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32 Cards in this Set
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1) what is west nile virus? 2) pathogenesis 3) risk factors |
1) mosquito-borne zoontic arbovirus found in tropical regions, first found in uganda 2) vector mosquitos to birds to "incidential" hosts ie humans or horses. replicate at site of inoculation and spread to lymph nodes then blood stream. penetrates CNS 3) age over 50, more in men then women, individual health, July - October, length of time spent outdoors, midwest and southern states, living in flooded area and presence of mosquitos in home |
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1) west nile clinical manifestations - mild - severe 2) patient history taking |
1) mostly asymptomatic - mild symptoms (fever, headache, nausea, vomiting, fatigue, myalgias) - severe (neurologic illness): meningitis, encephalitis, acute flaccid paralysis, altered mental status, tremor 2) symptoms: sudden onset of fever, malaise, myalgia, arthralygia, pharyngitis, anorexia, abd pain, visual disturbance, headache, rash, needle injury, blood transfusion, travel history (pandemic area), mosquito bites, length of outdoor activity |
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west nile 1) Physical exam 2) differential diagnoses 3) diagnostic tests |
1) 60-80% asymptomatic, s/s: fever, headache, weakness, myalgia, arthralgia, anorexia, rash, chorioretinitis. severe: meningitis, encephalitis, acute flaccid paralysis 2) flu, febrile, meningitis, Guillain- Barre Syndrome, lyme disease, varicella or herpes zoster, dengue fever 3) ELISA (serum of CSF) and plaque-reduction neutralizing tests (PRNTs)
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west nile 1) non pharm management 2) pharm management 3) patient education |
1) supportive therapy: NSAIDs/ASA, IV hydration, IV nutrition, airway support, tx secondary infections, rehab speech therapy, OT therapy 2) no accepted treatment for west nile, ribavirin, IV immunoglobulin and alpha interferon ARE NOT recommended 3) avoid spending time outside when mosquitos are most active, wear pants and long sleeved shirts, apply insect repellent, close doors and windows and make sure they have screens. eliminate standing water where they can breed. cover infants with mosquito net
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west nile 1) patient monitoring 2) referals 3) pregnancy considerations |
1) monitored in primary care setting unless symptoms of west nile neuroinvasive disease are present - patients with WNND admitted where they can get a lumbar puncture and MRI, 2) consult an ID expert, hospital, physical therapy, speech therapy, occupational therapy, psychiatry 3) adverse health effects of newborn infant to WNV infected mother are rare |
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meningitis 1) what is it and what is it caused by? 2) what's the most common type of meningitis? 3) how is it spread? 4) risk factors |
1) inflammation of the meninges, membranes or CSF surrounding the brain and spinal cord. can be caused by a viral, bacterial, fungal, parasitic or noninfecious proccess 2) viral, less severe and self limiting, non-polio enteroviruses, others include mumps, herpes, measles, flu 3) spread through close contact with a person who has causative virus 4) kids younger than 5, infants, < 1 month, weakened immune system |
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bacterial meningitis 1) more or less severe than viral? 2) how is it spread? 3) what is the most common causitive bacteria for - adolescents and young adults - elderly 4) risk factors |
1) bacterial is more severe 2) close contact with a contagious person 3) teens: neisseria meningitis, strep pneumoniae elderly: neisseria meningitis, strep pneumoniae, listeria monocytogenes 4) infants, community settings (college dorms), weakened immune system, frequent exposure to meningitis causing pathogens, trip to sub-saharan africa |
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meningitis 1) fungal 2) parasitic 3) non infectious |
1) rare, spreads through blood, cryptococcus contracted by inhaling soil that has bird droppings, candida is most frequent cause of hospital acquired fungal meningitis 2) rare form, naegleria fowleri in freshwater and enters through nose. risk factors; weakened immune systms 3) secondary to cancer, lupus, meds, head or brain injury |
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meningitis 1) clinical presentation (think triad) 2) who has atypical presentation? 3) history |
1) acute or subacute, progression over hours to several days, triad: fever, nuchal rigidity, alteration in mental status. headache, n/v, photophobia, confusion, irritability, sleepiness, rash, seizures 2) elderly, immunocompromised patients, patients with ventriculoperitoneal shunts 3) OLD CART, vaccination, living situation, antibiotic, travel, sexual hx, cochlear implants, hx of alcoholism or cirrhosis? |
