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135 Cards in this Set

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First and most important step in managing septic shock:
IV NS
PMN count for dx of spontaneous bacterial peritonitis
>250
Follicular occlusion tetrad:
suppurative hiradenitis, pilonidal dz, dissecting folliculitis of the scalp, acne conglobata
multiple painful nodules and pusltes of axillae & groin --> sinus formation 7 fibrosis
tick bite: thrombocytopenia, leukopenia, elevated LFTs
ehrlichiosis
spotless RMSF
tx: Doxy
Gram Negative Tickborne
Pt with Anti-HBsAg is stuck with HepB Tx:
Reassure; HBV and HBIG only for those with unknown immunity
most common cause of otitis externa in diabetics

+ Tx
psuedomonas is the most common cause of otitis externa even in diabetics
tx: cipro
Undiagonsed plueral effusions
workup
always tapped unless there is clear evidence of heart failure.
Looks like streptococci but is branching instead of just straight
--> Nocardia --> Bactrim
Risk by deficient Cell Mediated Immunity
"weakly acid fast branching filamentous rods"
"weakly acid fast branching filamentous rods"
in sputum
Looks like streptococci but is branching instead of just straight
--> Nocardia --> Bactrim
Risk by deficient Cell Mediated Immunity
"weakly acid fast branching filamentous rods"
skin infection: eryspelias vs impetigo
erysipelas = strep, sharp raised, advancing
impetigo = strep or staph
HepA vaccine in HIV?
yes if:
-have hepB or C
-IV drug use, sex with men or preexisting liver dz
---> so not everybody
BCG is live may casue dissmeinated TB in HIV pt
vaccines in HIV pts
HIV pts w/ CD4+>200 get Pneumococcal vaccine
they do not all get meningococcal vaccine unless splenectomy or high risk travel
HIV pts s immunity & >200CD4+ get MMR even though live -exception is because Measles is so deadly to HIV pts

HepA vaccine in HIV:
yes if:
-have hepB or C
-IV drug use, sex with men or preexisting liver dz
---> so not everybody
BCG is live may casue dissmeinated TB in HIV pt
Chronic Granulomatous Dz: subject to which infxs?
Catalase positives:
staph aureaus, serratia mascerens, burkholderia cepacia, kleb & aspergillus
Numberous umbilicated vesicles over area of healing atopic dermatitis
Eczema herpeticum: herpes superimposed on atopic dermatitis
life threatening in infnats
All newly dx'd HIV pts receive:
2x HIV [RNA] levels
CD4 count
VDRL, PPD tests
anti-toxoplasma antibody titers
HepA & B serology, vaccines prn
Mini MSE
pneumococcal vaccine unless CD4<400

additionally (but not at diagnosis) before starting retroviral tx:
1. CBC, Chem, LFTs, Lipids, CD4 count & HIV load titer
EBV DNA + CSF in HIV pt -->
1* CNS lymphoma
weakly ring-enhancing mass; solitary & periventricular.
HIV & Toxoplasmosis Tx
Bactrim used for toxoplasmosis prophyulxis in HIV, sulfadiazine + pyrimethamine used for treatment.
Esophagitis in HIV pt
MCC, Course of Action
MCC: Candida.
