticides containing DEET - inspect entire body for ticks, esp moist areas of body eg groin, axillae - removal of tick w/i 24 hours of attachment monitoring - reinfection (another rash), symptoms that get worse, monitor for neuro symptoms |
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post lyme disease syndrome |
- small % of patients - S & S lasting > 6 months despite resolution of objective manifestations of infection with antibiotic therapy (ongoing pain, neuro, fatigue) - hard to distinguish from chronic fatigue syndrome or fibromyalgia - DO NOT GIVE more antibiotics |
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lyme disease considerations for pregnancy |
- all should be treated for lyme - no life-threatening effects on fetus have been found in cases where mother receives appropriate antibiotic tx - doxy is contracindicated so tx with amoxicillin - no reports of being transmitted in breast milk |
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lyme disease referrals |
- infectious disease: esp in pregos and kids - rheumatology: lyme arthritis, esp using DMARDs - cardiology: lyme carditis - neurology |
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MRSA 1) what kind of bacteria is it? 2) what are the two types, which is decreasing and which is increasing? 3) who gets MRSA? |
1) methicillin- resistant staphylococcus aureus, gram + cocci 2) a) healthcare associated - decreasing b) community associated- increasing 3) kids, minorities, homosexual men, IV drug users, elderly living communities, prisoners, football players
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MRSA 1) who is the average patient that gets community acquired MRSA (CA-MRSA)? 2) signs and symptoms 3) health history |
1) young, healthy, recently hospitalized, high risk, median age 23, underlying disease 2) redness, swelling, warmth, pain/tenderness, pain of a "spider bite", palpable, fluid-filled cavity, movable, compressible, yellow or white center, "head", draining pus, necrotic center 3) athletic activities, whirlpool, astroturf, recent antibiotics, infection, joint pain, fever, IV drug use, surgery, hospitalization, diabetes, hemodylasis, nursing home, healthcare professional
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CA- MRSA 1) physical exam 2) differential diagnosis 3) diagnostic tests
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1) vital signs (look for infection/sepsis), level of consciousness, skin assessment, in the community, most are skin infections that may look like pustules or boils, mistaken for spider bites, or at visible sites of trauma like cuts and abrasions. neck/lymphatics, lungs, heart, msk 2) bactermia, burns, impetigo, IBS, RA, kawasaki disease, osteomyelitis, rhemuatic fever 3) cultures from site of infection, anterior nares, sputum, urine. biopsy tissue, rapid blood test, erythromycin induction test. check for osteomyelitis, septic arthritis (tap the joint), endocarditis (blood cultures + echo) and pneumonia (x-rays) |
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CA-MRSA treatment: abscesses (3) 1. how do you take care of a wound? 2. when do you use antibiotics? 3. when do you avoid using antibiotics? |
1) incision and drainage (all) 2) antibiotics: complicated abscesses, progressive, cellulitis, systemic s/s, immunosuppresion, elderly, pediatric, drainage 3) do not use antibiotics if abscess is less than 5 cm
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CA- MRSA treatment for 1) purulent cellulitis 2) surgical debridement + empiric antibiotic therapy 3) decolonization 4) bacteremia and endocarditis 5) pneumonia 6) bone & joint |
1) clindamycin, TMP-SMX 2) vancomycin, linezolid, daptomycin 3) mupirocin 4) vanco, linezloid, clindamycin, NO daptomycin 5) vancomycin, linezolid 6) surgical debridement, vanco IV, daptomycin IV
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CA- MRSA 1) duration of therapy 2) monitor for s/s systemic illness 3) monitoring on vancomycin |
1) depends on patient response to treatment (1-2 weeks) 2) fever, non-healing wound/abscess, hypotension, risk for progression to sepsis, endocarditis, kidney/lung infection, necrotizing fasciitis, osteomyelitis 3) serum troughs once at steady state 15-20 mg/mL - < 2 mg/mL clinically responding, continue with vanco treatment duration based on response |
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CA- MRSA patient education |
how to prevent another infection - finish antibiotics - hand washing - wounds clean & change bandages - avoid sharing towels or razors - wash and dry clothes on warmest temperatures - tell your providers you have MRSA |
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CA- MRSA 1) referals 2) considerations for pregnancy |
1) infectious disease consult & microbiologist 2) pregnant women can carry MRSA bacteria and not the infection, if there's no infection then no risk to the baby if a pregnant woman has a MRSA infetction there's a small chance of passing the infection during vaginal delivery - screening for MRSA is completed by swabbing nose & throat 34 weeks of pregnancy, MRSA + must be given antibiotic - preparation for birth, shower daily with medicated shower cell called octenisan, wash her hair with this on day 1, 3, and 5 and around 34-35 weeks of pregnancy, the same 10 days she must apply Naseptin cream to both nostrils 4x daily. |
