Maya - Gen Med Final Question

Front 1

What parts of the brain regulate adh release?

Back 1

pituitary and the hypothalamus

Front 2

When ADH reaches the collecting ducts this protein is released:

Back 2

Aquaporin-2 (causes water retention)

Front 3

3 cases of primary polyuria (which is most common?)

Back 3

1) Osmotic diuresis (most common)
2) ADH deficiency (CDI)
3) Inability to respond to ADH (NDI)

Front 4

5 Causes of osmotic diuresis

Back 4

1) Diabetes mellitus -> glucose
2) Renal insufficiency -> urea
3) Amino acids/ proteins
4) Fanconi syndrome (AA or fatty acids)
5) Glomerulonephritis (protein losing neuropathy)

Front 5

What is the most common cause of central diabetes insipidus?

Back 5

Idiopathic (cause generally not found)

Front 6

4 causes of nephrogenic diabetes insipidus

Back 6

1) Congenital lack of ADH receptors (rare)
2) Gram negative endotoxins (pyometron)
3) Pyelonephritis
4) Chronic kidney disease
5) Metabolic disorders

Front 7

5 metabolic disorders that induce NDI (most common?)

Back 7

1) Hypokalemia
2) Hypoadrenocorticism
3) Hyperadrenocorticism
4) Hyperthyroidism
5) Hypercalcemia (Most common - from lyphoma generally)

Front 8

How do you distinguish pollakiuria and dysuria from pu/pd?

Back 8

By confirming the polydypsia --> have owner quantify water intake

Front 9

Which is more often the primary problem polyuria or polydypsia?

Back 9

Polyuria! (then they drink because they are dehydrated)

Front 10

3 causes of consistent isothenuria on a U/A? What is the specific gravity reading for isothenuria?

Back 10

1) Renal insufficiency
2) Partial CDI
3) Nephrogenic DI

1.008-1.012

Front 11

4 renal values in a blood chemistry

Back 11

1) BUN
2) Creatinine
3) K+
4) PO4

Front 12

If you see an increased ALP on a chemistry profile for a pu/pd patient what disease do you suspect?

Back 12

Cushings - Hyperadrenocorticism

Front 13

If a pu/pd patient has a normal blood glucose and glucosuria what disease does this indicate?

Back 13

Fanconi syndrome (lose glucose and protein in their urine but they don't have diabetes so their bg is normal)

Front 14

What would a cushing's disease patient's adrenal glands look like on ultrasound?

Back 14

Hyperechoic (whiter)

Front 15

What is the normal size of an adrenal gland on ultrasound?

Back 15

<7mm

Front 16

What specialized test can be used to differentiate Diabetes insipidus from Psychogenic polydypsia?

Back 16

Plasma osmolality (hi with DI and low with P-PD)

Front 17

What test can be used to differentiate CDI/ NDI/ and psychogenic pd?

Back 17

Modified water deprivation test

Front 18

What patients should not have a water depravation test done on them?

Back 18

1) Patient that is clinically dehydrated
2) Patient with a plasma osmolality >320 mOsm/kg

Front 19

8 behavioral signs a horse is in pain

Back 19

1) Abnormal standing position
2) Low head position
3) Ears pinned back
4) standing in the back of the stall not interacting when a person approaches
5) Spontaneous locomotion
6) Scared when the door is open
7) Lifting feet up
8) Not interested in grain when offered

Front 20

6 side effects of pain (its a medical condition)

Back 20

1) Cortisol release
2) Cardiovascular effects - tachycardia, arrhythmias, hypertension
3) GI effects - ulceration, ileus
4) Respiratory effects - pulmonary dysfunction, respiratory acidosis
5) Immune dysfunction
6) Clotting dysfunction

Front 21

Nmda receptor agonist used for acute pain treatment

Back 21

Ketamine

Front 22

Which neurons cause wind up and amplify the pain signals?

Back 22

Neurons of the dorsal horn of the spinal cord

Front 23

What drug can be used as an intra-articular analgesia to down regulate pain receptors?

Back 23

morphine

Front 24

What are the 5 cardinal signs of inflammation?

Back 24

1) Pain
2) Redness
3) Heat
4) Swelling
5) Loss of function

Front 25

What is the most potent class of analgesics?