First Step: 2 weeks of oral fluconazole
Persistent: Scope & Bx
large shallow superficial ulcerations --> CMV --> Ganciclovir
multple small well circumscribed deep ulcers "volcano like" --> HSV --> Acyclovir
Tx: HepC vs HepB
HepC: Inferferon + Ribavirin
HepB: Interferon + Lamivudine
Adult pneumococcal vaccine
given to all adults >65
given once to all adults <65 with chronic immunocomprimzing dzs
Pneumonia in immunocompromised pt
CXR shows halos
Aspergillosis
Pneumonia with GI Sx
Legionella, also hyponatremia

Legionella pneumonia features: GI sx, hyponatremia, elevated LFTs
Dx: Urine antigen, Tx: Quinolone or Macrolide
Pneumonia with Hyponatremia
Legionella, also GI Sx
Legionella pneumonia features: GI sx, hyponatremia, elevated LFTs
Dx: Urine antigen, Tx: Quinolone or Macrolide
MCC: subacute endocarditis in non-drug users
mitral valve prolabse/mitral regurge
Histoplasmosis vs Blatomycosis
Blastomycosis: 1* pulm infx is asx/flu like; cutaneous lesions (ulcerative or warty, violacious hue); source: soil, rotting wood; not an immunocompromised pt
Histoplasmosis: manifests as acute pneumonia, palatal ulcers, but no cutaneous lesions; occurs in immunocompromised pt; pancytopenic;
Fist Bite Antibiotic Prophylaxisis
Augmentin
Febrile neutropenia:
colon flora taking over, must cover pseudomonas & gram postiives
Monotherapies: ceftazidine, cefepime (4th gen, full spectrum), imipenem or meropenem
combo = aminoglycoside + anti-pseudobetalactam
2* syphillis
palms & soles & mucosa
Tx: chronic HepB
lamivudine & interferon are only two drugs approved
these drugs are unlikely to be useful in pts with normal ALT
ALT 2x ULN will respond well
lamivudine is oral & has less side effects
Asymptomatic Isolated Thrombocytopenia
Often an early presentation of HIV
anti-smooth muscle and anti-LKM antiboides
are associated with acute & chornic hepatitis; higher titers = chronic active heptatiis.
TB test readings: postivie if
>15mm in normal individual, no risk factors
>10mm in people with risk factors (exosure, youth, other dzs)
>5 mm in immunocompromised
Pt on INH with elevated LFTs
20% of pts on INH will have sublcinical hepatic injury, transaminases willl stay <100, excellent prognosis, self limited;
suspected HSV encephalitis
course of action
Do not delay acyclovir for suspected HSV encephalitis; diagnosis is PCR not cx!
Cat bite infection
DOC: 5 days of Augmentin vs Pasturella multocida (anaerobe)
anaerobic lung infection doc
clindamycin
where do aspiration anaerobes go
recumbant: posterior segment of upper lobe
standing: superior & basilar segments of lowe lobe
FU: pt has chronic HepB
evalute chornic HepB with liver Bx
lytic bone lesions, ulcerated skin lesions + upper lobe lesions
Balstomycosis:
infx from salad
are aureus not bacillus, because they think of salad as containing mayonase for some reason
what constitutes an acceptible specimine for sputum culture of pneumonia
>25 PMN & <10 epithelial cells per low powered field
rarely ordered for CAP
MCC: COPD exacerbations
S pneumo, H flu, M catarrhalis
Post-exposure prophylaxis vs Varicella:
Vaccine within 5 days to healthy individuals
VZIG within 4 days to pregnant, immunocompromised indiividuals --monoitor as the vaccine could just delay onset
healthy unvaccinated individual >5d from expose --> going to get chickenpox
acyclovir for pts >12 yo or immunocompr
nothing for healthy pts <12 yo
Tx: pertussus
Bordetella pertussis is treated with erythromycin - given at any stage of dz
hospitalize infants <3 mo or <6 mo with seere paroxysms
HIV pt with bloody diarrhea & normal stool sample
MCC: CMV
bx confirms with erosions &
eosinophilic nuclear inclusions + basophilic intracytoplasmic inclusions ("Owls eye")
Unvaccinated pt with HepB needlestick:
IVIG now + Vaccine
Vaccines for Chronic Hepatitisers:
Tdap as with normal pop, annual influ as with normal pop
HepA: 2 doses 6 mo apart for seronegative
HepB: 3 doses at: 0, 1 & 4 mo for negative
PPSV: 1 dose q 5 years
MCC: viral meningitis
non-polio echoviruses (echo, coxsackie)
Acne step up ladder
: topical Retinoids for mild, topical antibiotics for moderate, oral antibiotics for papular/pinflmmatory acne, oral isotretinoin for nodulocystic and scarring acne.
MCC: endocarditis c prosthetic valve:
staph epi
MCC: mucopurlent cervicitis
= Chlamydira
confirm the dx of babesiosis
: giemsa stained thick & thin blood smear
chronic diarrhea with weightloss, non-tender LAD
HIV pts can present as chronic diarrhea with weightloss, non-tender LAD
Joint WBC cellularity
<200 = normal
200 - 2k = OA
2-5k = Inflammatory A
>50k = septic
MCC: osteomyelitis in adults with Hx nail pnx
Pseudomonas aeruginosa
Tx: quinolones & aggressive surgical debridement.
