Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
136 Cards in this Set
- Front
- Back
|
What is top 3 causes of UTI?
|
i)E coli ii)Staph Sapro iii)enterococc
|
|
|
most common nosocomial pnumonia? x2 Community acquired? x1
|
ia)staph aureus b)gram-- rods ii)a)strep pneum
|
|
|
What are 2 methods of prevention of pneumonia? When do you give pneumovax? x6
|
i)flu vaccine ii)pneumovax: >65 y/o and peeps at high risk (a)heart dz b)SCD c)pulm Dz d)DM e)EtOH cirrhosis f)asplenic)
|
|
|
What are 3 most common typical CAP?
|
i)S pneum ii)H flu iii)Klebsiella (G-- rods)
|
|
|
How does classic CAP present?
|
sudden chill followed by fever, pleuritic pain, and productive cough
|
|
|
How does atypical pneum present?
|
sore throat and H/A->nonprod cough and dyspnea
|
|
|
What signs are seen w/typical CAP? x5
|
i)tachycardic/tachypnic ii)late crackles iii)incr tactile and vocal fremitus iv)dullness on percussion v)pleural friction rub (Pleural effusion)
|
|
|
What is only way to differentiate b/w pneumonia and acute bronchitis? What does the modality show?
|
i)CXR ii)lobar consolidation
|
|
|
What are common agents of atypical? x3
|
i)mycoplasma * ii)chlam pneumonia iii)legionella iv)flu virus; adenovirus; parainfluenza
|
|
|
What is symptoms of atypical CAP? x3 What are signs? x3 What does CXR show?
|
i)a)sxs: insidious b)dry cough w/o sputum c)fevers w/o chills ii)a)wheezing b)pulse-temperature dissociation: normal pulse in setting of high fever c)crackles and rhonchi iii)diffuse reticulonodular infiltrates
|
|
|
How to DX pneum? x3
|
i)PA and lateral CXR*: don't treat w/Abx if not showing pneumonia. ii)sputum gram stain and culture: see strep pneum. iii)special stain of sputum: acid fast for TB; silver stain for HIV
|
|
|
How to treat pneum? x3
|
i)decide if hospitalize or treat as outpt. ii)Abx: empiric therapy (doxycycline for young people: for S pneum, myco, chlam, legion). iii)old peeps: typical CAP->cephalosporin or levofloxacin iv)hospitalized peeps: give cipro or a 3rd gen cephalosporin w/macrolide
|
|
|
what is cryoglobulinemia? Assn?
|
i)proteins that become insoluble at <4 C ii)Hep C
|
|
|
what is HBV ass'd w?
|
Polyarteritis nodosa
|
|
|
What is mechanism of abscess formation?
|
i)infected lung tissue becomes necrotic and forms suppurative cavitary lesion. ii)aspiration of oropharyngeal contents or food
|
|
|
What are 4 ways abscesses happen?
|
i)aspiration ii)necrotizing pneumonia (gram--) iii)hematogenous spread iv)direct inoculation
|
|
|
What is the main risk factor for pulm abscess? What types of patients have it x7? What is one other risk factor?
|
i)predispo to aspiration ii)alcoholics, drug addicted, CVA, seizure, anesthesia, NG or ET tube iii)poor dental hygiene. Toothless=less likely to aspirate
|
|
|
What are signs and sxs of lung abscess x4?
|
i)cough:smelly means anaerobes, can be blood tinged ii)fever/chills iii)SOB iv)constitutional sxs: malaise, wt loss
|
|
|
How to DX abscess? x3
|
i)CXR: thick walled, air-fluid leveled cavitation. ii)CT: differentiates abscess and empyema iii)cultures via bronchoscopy vs sputu b/c of contamination w/oral flora
|
|
|
pulm Abscess: What is treatment? Need hospitalization? When do you stop meds
|
i)Need hospitalization w/postural drainage. ii)antimicrobial: G+=unasyn or vanc for S aureas; anaerobes=clinda or metro; G--=fluoroquin or 3rd gen cephalo. iii)Continue until cavity gone or CXR is much better
|
|
|
When is TB contagious? how is it transmitted?
|
i)When it is reactivation and not primary dz. ii)aerosolized respiratory droplets
|
|
|
How do "Primary" TB bugs live in lungs? How are they dormant? What can activate TB?