Back 25

Opioids

Front 26

Which opioid are horses probably being underdosed with? (we aren't using a therapeutic dose if we use plumb's)

Back 26

Butorphanol (.2 optimal but .02 is the clinical dose )

Front 27

What route of administration for opioids can greatly decrease the chance of side effects?

Back 27

dermal patch (fentanyl patch but it can get expensive quick)

Front 28

What 2 drugs together as a CRI are good for a standing procedure in a horse?

Back 28

Xylazine and detomedine

Front 29

How are edema and effusion different?

Back 29

Edema -> fluid in the tissue interstitum
effusion -> fluid into a body cavity

Front 30

What 3 tissues swell rapidly with angioedema?

Back 30

1) Skin
2) Mucosa
3) submucosa

Front 31

4 important variables of starling's equation?

Back 31

1) Capillary hydrostatic pressure
2) Interstitial hydrostatic pressure
3) Capillary oncotic pressure
4) Interstitial oncotic pressure
(the rest are constants for that tissue)

Front 32

What percent of fluid absorbed into capillaries actually stays in the blood?

Back 32

Only 10% (90% of the fluid absorbed into capillaries is resorbed into the tissue)

Front 33

4 causes of edema/ effusion (general terms)

Back 33

1) Increased capillary hydrostatic pressure
2) Decreased capillary oncotic pressure (decr albumin)
3) Impared lymphatic drainage (blockage)
4) Loss of vascular integrity

Front 34

3 causes of a loss of vascular integrity

Back 34

1) Inflammation
2) Neoplasia
3) Heat/toxins -> leaky vessels

Front 35

2 main types of edema

Back 35

1) Peripheral edema
2) Pulmonary edema

Front 36

3 main ddx's for abdominal distention

Back 36

1) Organomegaly (gastric dil, si, li, bladder,liver, spleen, kidney)
2) Abdominal mass lesions
3) Effusions

Front 37

4 ways fluids are classified with fluid analysis

Back 37

1) Transudates
2) Modified transudates
3) Exudates
4) Neoplastic fluid

Front 38

3 specific types of exudates

Back 38

1) Chyle
2) Blood
3) Inflammatory

Front 39

how are transudates/ mod transudates/ and exudates differentiated?

Back 39

Transudate -> low cells and low protein (sg <1.015 cells <1500/ul)
mod transudate -> Moderate cells and moderate protein level (sg 1.015-1.025, <7000 cells/ul)
exudate -> hi cells, hi protein (sg >1.025, >7000 cells/ul)

Front 40

2 general causes of transudates with example conditions

Back 40

1) hypoalbuminemia ( protein losing enteropathy/nephropathy, liver disease)
2) Liver disease with portal hypertension (presinusodal or sinusoidal liver disease)

Front 41

2 general causes of modified transudates with example conditions

Back 41

1) Increased hydrostatic pressure
1)Post sinusoidal liver disease with portal hypertension
2) Budd chiari syndrome (post vena cava obstruction)
3) Heart failure
4) Pericardial disease (causes heart failure)
5) Lung lobe torsion

2) Damaged vascular wall
6)Neoplasia
7) Diaphragmatic hernia

Front 42

4 signs of heart failure (other than a mod transudate)

Back 42

1) Jugular venous distention
2) Abnormal jugular pulses
3) Hepato/splenomegaly

Front 43

4 disease that can cause pleural effusion

Back 43

1) Myocardial disease
2) Pericardial disease
3) Mitral/ tricupsid insufficiency
4) Severe R or L heart failure

Front 44

5 causes of a chylous effusion? (most common?)

Back 44

1) Trauma (lymph leakage from si)
2) Neoplasia (lymph node drainage is compromised)
3) Idiopathic (Most common)
4) Heart failure
5) Lung lobe torsion (lymph flow obstruction)

Front 45

4 causes of a blood effusion

Back 45

1) Trauma
2) Coagulopathy
3) Neoplasia (HSA)
4) Lung lobe torsion

Front 46

What is the general cause of an inflammatory effusion?

Back 46

Severe increase in vascular permeability

Front 47

5 causes of non-septic inflammatory effusion

Back 47

1) Pancreatitis
2) FIP
3) Bladder rupture -> Urine
4) Bile duct rupture -> Bile
5) Neoplasia

Front 48

3 parts of Beck's triad on a physical exam (what does this indicate?)