Extra-Hepatic Complixns of Hep C
Cryoglobulinemia
B cell lymphomas
Plasmacytomas
Autoimmune diseases
Lichen planus
Porphyrea cutanea tarda
ITP
Membranoproliferative glomerulonephritis
extreme tenderness to gentle percussion on spine
: osteomyelitis, most likely staph aureus
elevations of ESR and platelets are better indicators of infection than fever & WBC count
Diagnostic Confirmation: MRI
Tx: Long ter IV antibiotics
confirm the Dx of Lyme Dz with:
Serum ELISA and Western blot
toxoplasmosis in HIV prevention
you can prevent toxoplasmosis with Bactrim
occurs at <100
screen for toxoplasma gondii at time of dx, those who havge antibodies against get prophylactic Bactrim to prevent reactivation
Critera of Lyme Prophylaxis:
Must Meet all 5
1. Ixodes "Deer" Tick
2. Tick attached >36 hours or engorged
3. <72h since tick removed
4. Endemic burden >20% of ticks (i.e New England)
5. No traonads to doxycycline (lactating/pregnant/<8)
Long term neurologic sequelae of bacteiral meningitis:
1. hearing loss
2. neuronal loss of dentate gyrus in hippocampus --> loss of cognitive fnx
3. szs
4. mental rettardation
5 spacticity/paresis
Recurrent mucopurulent sputum
course of action
think bronchiectasis (non purulsent chronic bornchitis)
Dx: High Res CT
C dif colitis suspected
course of action
empiric metronidazole & stool Cx
Most common organisms of orbital cellulitis:
Staph aureus, Strep pneumo, other Strep
Orbital Celluitis vs Preseptal celluitis:
Pain with extraocular movements or Opthalmoplegia (inability to move eye) indicates ORBITAL;
Proptosis and Visiual Impairment may not be present, but if present are ORBITAL;
Again, red flags are: decreased visual acuity, diplopia, ophthalmoplegia and proptosis.
Preseptal: outpt oral abx
Orbital: IV abx
Complixns: blindness, subperiosteal abscess, cavernous sinus thrombosis, intracranial infection, death
breastfeeding mastitits:
tx
dicloxaciillin or cephalosporins vs S aurus ( which is coming from the baby's nose)
abx + analgesics + continue breast feeding
lyme dz treatment:
oral doxycycline
preggers & <8 yo --> oral amoxicillin or cefuroxime
azith reserved for allergies to PCNs
osteomyelitis s nail pnx
Staph aureus is MCC in children & adults without nail punx.
In gneral CoNStaph & Streptococci don't cause osteomyelitis
Empyema vs CAP antibiotics
Emypema is poorly responsive to CAP antibiotics because it progresses to mixed aerobe/anaerobe environment
bartonella henselae & Bartonella quintana
bacillary angiomatosis in immunocompromised. angioma like blood vessel growth both visceral and cutanous. prone to hemorrhage. dx with bx with extreme acuation. Tx: erythromycin;
Child with pertussus:
tx with macrolide, respiratory isolation x5d of erythromycin,
provide macrolide to household x14d
pertussus is highly contageious dispute immunizations;
HIV pts with CD4<50 should receive
azithromycin prophylaxis vs Mycobacterium avium complex.
&
Ganciclovir prophylaxis vs CMV
Clarithrymycin + Ethambutol = Tx for MAC not prophylaxis
Immunosuppressed pt looks like they have TB
include Nocardiosis in DDX: unlike Mtb is partialy acid fast gram positive, filamentous branching. AEROBIC DOC: Bactrim
include Actinomyces: filamentous gram positive bacterium. ANAEROBIC. More likely to cause cervicofacial than pneumonia. Assoc w/ sulfur granules. DOC: Pen G
drains serous fluid
"gram positive branching" = actinomyces
Bone Marrow Transplant Receipient with lung & intestinal complaints 2 months out;
CMV
MCC: orbital cellulitis
extension from bacterial sinusitis
Tx: S aureus cellulitis
mild: oral dicloxacillin
moderate-severe: IV nafcillin
HIV Rx Toxicities
indinavir: crystal nephropathy
didanosine: pancreatitis
any NRTI's: lactic acidosis
NNRTI's: JSJ
Nevirapine- liver failure
antibiotics of infective endocarditis
oral antibiotics are not used as monotherapy for pts with endocarditis.