|
i)Multiply in macrophages->disseminate via lymphs->live in walled off granulomas ii)live in granuloma iii)insult to immune system
|
|
|
What are exs (x5) of when secondary TB happens? What is a complication? What is extrapulm TB and who is it common in?
|
i)a)HIV b)malignancy c)poor nutrition d)immunosuppressants e)substance abuse ii)hematogenous spread or lymphatic spread->miliary TB iii)Extrapulm TB: if immunosupp, they might not be able to contain bacteria at primary or 2/2 stage of infection, and can get it all over body. common in HIV pts
|
|
|
What kinds of signs and sxs in primary TB?
|
i)asx; pleural effusion can happen; if little immunity, then can get pulm and constitutional sxs (progressive, primary TB)
|
|
|
Signs and sxs of 2/2 TB x3? Extrapulm TB: where? What is miliary TB due to and what are signs x3?
|
i)a)constitutional signs; b)cough w/hhemoptysis (advanced); c)rales ii)LNs, pleura, GU tract, spine, intestine. iii)Hematogenous dissemination, due to reactivation or new infection. Signs of miliary TB: organomegaly, reticulonodular infiltrates on CXR, choroidal tubercles in eye
|
|
|
What is definitive DX for TB? what is another test to be used inpt? Screening for TB w/HIV?
|
i)sputum culture: get 3 sputum specimens; PCR is more sensitive; ii)PPD in HIV needs <5 mm for HIV pts
|
|
|
How to treat active TB? 2nd treatment for TB?
|
i)isolate pt until sputum is neg for AFB ii)1st line=INH, rifampin, pyrazinamide, ethambutol for 2 months; 4 months of INH and rifampin
|
|
|
What are annual epidemics in influenza due to? What are our pandemics due to? What are clinical findings for Flu? What is treatment?
|
i)genetic reassortment ii)genetic recombination iii)rapid onset of fever, chills, malaise, H/A, nonprod cough, sore throat. iv)amantadine or rimantadine decr duration of symptoms, but TX is SUPPORTIVE
|
|
|
What is hallmark clinical manifestation of botulism? What other things can happen?
|
i)descending flaccid paralysis: dry mouth->diplopia and dysarthria->limb paralyzed. ii)N/V, ab cramps, diarrhea
|
|
|
How to DX botulism? What is treatment if suspected? If wound infected?
|
i)ID toxin in serum, stool, gastric contents. ii)if suspect, admit and observe respiratory status; Gastric lavage good if w/in several hours after food ingestion; Give anti-toxin as soon as lab specimens obtained. iii)contaminated wounds: wound cleansing and pcn
|
|
|
What is DDX of botulism? x4
|
subtype of GBS; Myasthenia; Eaton lambert; diphtheria
|
|
|
What is cause of intra-ab abscess? x5 What is origin? How to DX? What is TX? What bacteria do you want to empirically treat?
|
i)a)SBP b)TOA c)Colon perf d)pancreatitis e)OM of vertebrae ii)polymicrobial iii)broad spectrum G--, enterococci, anaerobes
|
|
|
What are other organisms causing UTI besides E coli? x5
|
i)staph sapro ii)enterococc iii)kleb iv)pseudomonas v)proteus
|
|
|
What are host dependent risk factors? x5
|
i)pregnant ii)diabetes iii)spinal cord injury iv)impedence of urinary flow: incomplete void, neurogenic bladder, BPH, calculi v)immunocompromised. Uncut cock; anal
|
|
|
What are noninfectious causes of cystitis or cystitis like sxs? x4
|
i)cytotoxic agents (cyclophos) ii)radiation to pelvis iii)dysfunctional voiding iv)interstitial cystitis
|
|
|
What does leuk esterase mean? nitrite test?
|
i)pyuria ii)G- bacteria
|
|
|
U/A: What does epi cells mena? What are critera for UTI? x2
|
i)vulvar or urethral contamination: if contamination suspected, need straight cath. ii)a)>1 bacteria/HPF; but need WBC or else may be contaminated b)>8WBC/HPF.
|
|
|
What is UTI treatment usually based on? When get cultures? x5
|
i)U/A and gram stain ii)a)DM b)age >65 c)recurrent UTI d)use diaphragm e)sxs present >7 days
|
|
|
What are complications of UTI? x3 and how do they present? What are risk factors for upper UTI? x3 Risk factors for recurrent infections?