Back 48

1) Muffled heart sounds
2) Venous congestion (jugular pulses)
3) Weak femoral pulses
--> Clinical signs of pericardial effusion

Front 49

What is the treatment for pericardial effusion?

Back 49

Pericardiocentesis (get the fluid out!)

Front 50

What is the best course of treatment for a hemangiosarcoma?

Back 50

Patient must have resection surgery and chemo (only one or the other much worse prognosis)

Front 51

5 steps of the cough reflex

Back 51

1) Air inspired
2) epiglottis and vocal folds close
3) Diaphragm, Internal intercostals, and abdominal muscles contract
4) Epiglottis and vocal folds open
5) air is expelled

Front 52

What causes the sound you hear with a cough?

Back 52

Air and tissue vibration from turbulent air flow

Front 53

5 things that initiate a cough reflex

Back 53

1) Fluid
2) Noxious gasses
3) Particulate matter
4) External compression
5) Bronchoconstriction

Front 54

What is a cough without inspiration called?

Back 54

expiratory reflex

Front 55

When does a expiratory reflex happen?

Back 55

With direct stimulation (like intubation)

Front 56

Distal vs proximal airways
What kind of stimulation is each more susceptible to?

Back 56

Distal -> Chemical stimulation
Proximal -> Mechanical stimulatoin

Front 57

What specific receptor of the airways stimulates a cough?

Back 57

C-fibers

Front 58

What is the reflex loop of the C-fibers? (nerves ect involved)

Back 58

C-fibers --> Vagus n. --> Medulla --> cough center --> efferent muscles of the larynx, trachea, bronchi...ect

Front 59

What species is less susceptible to mechanical tracheal stimulation (to cause a cough)?

Back 59

Horse

Front 60

Where are most receptors that initiate cough by contact with irritants?

Back 60

Larynx and carina (they are also in may other places in the resp tract)

Front 61

3 Cardiovascular ddx's for cough

Back 61

1) Pulmonary edema
2) L atrial enlargement
3) Thromboembolic disease

Front 62

Important ddx's for a foal with a cough

Back 62

Septecemia or Rhodococcus equi pneumonia

Front 63

Top ddx for a toy breed with a cough

Back 63

collapsing trachea

Front 64

American cocker spaniel with a cough - ddx?

Back 64

Bronchitis (predisposed)

Front 65

Young cat with acute onset of cough and dyspnea - top ddx?

Back 65

Feline asthma

Front 66

Dog or cat with a heart murmur on the L side and a cough - top ddx?

Back 66

L sided heart failure w/ mitral regurgitation

Front 67

Dog or cat with a right sided heart murmur and cough

Back 67

Pulmonary hypertension with tricuspid valve regurgitation (r sided murmur less suggestive of underlying heart disease more suggestive of pulmonary disease)

Front 68

Dog or cat with weak irregular pluses and a cough

Back 68

cardiac disease (most likely cardiac and not respiratory)

Front 69

CT with contrast is done when what disease is suspected in a cough patient?

Back 69

Pulmonary thromboembolism

Front 70

Where do the most effective cough suppressants work? What class of drug are they?

Back 70

They work centrally (brain). Opioids

Front 71

When is treatment of the cough symptoms specifically contraindicated?

Back 71

Bacterial pneumonias

Front 72

4 cough suppresant drugs (most effective?)

Back 72

1) Butorphanol - most
2) Hydrocodone -most (2 of them)
3) Codeine
4) Dextromorphan

Front 73

2 treatments for bronchoconstriction leading to cough

Back 73

1) Methylxanthines (theophylline, theobromine)
2) Beta 2 agonists (albuterol, terbutaline)

Front 74

3 general causes of dyspnea

Back 74

1) Hypoxemia
2) Hypercapnia
3) Acidemia

Front 75

2 chemoreceptors for hypoxemia

Back 75

1) Aortic body (aorta :) )
2) Carotid body (subclavian a.)

Front 76

What is the bodies response to stimulation of central and peripheral chemoreceptors in the airways?

Back 76

Increased respiratory rate (try to compensate)

Front 77

7 general ddx's for dypsnea

Back 77

1) Airway disease (brachycephalic syndrome, nasopharyngeal polyps)
2) Pulmonary parenchymal disease
3) Pleural wall disease
4) Peripheral neuropathy/ myopathy (myasthenia gravis, botulism, polyradiculoneuritis, tick paralysis)
5) Thoracic wall disease (neoplasia, neuropathy, flail chest-rib fractures,penetrating chest wound)
6) Pain
7) High environmental temps

Front 78

What is the term for increased rate and effort of respiration?

