Awesome Review Index cards - finished Flashcards
(500 cards)
1
Q
Activated charcoal is not effective when the overdose is with what?
A
Caustics, cyanide, electrolyte overages, alcohols, hydrocarbons, heavy metal poisoning , lithium
2
Q
Alkalinization of the urine to a pH of greater than 7 increases excretion of what?
A
Aspirin, tricyclics, phenobarbital.
3
Q
Acidification of the urine with ammonium chloride increases excretion of what?
A
Amphetamines and PCP.
4
Q
Hemodialysis is effective in removing drugs with low molecular weights that are not lipid soluble, protein bond, or tissue bound. What drugs are effectively removed by hemodialysis?
A
Lithium, chloral hydrate, salicylates, and alcohols (methanol and ethylene glycol).
5
Q
What pain medications are associated with seizures in toxicated patients, especially those on dialysis?
A
Meperidine, tramadol, propoxyphene
6
Q
How do you treat aspirin overdose?
A
Decontamination with activated charcoal with a cathartic (sorbitol or magnesium citrate) and serum/urine alkalinization using sodium bicarbonate and aggressive hydration
7
Q
What is the treatment for acetaminophen overdose?
A
Activated charcoal is beneficial if given within 4 hours of ingestion. N-acetylcysteine which increases glutathione is effective of an 8 to 16 hours after overdose. even if it’s given late it’s yours to decrease mortality.
8
Q
What is the mnemonic for anticholinergic overdose?What is the treatment?
A
Red as a beet (cutaneous vasodilation), hot as a hair (hyperthermia), blind as a bat (mydriasis), mad as a hatter (hallucinations) and full of flask (urinary retention) & tachycardia.Treatment is physostigmine which is an anticholinesterase.
9
Q
How is a pure or dose of benzos seen? (Many times benzo overdose will present for the mixed picture)
A
Coma with normal vital signs.Treatment is with flumazenil, but can cause withdrawal seizures.
10
Q
How do you treat tricyclic overdose?
A
Give activated charcoal within 2 hours. QRS prolongation correlates most closely with the degree of intoxication. Block this by keeping patient alkalemic via hyperventilation or IV bicarbonate: target pH is 7.5 to 7.55. if arrhythmias still persist give lidocaine (first line) or phenytoin as needed. Use benzos for seizures.
11
Q
What is the clinical presentation of digoxin toxicity?
A
Nausea vomiting, abdominal pain, changes in color vision, scotoma, bradycardia with hypotension, anorexia.
12
Q
What labs do you see with digoxin toxicity?
A
Acute toxicity will show hypokalemia and chronic toxicity will show hyperkalemia and you will see kidney injury which is usually the cause of toxicity
13
Q
What does the EKG look like with digoxin toxicity?
A
Flattened or inverted t waves, shortened QT interval, and depressed lateral ST segments often referred to as the digit effect.
14
Q
How do you treat digoxin overdose?
A
Give activated charcoal if patient presents with in 2 hours. Use Fab fragments to treat patients who have serious ventricular arrhythmias, k>5, renal failure or changes in mental status.
15
Q
How do you treat cocaine overdose?
A
Nitroglycerin and calcium channel blockers for the chest pain, and benzodiazepines.
16
Q
How do you treat PCP overdose?
A
IV benzos as needed and supportive care for complications such as rhabdomyolysis, hypertension
17
Q
What treats iron overload?
A
Deferoxamine
18
Q
What supplements affect Warfarin?
A
Gingko Balboa increase risk of hemorrhage.St. John’s Wort increase metabolism of Warfarin and hence cause under-anticoagulation.
19
Q
Drugs that precipitate seizures in patients on hemodialysis when not dose-adjusted are.
A
Beta-lactam antibiotics, metoclopramide, toxic levels of theophylline, lithium, acyclovir, carbamazepine and meperidine.
20
Q
Screening recommendations for patients with a history of colorectal cancer consist of follow-up colonoscopy at ___ year and ___ years after curative surgical resection; if results of these colonoscopies are normal, the surveillance interval can be extended to ___ years.
A
1 yr, 3 yr and then every 5 yrs
21
Q
- Patients with large (≥10 mm) or dysplastic sessile serrated polyps or traditional serrated adenomas should undergo colonoscopy in ____ years.2. The recommended postpolypectomy interval for patients with sessile serrated polyps smaller than 10 mm is ____ years.