|
i)spread beyond bladder (pyeloneph, prostatitis, urosepsis). Risks: Pregnant, DM, VUR. ii)pregnancy: PTL, low birth weight. iii)Recurrent infxns: usually due to new organism; risks=pregn, VUR, sex
|
|
|
How do you treat pregnant women w/UTI? How about men? What to do in men if complication or recurrence? What to do if recurrent infxn w/in 2 weeks vs not?
|
i)cephalo, ampicillin, or amoxicillin x7-10 d. no quinolones ii)like women except 7 days. do uro w/u if recurrs or complications iii)w/in 2 weeks, treat w/same abx for 2 weeks and cx. if not, treat as uncomp cystitis.
|
|
|
what is most common cause of pyelo? (other organisms same as uti)
|
E coli (staph sapro, proteus, kleb, entero, pseudomonas)
|
|
|
What are complications of pyelo? x3
|
i)sepsis ii)emphysematous pyelo: gas producing bacteria in DM iii)chronic pyelo w/scarring
|
|
|
How to treat uncomplicated pyelo as oupt?
|
i)give dose of ceftri or gentamicin, then bactrim or fluoroquin for 10-14 days for G- and amoxi for G+ cocci. Repeat urin cx after cessation of tx. If failed after 2 days, adjust to urine cx. if failed now, need uro exam.
|
|
|
When to hospitalize for pyelo (x5)and what to do? x4
|
i)a)very ill b)elderly c)pregnant d)can't tolerate po meds e)urosepsis suspected. ii)a)IVF b)broad-spec IV amp+gentamicin or fluoroquin c)if neg bcx, then treat w/IV abx until afebrile. d)if uroseptic: IV abx x 2-3 wks.
|
|
|
What is pathophysiology of acute prostatitis? x3 What are the bugs? How old is pt for acute vs chronic?
|
i)a)asc infection from urethra and reflux of infected urine b)may occur after urinary cath c)direct or lymphatic spread from rectum ii)same as UTI and same for chronic/acute iii)acute is young, chronic is old
|
|
|
What should you avoid doing in acute prostatitis? what are sxs of acute prostatitis?
|
i)prostate massage b/c causes bacteremia: can skip rectal usually ii)toxic appearing; dysuria, freq, urgency; low back pain, perineal pain, urinary retention
|
|
|
What does DRE show for prostatitis? U/A? UCx? When to get CBC and bcx?
|
i)boggy, tender prostate ii)sheets of WBC iii)pos UCx iv)if toxic looking or if sepsis suspected.
|
|
|
How to treat prostatitis?
|
outpt basis if mild, 4-6 weeks w/quinolone + doxy or just bactrim.
|
|
|
What bug are most reiter's cases due to?
|
chlam
|
|
|
what cancer is chlam a risk factor for? How to DX chlam? x3 How to treat? x2
|
i)cervical ca ii)a)PCR! b)cx c)immunoassay iii)one dose azithro or 7 days doxycycline
|
|
|
what are complications of chlam in men? x2 of gonorrhea?
|
epididymitis or prostatitis ii)same
|
|
|
What are the findings in disseminated gonococcal infxns? x3
|
i)fever, arthralgias, tenosynovitis ii)migratory polyarth/septic arth, endocard iii)skin rash
|
|
|
How to DX gonococc? x2
|
i)gram stain of organisms w/in leukocytes ii)get cx; treat empirically b/c cx takes long time. Get blood cx if disseminated
|
|
|
How to treat gonocco? x2 If disseminated?
|
i)ceftriaxone IM one dose (good for syph also) ii)azithro or doxy for chlam iii)IV ceftriaxone x7 d
|
|
|
What are the 4 stages of HIV infection? what are the sxs?
|
i)primary: mono like syndrome 1 mo after HIV exposure. Fever, sweats, alaise, arthralgia/myalgia, lymphad, truncal rash. ii)asympto infection: seropos but no clinical evidence. lasts 4-7 yrs if treated. iii)sympto (pre-aids): 1-3 years w/o tx. constitutional sxs, lymphad, fungal infxns, oral hairy leukoplakia on tongue, seborrheic derm, psoriasis exacerbation, warts. iv)AIDS: OIs, CD4<200
|
|
|
What OI's are at CD4 200-500? x5
|
i)herpes zoster ii)TB iii)lymphoma iv)bacterial pneumonia v)Kaposi's. Most OI's <200.