Back 78

Hyperpnea

Front 79

4 ddx's for tachypnea

Back 79

1) Pulmonary parenchymal disease
2) pleural space disease
3) Thoracic wall disease
4) Metabolic acidosis (DKA, Ethylene glycol tox, renal failure, lactic acidosis, salicylate tox, diarrhea, ammonium chloride)

Front 80

Why should you take note if a coughing patient was recently treated with glucocorticoids?

Back 80

GC can cause pulmonary thromboembolisms b/c they can cause a hypercoagulation state

Front 81

What diagnostic can be used to diagnose cilliary dyskinesia?

Back 81

Nasal biopsies

Front 82

Which sinus is not a "true" sinus?

Back 82

Maxillary sinus

Front 83

Which species has a functional sphenoid sinus?

Back 83

cats

Front 84

What causes nasal congestion (in general terms)?

Back 84

When nasal capillaries become distended with blood

Front 85

When stimulated this nerve causes a sneeze

Back 85

Trigeminal nerve

Front 86

6 steps of a sneeze

Back 86

1) Rapid inspiration of air
2) Thyroarytenoideus contracts and closes the vocal folds
3) Abdominal muscles contract (air increases in pressure)
4) Caudal part of the tongue pushes up the soft palate
5) vocal folds open
6) Air is released (sneeze)

Front 87

What kind of reflex is a reverse sneeze?

Back 87

aspiration reflex

Front 88

What kind of disease does reverse sneeze point to?

Back 88

nasopharynx disease

Front 89

A dog is standing with its head and neck extended in a reverse sneeze what phase is this?

Back 89

the paroxysmal inspiratory phase

Front 90

In general what kind of nasal discharge does inflammatory disease have?

Back 90

serous or mucoid

Front 91

What inflammatory nasal diseases often present with epistaxis?

Back 91

fungal infections - Cryptococcosis and aspergillosis

Front 92

Young dog with recurrent pneumonia and sneeze -top ddx?

Back 92

Ciliary dyskenesia

Front 93

Young cat with sneeze, nasal discharge and is not from a shelter - top ddx?

Back 93

Nasopharyngeal polyp or stenosis

Front 94

German shepherd or other large breed dog with sneeze and nasal discharge - top ddx?

Back 94

Nasal aspergillosis

Front 95

10 year old dog with chronic sneeze and nasal discharge - top ddx?

Back 95

Nasal tumor

Front 96

New cat from a shelter with chronic nasal discharge - top ddx?

Back 96

Feline upper respiratory infection complex

Front 97

Dog with acute sneezing that is rubbing it's face - top ddx?

Back 97

nasal foreign body

Front 98

Horse with a lowered head and a ton of purulent nasal discharge - top ddx?

Back 98

guttural pouch empyema

Front 99

Horse has just finished exercising and now has nasal discharge - top ddx?

Back 99

lower respiratory tract lesion

Front 100

4 non specific treatments to clears respiratory secretions

Back 100

1) Humidification
2) Saline nasal drops
3) decongestants
4) Mucolytics

Front 101

Treatment that can cause increased nasal congestion and discharge once stopped

Back 101

decongestants

Front 102

What is the treatment for lymphoplasmacytic rhinitis?

Back 102

Immunosuppression - prednisone or prednisolone (and azathioprine, chlorambucil and cyclosporine possibly to decr side effects)

Front 103

What drug might be beneficial for nasal carcinomas and lymphoplasmacytic rhinitis?

Back 103

COX-2 inhibitory NSAIDs

Front 104

What is the treatment of choice for nasal aspergillosis?

Back 104

Clortrimazole or eniconazole

Front 105

What drug is indivated if there is a fungal infection of the sinuses that has ocular involvement?

Back 105

Fluconazole

Front 106

What is the treatment of choice for cats with severe CNS signs and nasal discharge?

Back 106

Amphotericin B and flucytosine (fungal infection)

Front 107

4 Functions of the nasal passages

Back 107

1) Filter air
2) humidify air
3) Moisten air
4) Sense smells

Front 108

A horse that recently walked into a pole - it's shoulder seems to pop out during weight bearing phase - What nerve was damaged?