A
- 3 yrs2. Five yrs
22
Q
Hydrophilic statins are less likely than lipophilic statins to cause statin-induced myopathy and can be used at low doses in patients with previous statin-related myalgia, myopathy, or mild rhabdomyolysis. Lisit both types.
A
Hydrophilic: Rosuvastatin (especially) but also pravastatin and fluvastatin.Lipophilic: Atorvastatin, simvastatin, and lovastatin.
23
Q
- Patients with bite wounds should be vaccinated with Tetanus toxoid should be given to patients if they have not received a tetanus immunization within the past 5 years for “dirty wounds”. How do you define such wounds? For a clean and minor wound, a booster dose of tetanus toxoid would be given to prevent tetanus if more than ____ years have elapsed since immunization.2. ___ and ____ are given to pateints who have had <3 doses of Td during their lifetime or whose status is uncertain AND they have a dirty wound.
A
- Dirty wounds are those contaminated with soil, saliva, dirt, or feces; avulsions; puncture wounds; and wounds resulting from burns, frostbite, crushing, or missiles….10 yrs2. Tetanus Immunoglobulin + Td
24
Q
The use of ______ is considered first-line treatment for lichen sclerosus: Patients with lichen sclerosus have inflammation in the skin, which leads to thinning, hypopigmentation, and scarring or sclerosus.Areas of long-standing lichen sclerosus are at risk of developing _____
A
high-potency topical glucocorticoids….squamous cell carcinoma
25
Women aged ____ and older and younger women who have a fracture risk of ______ higher should be screened for osteoporosis.
65 years ......9.3%
26
The USPSTF published a new statement recommending statin therapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) in adults aged _____ with a 10-year ASCVD event risk of ______ or higher and one or more ASCVD risk factors (dyslipidemia, diabetes, hypertension, or smoking
40 to 75 years.....10%
27
According to the USPSTF, acceptable screening strategies include high-sensitivity ____ every year, ____ every 5 years, ____ every 5 years, combined flexible sigmoidoscopy every ____ with high-sensitivity fecal occult blood testing every year, or ____ every 10 years
Fecal occult blood testing (gFOBT or FIT)Flexible sigmoidoscopy CT colonography 10 yearsColonoscopy
28
1. What is the treatment for severe menopausal vasomotor symptoms (e.g. night sweats, mood lability, vaginal dryness, dyspareunia, etc) in women?2. Treatment of severe menopausal vasomotor symptoms in a woman whose uterus has been removed is with what? Why?
1. Tx is Hormone replacement therapy: Estradiol-progestin combination pill. The absolute risks for use of hormone therapy in healthy women younger than 60 years are low, as are the risks of adverse cardiovascular events if time since menopause is less than 10 years.2. Estrogen therapy alone w/o concurrent progesterone: these women do not require the use of a progestin to oppose the proliferative effects of estrogen on the endometrium,
29
Pruritic, purple, polygonal papules are what? In what disease do you find these?
Lichen PlanusLP occurs with increased frequency in patients with liver disease, particularly hepatitis C, although the reasons for this remain unclear
30
The risk of ovarian cancer may be especially increased in women with what autoimmune disease, esp in the 1st 2 years after diagnosis. So what should you do in these patients?
Dermatomyositis....transvaginal US
31
The joints most commonly involved in osteoarthritis are weight-bearing joints. Affected non–weight-bearing joints in the hand typically include the ___, ___ & ___._____ &/or ____ nodes, or ossified growths at the medial and dorsolateral aspects of the DIP or PIP joints, respectively, may be present.
First carpometacarpal, distal interphalangeal (DIP), and proximal interphalangeal (PIP) joints.Heberden and/or Bouchard
32
Patient has Alzehimer's disease with MMSE score of 22/30...you start a cholinesterase inhibitor (fyi donepezil is specifically approved for severe disease)....12 weeks later, pt. has serious GI SE's: MMSE now is 20/30. What is the next step?
D/c the cholinesterase inhibitor...once GI sxs resolve, start with donepezil +/- memantine (NMDA-receptor antagonist
33
Patient has pain with eye movement, central scotoma, and an afferent pupillary defect. What is the dx? What is the next step?
Optic Neuritis....do MRI brain to check for MS lesions
34
Neurosyphilis classic pupillary abnormality is Argyll-Robertson pupil, in which pupils are ____.