|
|
|
What is indications for antiretro tx? x2
|
sympto: treat; asympto: if CD4<500.
|
|
|
Wha is HAART? How do you monitor response to tx? What is the goal? What do you do for pregnants?
|
triple drug therapy using 2 NRTIs and either NNRTI or protease inhibitor. Don't give if pt will be noncompliant. ii)RNA load: want to get undetectable. iii)continue HAART
|
|
|
What is leading cause of death in pts w/aids? What CD4 count does it occur at? When are you susceptible to MAC(most common OI) or CMV?
|
i)PCP ii)at CD<200. Have diffuse interstitial infiltrates; treat w/bactrim and can add steroid if increased A-a or hypoxic. iii)at <50
|
|
|
When are you susceptible to esophageal candidiasis?
|
CD4<100
|
|
|
What are the 4 prophylaxis for OIs and at what CD4 count?
|
i)PCP: Bactrim when CD4<200 or if h/o candidasis. ii)TB: screen w/PPD yearly and give B6+INH if +. iii)MAC: azithromycin when CD4<100. iv)Toxo: Bactrim when CD4<100.
|
|
|
What vaccines are given for HIV? x3
|
i)Flu ii)pneumovax iii)HBV. No live virus!
|
|
|
What dz contraction is genital herpes ass'd w/? ii)What dz is HSV1 ass'd w/?
|
HIV ii)bell's palsy
|
|
|
How long are the symptoms in primary HSV2? Recurrent infections? What are the findings in HSV2? What dz's can arise from Herpes?
|
i)3 weeks ii)10 days iii)constitutional + tender inguinal lymphad, multiple painful vesicles, vaginal/urethral d/c iv)a)disseminated: enceph, mening, keratitis, chorioretinitis, pneumonitis, esophagitis b)neonatal (vertical): malformed, IUGR, chorioamnionitis, death. c)ocular: keratoconjunctivitis
|
|
|
How to DX herpes? x3 Which is 1st test, and what is gold standard? What to treat w/?
|
i)Tzanck: but can't rely on it ii)culture is gold standard iii)direct fluorescent assay iv)valacyclo, famciclovir, acyclovir
|
|
|
What is herpetic whitlow? how to treat?
|
i)infection of finger due to inoculation into open skin surface. Get fever and axillary lymphad. no incision or drainage
|
|
|
What is primary stage of syphilis defined as? 2ndary? latent? tertiary?
|
i)painless single chancre; painless lymphad; highly infectious ii)maculopapular rash; constitutional sxs, generalized lymphad. iii)latent: +sero test w/o signs/sxs. 2/3 stay at latent. Not infectious if >1 year iv)tertiary: neurosyphilis, cardiac or gummas. NEed CSF to dx
|
|
|
How to DX syphilis x2? What is most commonly used and which is definitive dx test? What else should you test for?
|
i)a)darkfield microscopy (definitive) b)serologic tests: nontrep (vdrl) has high sensitivity and more commonly used; FTA-ABs more specific. ii)HIV
|
|
|
What is TX for syphilis for early vs late
|
i)Abx is good for early syphilis, not as much for late. ii)PCN G (1 dose IM); if allergies and nonpreg, oral abx (doxy, tetra) for 2 weeks. iii)latent or tertiary: PCN IM 3x 1x/week.
|
|
|
What is dx of chancroid? x4
|
i)painful, multiple ulcer ii)unilat tender lymphad (bubo) 1-2 wks post ulcer iii)syphilis r//o iv)HSV r/o clinically or neg cx. No serology
|
|
|
how to treat chancroid?
|
IM azithro or ceftriaxone one time
|
|
|
What is LGV transmitted by? What are clinical features? What can happen if untreated? How to DX? What is treatment?
|
i)Chlam ii)painless ulcer, weeks later get unilat tender inguinal lymphad+constitutional iii)proctocolitis w/perianal fissures and rectal stricutre. Can get elephantiasis. iv)serologic tests v)doxycycline PO x21 days
|
|
|
What is cellulitis? Why do pts get recurrences in same area? What is most common cause x2? What are causes via wounds/abscess?
|
i)inflamm condition of skin and subq tissue. ii)damage that occurs to local lymphatic vessels iii)GAS or S aureus iv)staph
|
|
|
How to DX? what is a medical emergency for cellulitis?