Strep viridans susceptible to PCN is treated with IV PenG or IV Ceftriaxone
vancomycin is most commonly used empiric (staph = most commonf)
The most sensative test for diagnosing histoplasmosis is
antigen in urine or serum
Tx: Histoplasmosis in HIV pt
Itraconazole alone for mild case
Amphotericin B for 2 weeks followed by year of itraconazole for severe case.
complications of mononucleosis:
2-3 weeks after onset: autoimmune hemolytic anemia & thrombocytopenia from cold agglutinin "anti-i antibodies" --> complement mediated destruction
all post-transplatn pts should recieve
TMP-SMX just like HIV
& ganciclovir
when can mono pts return to sports
when you can't palpate their spleen anymore
HIV pt: Kaposi Sarcoma vs Bacillary Angiomatosis
Kaposi sarcoma becomes dark
BA stays bright red
stye vs chalazon vs hordeolum
chalazon: chronic sterile granulomatous inflammation of meiboian glands
hordeolum: purulent infection of eyelid
stye: small hexternal hordeolum involving zeis or molls glands
Tx: reactive arthritis
= NSAIDs
arthritis + urethritis, conjunctivitis, mouth ulcers
Iron overload predisposes pt to infx with iron lovers:
Hematochromatosis most vulnerable to Listeria monocytogenes

Listeria monocytogenes, Vibrio vulnificus, and Yersinia entercolitica
New Diabetic Admit to Hospital for Pneumonia
--> New Diabetic Admit for anything, check for renal failure, hold metformin
Pt bit by known dog s signs of rabides:
Think Rabies
Give post-exposure prophylaxis if bit in head or neck
Keep Dog 10 days for observation: any signs, start prophylaxis
Tx: Molluscum COntagiosum
= Curetage or Liquid N2
self limited but treat to prevent spread
diagnostic features of BACTERIAL rhinosinusitis:
>10d or >5d after initially improving viral URI, >39C
Viral URI's are the most common predisposing factor for Acute Bacterial Rhinosinusitis.
Treat with Oral Augmentin/Amox.
MCC: septic arthritis
Staph aurus & Streps - including sp joint replacement
IV Vanc
Empiric Tx: Cystic Fibrosis Pt with Pneumonia
antipseudomonal PCN + an aminoglycoside:
Piperacillin + Tobramycin
IV Ceftazidime + Gent
Non-toxic child with unilateral cervical lypmhadenitits:
MCC: Staph aureus
MAC prophylaxis
HIV with <50 get azithromycin or clarithromycin vs as prophylaxis vs MAC; rifabutin if allergic to macorlides.
what organisms cause brain abscesses via contiguous spread for the sinuses
anaerobes esp aeorbic & anaerobic streptococci & bacteroides
Periodicity of malarial fevers:
malariae: q72h
vivax/ovale q48
falicparum: non-perioricity
Treating the flu:
acetaminophen & bed rest
amantadin/rimantadine: given for type A (only work on type A)
zanamivir/oseltamivir: given for type B (work on either)
--> these are only effective if given within the first 24h of presentation of sx --> really not worth it.
Hyperthyroid pt being treated with antithyroid drugs has a sore throat
both PTU and MMI can cause granulocytosis
stop the drug and measure the WBC's
if <1k, do not continue drug
if >1.5 drug is okay
NOT useful to monitor, just tell pts to stop drug & come in if sore thraot & fever
MCC: bacterial pneumonia 2/2 influenza:
S aureus
Listeria vs Legionella
Listeria is a gram positive rod, legionella is a gram negative rod
Trichomonas: oral vs vaginal metronidazole
oral- higher cure rate
epiglottitis: MCCs:
H flu & S pyo
sporadic yersiniosis:
undercooked pork
daycare hemorrhagic diarrhea
shigella =
Tx: HIV pt with cyptococcus meningitis:
Amphotericin + Flucytosine; once stabalized --> oral fluconazole for maintenance
Timeline of LP/CT vs Abx:
Children: Pnx then Abx
Adults: Abx then Pnx
--> fontenelles mean less chance of herniation in children
dexamethasone will prevent hearing loss if administered <1h of abx
Confirm the Dx: Amebic Liver Abscess
NB: Entamoeba Histolytica
Single abscess, right lobe
Confirm with Stool for Trophozoites, Serology & Imaging
Tx: metronidazole
If serology is negative, alternative tests (aspiration)
Hydatid Cyst
Caused by Echinococcus granulosus
Aqd via intimate contact with Dogs
"Egg shell" calcifications in liver.