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meningitis 1) physical exam key elements 2) symptoms of meningococcemia 3) signs |
1) triad: fever, stiff neck/headache, cerebral dysfunction (confusion, delirium, decreased LOC), photophobia, seizures, cranial nerve palsies 2) rash: diffuse, purpuric lesions, primary on extremities, cold hands/feet, hypotension, tachycardia 3) brudzini's and kernig's signs |
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meningitis 1) differential diagnoses 2) diagnostic tests |
1) CNS vasculitis, subarachnoid hemorrhage, neurosyphilis, CNS infection (ansecess, encephalitis), neoplasms, delirium tremens, malignant HTN, migraine 2) CSF analysis, gram stain/culture, PCR assay, blood cultures, CT scan, blood work with diff |
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meningitis 1) non pharm 2) pharm a. bacterial b. viral 3) patient education |
1) bed rest, fluids, electrolytes, elevate head of bed 30 degrees, decrease environmental stimuli 2) a. bacterial: antibiotics vancomycin, cefotaxime, ceftriaxone b. viral: antivirals, OTC meds 3) vaccinations: flu, pneumoccocal, prophylactic antibiotics, healthy habits (no smoking, rest, do not get into close contact)
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meningitis 1) patient monitoring 2) referrals 3) considerations for pregnancy |
1) dehydration, septic shock, hemodynamic compromise, cerebral edema, disseminated intravascular coagulopathy, myocarditis, hyponatremia, seizures, death, long term sequelae: learning disability, hearing impairment, seizure disorder, visual and motor impairment, ataxia, hydrocephalus, DM I 2) bacterial: hospital admission, specialist ID, critical care, neurology, neurosurgery, follow up care too 3) vaccinate, meningococcal, PCV12 and PPSV23 are not evaluated |
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herpes zoster 1) what is it? 2) most common characteristics 3) patho |
1) dermatologic eruption caused by a reactivation of varicella- zoster virus (VZV) that follows a primary VZV infection. 2) painful vesicular lesions that may last 7-10 days or more. typically unilateral following the infected dermatome 3) VZV lies dormant in dorsal root ganglia after initial infection - once reactivated, VZV replicates and travels through the axons, spreading until it penetrates the epidermis - spread by direction contact with open lesions of shingles rah, contagious until blisters scab over |
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herpes zoster risk factors 1. age 2. disorders 3. treatments 4. what else to consider? |
1. 50+, 2. immunodeficiency disorders (CLL, HIV, multiple myeloma), 3. undergoing certain treatments (glucocorticoid therapy), chronic comborbid diseases 4. stress factors (trauma, surgery) |
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herpes zoster - clinical presentation clinical presentation 1. where does it erupt 2. symptoms at eruption 3. everything else 4. physical exam, common areas of involvement? |
1) unilateral eruption within one dermatome 2) symptoms preceding eruption of lesions - pain (burning, stabbing, aching, numbness, or tingling), dysesthesia, pruitius 3) low grade fever, lymphadenopathy, headache, photo sensitivity, fatigue 4) red rash (first red and maculopapular, clusters of clear vesicles within several hours, break open and crust over >> new lesions common areas; thoracic, cranial (esp trigeminal), lumbar nerves |
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hutchinson's sign what do you do? |
vesicles on the tip, side, or root of the nose, refer immediately to an opthamologist
trigeminal nerve root may produce symptoms and lesions on the mouth, ears, pharynx or larynx |
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herpes zoster important history questions |
- past medical history of chickenpox - recent sick contacts with VZV - prodromal symptoms preceding rash? - location? unilateral to dermatome, thoracic or cranial area - characteristics: painful, pruritus, red vesicles, unilateral - aggravating factors (tough, stress) |
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herpes zoster diagnostic tests and interpretation list two main tests |
1) tzack preparation: scrape the base of a fresh lesion, microscope then look for multinucleated giant cells, cannot differentiate between herpes zoster and other herpes viruses, negative does not rule out other herpes virus infection 2) direct fluorescent antibody (DFA) or PCR best for acute diagnostic confirmation, test vesicular fluid yield VZV antigen, better than Tzanck - differentiates between HSV and VzV |
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herpes zoster 1) culture 2) lab 3) imaging 4) management |
1) may take up to 2 weeks to result, skin biopsy is only used if difficult to diagnose (atpical lesions) 2) no diagnostic labs, may have some IgM and IgG response but could be elevated for other reasons 3) no imaging tests are indicated 4) reduce pain and stop viral replication, treatment reduces intensity, duration and course of illness, supplementary therapies include oral corticosteroids, analgesics, neural blockade |