|
i)clinical; get Blood Cx if pt has fever; tissue cx if wound or ulcer. image if think the wound is deep. ii)if spreads to orbits, but be worried if spread to face iii)may need dopplers to distinguish from DVT (same signs and sxs)
|
|
|
How to treat cellulitis? x1
|
With staph pcn (nafcillin oxacillin) or cephalosporin. Continue IV abx utnil signs of infection improve. 2 week oral abx after
|
|
|
What is erysipelas? what causes it? What is presentation? What are predisposing factors? x4
|
i)cellulitis usually confined to dermis and lymphatics ii)GAS iii)well-demarcated, fiery red, painful lesion usually on lower extremities and face. can have fever and chills iv)a)lymp obstruction (rad mastectomy) b)local trauma/abscess c)fungal infxn d) DM
|
|
|
How to treat erysipelas if uncomplicated; if complicated?
|
i)uncomp: IM or oral PCN or erythro ii)comp: treat for cellulitis
|
|
|
What is necrotizing fasciitis? What causes it? What are clinical feature x2? What can it progress to x3? What is tx? x2
|
i)life-threatening infection of deep soft tissues rapidly tracks along fascial planes ii)GAS or clostridium iii)fever and pain out of proportion to appearance, and extension leads to thrombosis of microcirculation->tissue necrosis, discolor, crepitus, cutaneous anesthesia. iv)sepsis, TSS, multiorgan failure v)surgical excision + parenteral antimicrobial
|
|
|
How to treat tetanus? x5
|
i)admit to ICU and give respiratory support, diazepam for tetany ii)neutralize unbound toxin w/passive immunization: IM dose of tetanus Ig iii)give active immunity w/tetanus/diphtheria toxoid iv)thoroughly clean and debride any wounds w/tissue necrosis v)give Abx (metro or PCN)
|
|
|
What are the ways microorganisms get into joints to cause infectious arthritis? x4
|
i)hematogenous: most common ii)contiguous spread from another locus (OM, abscess, or cellulitis) iii)traumatic injury to joint iv)iatrogenic (arthrocentesis, arthroscopy)
|
|
|
What are the signs of disseminited gonococcal arthritis? What should you do? What does gono arthritis present as? What should you co-treat with?
|
i)f/c, rash. ii)admit to hospital iii)mono or oligo arthritis that becomes migratory. iv)treat for chlam also
|
|
|
What is most common offender of infectious arthritis? what about young sexually active adults? what about scd, immunodef, IVDA? What are 3 risks for it?
|
i)Staph aureus, sometimes strep ii)Gonococcus iii)pseudo or salmonella. iv)a)prior jt damage (RA) b)jt prosthesis c)DM. iv)micromotion of jt causes severe pain in septic arthritis, and if painless range of motion, then septic arthritis unlikely
|
|
|
What is most common jt affected for infectious arthritis? when would you ahve polyarticular arthritis and what is its px?
|
i)knee ii)immunosuppresion or CT dz iii)worse px
|
|
|
What is clinical features of infectious arthritis? x3 How to DX? How to monitor? what else to do if gonococcal arthritis suspected?
|
i)jt is swollen, warm, painful ii)ROM is limited and effusion can be palpated iii)constitutional sxs. iv)jt tap w/80% PMNs and >50K WBC; gram stain; culture. v)monitor w/ESR and CRP vi)get cultures from mucosal surfaces (GU tract)
|
|
|
How to treat infectiuos arthritis?
|
i)prompt abx tx: don't delay; if stain is neg but still suspect, treat empirically ii)surgical drainage to prevent further damage: shoulder and knee ok(just aspirate qd), but hip should be opened.
|
|
|
What are complications of infectious arthritis? x3
|
i)destruction of jt and surrounding structures (ligs, tendons) leads to stiffness, pain and LOF ii)avascular necrosis of hipiii)sepsis
|
|
|
When does lyme dz peak in incidence? What happens after several weeks after erythema migrans and flu sxs? How to dx? x2
|
i)summer ii)meningitis, enceph, bilat bell's palsy; then cardiac; then late is arthritis (knees) iii)a) if clinically see it, treat empirically. b)sero: confirms clinical suspicion (eliza detects IgM and IgG; western confirms)
|
|
|
How to treat lymes if only at skin? If past the skin? For BAK(e)?