Back 108

Suprascapular n. (infra/supraspinatus muscles effected)

Front 109

Dog limping with severe atrophy of the triceps - what nerve is damaged?

Back 109

Musculocutaneous n.

Front 110

3 main nerves of the forelimb

Back 110

1) Musculocutaneous n.
2) Radial n.
3) Ulnar n.

Front 111

3 main nerves of the hindlimb

Back 111

1) Saphenous n.
2) Peroneal n.
3) Tibial n.

Front 112

What is the term for a behavior change seen in an animal before a seizure?

Back 112

Prodomal sign (aura)

Front 113

Non clinical seizure only seen on EEG

Back 113

Focal seizure

Front 114

Cat that all the sudden starts to tremor and bite the air after being pet on the back

Back 114

Simple partial seizure

Front 115

Dog staring off into space then starts biting it's flank mechanically

Back 115

Complex partial seizure

Front 116

Dog with dilated pupils, clinched jaw, and tonic muscle contractions

Back 116

Generalized seizure

Front 117

5 dog breeds with genetic predisposition for seizures

Back 117

1) German shepherds
2) Golden retreiver
3) English springer spaniel
4) Labrador retreiver
5) Standard poodle

Front 118

2 EMG abnormalities that may be seen in an animal with seizures (what should normal look like?)

Back 118

1) Fibs (biphasic -fried egg sound)
2) Sharps (monopolar - putt putt sound)
(normal should be a straight line - quiet)

Front 119

4 points of contact on the patient for a nerve conduction velocity test

Back 119

1-2) 2 stimulation sites
3) recording site
4) ground

Front 120

What is the unit for a nerve conduction velocity test? What is a normal reading?

Back 120

units - meters/ sec (m/s)
normal - >50 m/s

Front 121

Who has faster NCV readings dogs or cats?

Back 121

Cats (in general because they are smaller, athletic dog could be similar or faster)

Front 122

Which vestibular lesion causes ipsilateral conscious proprioception deficits?

Back 122

Central and paradoxical (not peripheral!)

Front 123

Dog that is circling, has increased extensor tone, and contralateral CP deficits - top ddx?

Back 123

Cerebral cortex lesion (has decorticate rigidity) - will also have no menace in the contralateral eye

Front 124

10 parts of the menance response reflex loop (hopefully she doesn't ask this)

Back 124

1) Threaten -> Optic n.
2) Optic chiasm
3) Optic tract
4) Rostral colliculli
5) Lateral geniculate
6) Occipital cortex
7) Association corext
8) Cerebellum
9) Motor cortex
10) Facial n. -> blink

Front 125

Acute onset of neuro clinical signs - 3 possible causes

Back 125

1) Trauma
2) Vascular injury
3) Infection

Front 126

Slow chronic progresssion of neuro clinical signs - 2 possible causes

Back 126

1) Neoplasia
2) Degenerative disease

Front 127

5 main segments of the spinal cord

Back 127

1) C1 - C5
2) C6 - T1
3) T2 - L3
4) L4 - L6
5) S1 - S5

Front 128

Cells that clear foreign substances in the liver

Back 128

Kupffer cells

Front 129

Term for bile resorption and recirculating in the portal blood to the liver

Back 129

Enterohepatic cycling

Front 130

6 functions of the liver

Back 130

1) Carbohydrate metabolism
2) Protein metabolism (Binding proteins, clotting factors/ inhibitors, lipoproteins)
3) Fat metabolism (FA, ketones, cholesterol synth)
4) Urea synthesis (NH3 -> urea)
5) Bile acid synthesis ( fat sol vitamin absorption also)
6) Detoxification (bilirubin, urea, aromatic aa)

Front 131

Where is conjugated bilirubin converted into urobilinogen?

Back 131

the bowel -> then some leaves in the urine

Front 132

6 ddx for hyperbilirubinemia

Back 132

1) Excess production
2) Hepatocellluar disease
3) Disturbed secretion of conjugated bilirubin (intra or extra hepatic bile obstruction)
4) Congenital syndrome in sheep
5) Hemolysis
6) Obstructive biliary disease

Front 133

Hemolytic disease from a toxin

Back 133

copper toxicity in sheep - most likely

Front 134

5 infectious causes of hemolytic disease

Back 134

1) Leptospirosis
2) Babesiosis
3) Eperythrozoon (hemoparasitic bacteria)
4) Equine infectious anemia
5) Clostridium toxin (secondary to myositis)

Front 135

What vaccine can cause hepatic disease?