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herpes zoster treatment 1) antiviral 2) analgesics 3) corticosteroids 4) Anticonvulsants 5) tricylic antidepressants 6) post -herpetic neuralgia |
1) acyclovir, famciclovir, valacyclovir relieve acute pain and speed healing of lesions, reduce post- herpetic neuralgia 2) APAP, NSAID, tramadol, oxygodone, caladryl lotion for open lesions 3) Prednisone 3 week tapering dose 4) Gabapentin (neurontin), Pregabalin 5) nortiptyline, amitripyine 6) capaicin, lidocaine |
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herpes zoster ophtalmicus |
- oral antivirals: tx within 72 hours after rash onset to reduce complications, - antiviral eye ointment - pain control - topical steroids - burow solution or wet to dry dressing with sterile saline |
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herpes zoster patient education |
- keep lesions clean, dry, and covered - avoid direct skin contact with susceptible persons (immunocompromised, pregnant women, varicella zoster virus naive) - medication adverse drug effects - seek medical attention if pain persists after rashes are cleared, ophthalmic involvement - prevention: zostavax, varicella zoster immune globulin |
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herpes zoster patient monitoring- what should you look for? |
- encephalitis - HZ opthalmicus with delayed contractlateral hemiparesis, myelitis, VZV, rentinits, PHN, postherpetic itch - reoccurrence rate of HZ in otherwise healthy adults |
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herpes zoster 1) referrals 2) considerations in pregnancy |
1) refer to opthalmologist for all patients with ocular involvement - physical therapy - social services for elderly patients who may not be able to self care - psychosocial support 2) There is no clinical or serologic evidence of VZV infection in infants whose mothers have developed perinatal zoster
if a susceptible pregnant woman is exposed to VZV, passive antibody prophylaxis with VZIG is indicated within 96 hours of exposure |
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chronic fatigue syndrome 1) risk factors 2) etiology 3) history 4) what do you screen for? |
1) female, 40+ years, depression or stress, maybe childhood trauma 2) multiple etiologies, research focuses on immune and adrenal system, genetics, biopsychosocial models, sleep & nutrition 3) full medical history, current meds, recent travel, insect bites, eating or exercise habits, evaluate fatigue like any other symptom 4) depression and substance use
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chronic fatigue syndrome red flag symptoms |
- chest pain - focal neurologic deficits - inflammatory signs or joint pain - lymphadenopathy or weight loss - shortness of breath |
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chronic fatigue syndrome 1) diagnosis and evaluation 2) what are the diagnosis challenges 3) history and physical 4) labs |
1) diagnose by exclusion 2) challenges: labs/biomarkers, common symptoms, remission & relapse, variance of symptoms 3) detailed history about meds, pain >6 months, flu like symptoms, memory, thorough physical and mental status r/o depression 4) labs to rule out other conditions |
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chronic fatigue syndrome diagnostic criteria |
- chronic fatigue for 6 or more consecutive months - significant interference with daily activities/work - concurrently has any of the 4: post exertional malaise lasting more 24 hours un-refreshing sleep multi joint pain w/o swelling or redness headache of new type, pattern or severity tender cervical or auxiliary lymph nodes frequent/ recurring sore throat muscle pain significant impairment of short term memory or concentration |
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chronic fatigue syndrome plan and management pharm |
no cure, can treat symptoms - low dose anti depressant - pain control: start low and go slow tylenol, advil, naprozen gabapentin, lyrica - sleep aid |
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chronic fatigue syndrome
non pharm patient education |
- counseling, CBT - graded exercise: start easy then work up - acupuncture, yoga, tai chi
- advocate for appropriate pain control, help them understand there's no clear solution - decrease guilt patient may experience - help develop a comprehensive skill set to pace themselves - support group
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chronic fatigue syndrome 1) patient monitoring 2) referrals 3) pregnancy considerations |
1) - daily weights and temperature - biannual visits - labs CBC w/ diff, CMP, TSH 2) sleep study, psychiatry CBT, personal trainer or physical therapist for graded exercise nutritionist occupational therapy for severe cases 3) little published information, outcomes were similar before and after CFS |