|
i)10 days PO doxycycline ii)20-30 days abx iii)30-60 days. iv)meningitis: IV abx x4 weeks
|
|
|
How to treat malaria? What might you add to falciparum? How to treat vivax an ovale? What to give for ppx?
|
i)chloroquine unless resistance->quinine and tetracycline or atorvaquone and mefloquine ii)IV quinidine and doxy iii)2 week primaquine regimen b/c of hypnozoites in liver iv)mefloquine if chloroquine resistant, otherwise just chloroquine
|
|
|
What are the clinical features of rabies? What are sxs in progressive order?
|
i)devastating deadly viral encephalitis: if sxs present, it is fatal. ii)sxs: pain at site of bite->constitutional sxs->encephalitis-hydrophobia (can't drink b/c laryngeal spasm w/drinking)->death. Some have ascending paralysis
|
|
|
How to dx rabies? x4
|
i)identify virus in infected tissue or saliva ii)fourfold increase in Ig titers iii)Negri bodies on histology iv)PCR detection of RNA
|
|
|
How to treat? x4
|
i)Clean thoroughlyi)if wild animal: kill and look at brain ii)domesticated animal is held for 10 days to see if it changes iii)passive Immunization to wound and butt iv)antirabies vaccine x3 over 28 days
|
|
|
What does candida look like? are they normal fungi in body? What are 2 risk factors besides immunosupp?
|
i)oval, budding yeasts w/hyphae and long pseudohyphae. ii)yes, it is overgrowth for candidiasis iii)a)DM b)abx therapy
|
|
|
Where are the diff places that candida usually affect? x4 what does it look like in each place? painful?
|
i)a)vagina: yeast infection w/cottage cheese that is painless but itchy b)mouth: thrush; painless c)cutaneous: diabetic patients under breasts d)esophagitis causes odynophagia
|
|
|
How to dx candidiasis? Invasive candidiasis?
|
clincally: KOH prep shows yeast. ii)dx by blood or tissue cx
|
|
|
What is treatment in general (x1) and for diff types of candidiasis (oral, vag, cutaneous, systemic?)
|
i)remove indwelling catheters or central lines ii)a)nystatin swish swallow for oral candida b)vag: miconzaole cream c)cutaneous: nystatin powder d)systemic: ampho B or fluconazole
|
|
|
What dz does aspergillosis cause x3
|
i)allergic bronchopulm asper: T1HS to asper; get asthma and eosinophilia ii)pulm asper: inhaled spores; chronic cough or hemoptysis; bronchiectasis, tb, histo, sarcoids are at risk iii)invasive: hyphae invade lung vasculature->thrombosis and infarction. risk pts are leukemic, xplant recipient, AIDS. can invade sinuses and brain and orbits.
|
|
|
How to dx asper? x2 what isn't helpful
|
i)Tissue bx: def dx; dx presumed if asper isolated from sputum of immunosupp pt w/clinical sxs. ii)CXR: fungus ball and dense pulm consolidation iii)blood cxs are unhelpful b/c rarely positive
|
|
|
How to treat asper if allergic? if pulm asper? if invasive? what to do if head or brain involvement suspicion?
|
i)avoid exposure and steroids ii)massive hemoptysis may need lung lobectomy iii)invasive asper: IV ampho B, or voriconazole iv)need prompt evaluation w/imaging, may need surgery
|
|
|
how does infxn happen in crypto? What is clinical features of cryptococcis? What to treat w/? What are sxs? How to DX?
|
i)inhale fungus to lungs, hematog spread to brain/meninges ii)CNS dz: menigitis or meningoenceph or brain abscess. iii)need aggressive treatment w/amphotericin B w/flucytosine for 2 weeks. iii)sxs: fever, H/A, irritable, confused. Can also get isolated pulm infection iv)DX: LP; Tissue bx shows lack of inflammation
|
|
|
what is the body's central control of temperature pathway?
|
Hypothal->limbic system->lower brainstem->reticular formation->spinal cord->symp ganglia
|
|
|
What is defn of fever? When is temp lowest and highest?
|
>99 in morning; >100 in afternoon. Nadir at 6 am and peak at 4 pm
|
|
|
What does temp >106 mean? What is defn of hyperthermia? What about hyperpyrexia?