Back 135

Tetanis antitoxin for theiler's disease

Front 136

3 most highly suggestive clinical signs of liver failure

Back 136

1) Icterus
2) Hepatic encephalopathy
3) Photosensitization

Front 137

Bilirubinuria is suggestive of what disease?

Back 137

Obstructive hepatic or biliary disease

Front 138

6 Indications of a poor prognosis for liver failure

Back 138

1) Hypoalbuminemia
2) Hyperglobulinemia
3) Prolonged PT
4) high GGT and ALP w/ normal - low SDH
5) Fibrosis
6) Hepatic encephalopathy or Hemolytic crisis

Front 139

5 ddx's for hepatocellular failure

Back 139

1) toxin
2) Immune mediated (transfusion or tetanus antitoxin)
3) Hypoxia, toxemia, and shock
4) Infectious disease (EIA, EVA ect)
5) Hepatic lipidosis ***can happen in any large animal (and cats too :) )

Front 140

What time of day are animals the hottest? coldest?

Back 140

hottest in the evening
coldest in the early hours of the morning (sleeping)

Front 141

3 main ways heat is lost

Back 141

1) Conduction
2) Convection
3) Radiation
4) Evaporation
(also cutaneous vasodilation & behavioral changes)

Front 142

What part of the body controls body temperature?

Back 142

Anterior hypothalamus - negative feedback

Front 143

If the set point of the anterior hypothalamus gets changed for body temperature what is the result?

Back 143

behavioral and homeostatic responses to lose or acquire heat

Front 144

4 responses of the body to activation of warmth sensitive neurons of the skin and mucus membranes

Back 144

1) Increased respiratory rate
2) Vasodilation
3) Sweating
4) Attempt to find cooler environment (behavior change)

Front 145

4 responses of the body to activation of cold sensitive neurons in the skin

Back 145

1) Vasoconstriction
2) Piloerection
3) Increased muscular activity
4) postural and behavioral changes to conserve heat

Front 146

Term for the hypothalamus responding to changes in blood temperature

Back 146

Central thermosensitivity

Front 147

What body temp will neonates with sepsis have?

Back 147

normal to low

Front 148

How are hyperthermia and fever differentiated?

Back 148

Hyperthermia - no pyrogens acting on the hypothalamus and not associated with a infection
Fever - is caused by pyrogens and related to infection (and possibly drugs if they cause the release of pyrogens)

Front 149

What is the genetic defect of malignant hyperthermia?

Back 149

Defective ryanodine receptor - pigs, horses, humans and dogs

Front 150

Term for the loss of ability to sweat - when is it really bad to see this?

Back 150

Anhidrosis
If seen during heat stroke animal is about to die

Front 151

4 top ddx's for a sustained hi temp with out a disease found

Back 151

All CNS origin
1) Head trauma
2) Encephalitis
3) Brain malformations
4) Degenerative diseases of the brain

Front 152

4 Clinical signs of central loss of temperature control

Back 152

1) lack of diurnal variation
2) Absence of sweating
3) Resistance to anti-pyretic agents
4) Excessive response to external cooling **important one

Front 153

Main exogenous pyrogen

Back 153

Interleukin-1 (IL-1)
(also break down products of proteins and LPS from bacteria)

Front 154

How can NSAIDs be used to differentiate hyperthermia from a true fever?

Back 154

If the fever responds to NSAIDs then it is a true fever (decr temp)

Front 155

7 Benefits of fever

Back 155

1) Increased survival for specific diseases
2) Enhanced antibody production
3) Enhanced immune system function (L0, M0, and interferon proliferation)
4) Hypoferremia (keep Iron away from bact. )
5) Inhibit growth of some tumors
6) inhibit growth of some microbes
7) Can be used to monitor disease and response to treatment

Front 156

Critical body temps for domestic animals

Back 156

cow >107
cat/ dog 106
Horse >105

Front 157

Useful diagnostic for a fever of unknown origin

Back 157

Blood culture (don't discontinue antibiotics b/c if Ab resistant it will be cultured anyway)