Do not aspirate --> anyphylactic shock from spillage
Tx: Albendazole + Surgery
most vestibulotoxic antibiotic
Gentamycin is the most vestibulotoxic of the amicoglycosides
(a class known for nephro/vestibulo toxicity)
toxicity may be transient or permenant
Productive Cough, Hemopytsis, intermittent fevers
-->TB suspect
Clinical Presentation: 1* HIV vs CMV
CMV: Tonsillar Exudate + Rash IF Abx
HIV: Diarrhea + Rash without Abx
"purified protein derivative" testing
is a sneaky way of saying TB test
SIRS:
2/4 of the following
- T >38.5 or <35
- P >90
- R >20
WBC >12k or <4k or >10% bands
Most Common Cause of Adult Viral Encephalitis:
HSV-1
Confirm with PCR
Treat with Acyclovir
Slow ascending paralysis over severla days
: tick borne paralysis.
Tx: local impetigo
= topical mupirocin (binds tRNA synthase in Gram +'s) or oral erythromycin
HIV pt has >5mm induration on ppd
if aSx then only need prophlyaxis: INH & B6 for 9 mo
don't need to treat with full regimen if aSx
chronic/subacute couch followup URI
--> 3 week trial of oral antihistamine
periorbital edema, myositis, eosinophilia
= trichinellosis
starts as stomach pain, on eweek later systemic hypersensitivity tolarval migration "splinter hemorrhages, periorbital edema, chemosis", 3rd week starts myositis.
rash + slow blinking
most common neurologic involvement of lyme is CN7
Tx: HIV + PCP
Bactrim/Bactrim + Steroids in severe PCP
indications for Steroids: PaO2 <70 or A-a gradient >35 mmHg
--> steroids significantly reduce mortality
Which malaria regions get which prophylaxis?
Plasmodium falciparum is in Subsaharan Africa & India = chloroquin resistant
--> mefloquin chemoprophylaxis started one week before travle & continued 4 weeks after

Plasmodium Vivax & Plasmodium ovale = primaquin
pt has rheumatic fever
course of action
Almost 100% of MS is 2/2 Rheumatic fever from GABHS
These pts are at high risk for recurrence & progression
--> All pts should recived continuous antibiotic prophylaxis to prevent recurrence
Rheumatic fever s carditis --> until age 21 or 5 years (whichever is longer)
Rheumatic fever c carditis s valvular dz --> until age 21 or 10 yrs (longer)
Rheumatic fever c carditis --> valvular dz --> until age 40 or 10 years (longer)
erysipelas vs imepetigo
erysipelas = strep, sharp raised, advancing
impetigo = strep or staph
photosensitizing antibiotics
tetracyclines are photosensitizing, macrolides are not
Best Testing for acute Heptatis B
HBsAg + anti-HBc
HBsAg is present early in the infection then dissapears for a "window period" before Anti-HBs appears & confirms immunity
anti-HBc appears shortly after appearnce of HBsAg and is present during the window period
NB: persistence of HBeAg indicates chronic infx but is not best means of screening for HB infx
Echinococcus:
granulosus = sheep = cystic
multilocalaris =
Kleb pneumo hot words:
alcohol, currant jelly, "mucoid colonies", upper lobes, encapsulated, Fridlander's pneumonia
early abscess formation & fulminant course
C dif colitis doesn't start for
5-10d after Clindamycin is initiated
asymmetric polyarthritis
--> gonorrhea
Reactive arthritis
: arthritis, conjunctivitis + urethritis = chalmydia
post-viral URI with hemoptsysis & abscessant nodularity
= S aureaus
Tb antibiotic therapy --> aquired sideroblastic anemia
--> Pyridixone deficiency --> defective heme synth -->
HIV diarrhea:
many organisms, sample & attempt to ID [Salmonella, capmylobacter, Cdif, Giardia, Crypto, MAC]
Most common @CD4 <180 = Cryptosporidium parvum, will have oocysts.