|
i)either hyperthermia or hyperpyrexia. ii)hypertherm: no change in hypothalamic setpoint when thermoregulatory control is overwhelmed by exogenous heat and heat production. iii)high fever (w/change in set point) usually due to CNS hemorrhage but can be obsered in pts w/severe infections
|
|
|
What are the cytokines that are part of fever? What is pathway to ignite the hypothalamus? What is main cytokine? What do cryogens do?
|
i)IL-1,6; TNF; IFN; PGE2 ii)cytokines stimulate OVLT in preoptic region, which has neurons entering hypothalamus. iii)PGE2 iv)prevent set point from rising out of control
|
|
|
How do you differentiate temperature elevation due to fever vs hyperthermia?
|
i)fever: shivering and peripheral vasoconstriction. Defervescence: vasodilation and sweating. ii)hypertherm: don't have these responses and h/o environmental or drug exposure and/or excessive exertion preceding development of high temp
|
|
|
What is cause of most outpt fevers and how long? When to suspect bacterial infection?
|
i)viral illness; 2 weeks. ii)very sick looking (pale,dyspneic, altered mental status, cool, clammy, hypotensive)
|
|
|
What to do after h&p and can't find source? What do you see on blood smear if bacterial? What do you see in viral? What 2 things is leukopenia ass'd w/? What is lymphocytosis w/atypical lymphocytes ass'd w/?
|
i)CBC w/differential; peripheral blood smear; U/A. ii)Immature band forms, peripheral blood smear, Dohle bodies. iii)leukopenia. iv)autoimmune or marrow infiltrative d/o's. v)EBV, CMV, HIV
|
|
|
What is monocytosis ass'd w? x2
|
Typhoidal disease and TB
|
|
|
If fever persists for more than 1-2 weeks, what other blood test can you do? When is an outpt considered to have FUO?
|
i)ESR and CRP: elevations in one or both indicate serious underlying dz. ii)>3 weeks or >3 visits
|
|
|
When is fever considered FUO in inpt for immunocomp? For immunocompetent w/o dx?
|
i)>3 days ii)>1 week
|
|
|
What are the 3 main causes of FUO? What do you start evaluating for if no infectious cause of fever is found? x3 What are misc causes of fever? x3
|
i)infectious; inflammatory; malignancy ii)autoimmune dz; CT dz; granulomatous dz. iii)thyroiditis and PE and drug fever
|
|
|
What is rational for using empiric abx vs not using?
|
i)stable pts w/o localizing signs, don't use abx ii)unstable pts w/o localizing signs, use empiric broad spectrum abx
|
|
|
What 3 characteristics are necessary for FUO?
|
i)a)fever >101 b)continues for at least 3 weeks c)no dx over the time period despite 1 week of w/u or 3 outpt visits
|
|
|
What infectious causes for FUO are most common? x8
|
i)TB and other mycobacteria ii)occult abscess (hepatic and retroperitoneal) iii)UTI/complicated UTI iv)endocarditis v)sinusitis vi)HIV vii)mono viii)malaria and parasites
|
|
|
What is 2nd most common cause of FUO? Which dzs? x2 What is 3rd most common cause? what are causes? x4
|
malignancy ii)leukemia and lymphoma (HL) iii)Collagen vascular dz a)SLE b)PAN c)temporal arteritis d)polymyalgia rheumatica.
|
|
|
What are other causes of FUO besides infection and CVD and malignancy? x6
|
i)Granulomatous dz: sarcoid, Crohn's ii)drug fever iii)PE iv)hemolytic anemia v)familial med fever vi)gout vii)subacute thyroiditis
|
|
|
What should you be suspicious of if there is persistent fever in ICU despite ABX x4
|
i)fungal infection ii)antimicrobial resistance iii)infectious requiring surgical intervention: occult abscess, wound necrosis iv)drug fever
|
|
|
What are rigors?
|
severe form of chills w/pronounced shivering and chattering of teeth
|
|
|
What imaging do you want in FUO? What invasive diagnostic tests would you want?
|
i)CXR, CT of chest and abs for tumors and abscess ii)tagged wbc scan iii)MRI, U/S, Echo if needed iv)bx of LN, BM, or other tissue if high suspicion of abscess
|
|
|
What causes hyperthermia? x3 How t treat? When do you treat fever w/antipyretics? x4
|
i)a)NMS b)malig hyperthermia c)heat stroke ii)cooling blanket, not anti-pyretics b/c won't come down. iii)a)temp>105 b)pt wants relief c)pt is pregnant d)significant cardiopulm dz (incr in O2 demand w/fever)
|
|
|
What happens in sepsis pathophysiology?
|
i)endothel damage leads to TF expression and activation of TF-dependent clotting cascade->thrombin formation (fibrin, plts, neutrophils, RBCs impair capillary blood flow to decrease O2 and nutrient delivery to tissues). ii)NO released to vasodilate and get impaired O2 delivery and anaerobic metabolism on cellular level. (lactic acidosis)
|
|
|
What are the criteria for SIRS? For sepsis For severe sepsis? Septic shock?
|
i)RR >20 or CO2<32 ii)WBC <4000 or >12000 iii)HR >90 iv)temp >101 or <96.8. ii)SIRS+evidence of infection iii)sepsis+hypoperfusion, organ dysfcn, or hypotension (lactic acidosis, oliguria, or altered mental status)
|
|
|
What is protocol for sepsis? x6
|
i)get CVP 8-12 (put central line in and add crystolloid or colloid until achieved) ii)MAP>65: add pressor(NE) if need. iii)broad spectrum ABX w/in 1 hr of dx (G+, G-, and antifungal in immunocompromised). iv)Protein C if severe sepsis at high risk of death (better mortality). v)regulate blood glucose levels w/insulin. vi)give DVT, PPI or H2 ppx
|
|
|
What are the organisms responsible for OM? x2 Wat are the 2 categories of OM and what is the subgroup of direct spread? x3.
|
i)S aureus; Coag neg staph ii)hematogenous (sepsis in kids) vs direct spread (adjacent infection like diabetic ulcer; trauma; vascular insuff like PVD)
|
|
|
What are the organisms in OM b/c of IVDA or neutropenia? x2 For SCD? For nosocomial? diabetic foot ulcer?
|
i)pseudomonas, fungi ii)salmonella iii)pseudo iv)polymicrobial
|
|
|
What are risk factors for complications or chronic OM? x4
|
i)open fractures: orthopedic hardware increases the risk (foreign body is site of bacterial colonization). ii)DM (cases predispo to infection and PVD) iii)IV drug use iv)sepsis
|
|
|
What are signs and sxs of OM?
|
i)pain over bone ii)localized erythema, warmth or swelling. iii)possible draining sinus tract
|
|
|
How to DX OM? x3?
|
i)FNA bx is best, and culture for ABX therapy. ii)MRI is best imaging (bone scans too nonspecific) iii)ESR and CRP good for monitoring response to therapy
|
|
|
What is tx of OM? x2
|
i)IV abx: empiric is penicllinase resistant pcn or 1st gen ceph ii)add aminoglycoside if G- thought iii)surgical debridement of infected necrotic bone
|
|
|
What are the bugs that cause catheter related sepsis? Where is the catheter usually? What are 3 risk factors for catheter related sepsis?
|
i)central venous catheters, esp in ICU ii)S aureus, S epidermidis iii)a)emergent placement b)femoral lines c)prolonged indwelling of line
|
|
|
What to do if suspect catheter related sepsis? Does site of insertion always show erythema and purulence?
|
i)remove catheter and send tip for culture. this usually gets rid of fever and decr leukocytosis. Start ABx and narrow spectrum once organism id'd. ii)no.
|
|
|
What is neutropenia defined as? What level of ANC (bands+mature)relates to very incr risk of infxn
|
i)ANC<1500 ii)<500
|
|
|
What are common causes of neutropenic fever? x4
|
i)BM failure (toxins, drugs) ii)BM invasion (heme malig, mets) iii)peripheral causes (hypersplen, SLE, AIDS) iv)agranulocytosis usually due to drug rxns.
|
|
|
What are the most common infxns seen in neutro fever? x3 Why is fever imp to catch?
|
i)a)septicemia b)cellulitis c)pneumonia ii)fever may be only manifestation of ragin infection
|
|
|
What do you need to obtain for neutropenic pt w/fever? x4
|
i)CXR ii)Pan culture (blood, urine, sputum, line tips, wound) iii)CBC iv)BMP
|
|
|
What room precautions do you do for neutro fever? What to do after cxs are drawn? If fever longer than 5 days, what to do?
|
i)reverse isolation (masks and handwashing for those entering) ii)give broad spectrum abx iii)give antifungals like IV amphotericin
|