Unreactive to light but constrict to accommodation
35
1. ____ is recommended for those with elevated BP or stage 1 hypertension and a 10-year cardiovascular risk of 10%2. Nonpharmacologic and ____ is recommended for those with BP ≥130/80 mm Hg and clinical cardiovascular disease or a 10-year cardiovascular risk ≥10% to a BP goal of 130/80 mm Hg.3. ____ is recommended for those with no cardiovascular disease and a 10-year cardiovascular risk of 10% for BP of ≥140/90 mm Hg.4. Adults with stage 2 hypertension and an average BP of ____ above their BP target should be treated with ____.5. BP target of 130/80 is for what conditions?
1. Nonpharmacologic therapy2. Drug treatment3. Nonpharmacologic and drug treatment 4. 20/10 mm Hg...a combination of two first-line antihypertensive drugs of different classes.5. Stable ischemic heart disease w/ HTN....HTN w/ HFrEF....HTN w/ PAD....CVA (after hospital d/c: Ischemic & hemorrhagic)....HTN & DM....HTN & CKD.
36
Guidelines recommend consideration of treatment with a bisphosphonate for low bone mass (osteopenia) only if there is 10-year fracture risk determined by the FRAX calculator of greater than or equal to ____ for a major osteoporotic fracture or greater than or equal to ____ for hip fracture.
20%.... 3%
37
Patients present with intense pain, photophobia, ciliary injection (redness at the junction between the cornea and sclera), an irregularly shaped pupil, and miosis: what is the diagnosis?
Iritis (or iridiocyclitis)
38
In patients with lung disease and sea-level oxygen saturation between 92% and 95%,____ testing can be used to determine the need for oxygen supplementation during air travel. If it's <92% they will need ____ during their flight.If this test is not available, what test can you do? In this test, oxygen saturation < ___% means, the patient will need oxygen while flying and If greater than this number, refer them to the above test.
Hypoxia altitude simulation.....oxygen6 minute walk test: if <84%, then patient will need oxygen.
39
Women with____ typically have elevated resting luteinizing hormone (LH) levels, which may be mistaken on home urinary LH kits for ovulation (consistent false positive pregnancy tests)
Polycystic ovary syndrome
40
Preeclampsia is classically defined as new-onset hypertension after 20 weeks of pregnancy with ____ but can also be diagnosed in patients without this and if the hypertension is accompanied by ____.
Proteinuria....other end-organ damage (e.g. thrombocytopenia, crackles, etc)
41
Insomnia is divided into 3 types: sleep-onset, sleep-maintenance and early morning awakenings.If its due to a stressor, we can give short term-oral therapy: ___, zaleplon and ramelteon have a short duration of action and so are prescribed for _____ type of insomnia.For maintenance insomnia, give ____, as it has a longer half-life and a longer duration of action.
Zolpidem...sleep-onset insomniaTemazepam
42
For scabies, you can treat with topical ____ or ____. Third line is ____ but this can cause ____ and so should be avoided in infants and ____.
Permethrin 5%....oral ivermectin....lindane...pregnant women
43
Calcium channel blocker overdose is treated with ___
IV calcium gluconate
44
1. Screening for lung cancer with annual low-dose chest CT is recommended for high-risk patients, defined as adults aged ____ years with a smoking history of ____or more, including former smokers who have quit in the last 15 years (meaning you must have quit within this time frame: if >15 yrs, and 30pack yrs, then no screening if asxs)2. The USPSTF recommends one-time screening for AAA with abdominal ultrasonography in all men aged ____ who have smoked at least ____cigarettes in their lifetime
1. 55 to 80....30-pack-years2. 65 to 75 years....100
45
____ are the mainstay of pharmacologic treatment for panic disorder
Selective serotonin reuptake inhibitors
46
1. Treatment of high-altitude pulmonary edema (HAPE) is with supplemental oxygen, rest, and consideration of descent from altitude; vasodilators such as ____ can be used as adjunctive treatment. The mechanism of HAPE is believed to be a noncardiogenic exaggerated hypoxic vasoconstriction of the pulmonary vasculature2. ____ is the preferred drug for preventing acute mountain sickness and high-altitude cerebral edema, but it is not useful in preventing HAPE.3. ____ is the preferred drug (in addition to supplemental oxygen) for the treatment of severe acute mountain sickness and high-altitude cerebral edema.
1. Nifedipine....or PED5 inhibitors (ie sildenafil)2. Acetazolamide3. Dexamethasone
47
___ may be a cause of acute kidney injury by triggering acute oxalate nephropathy, particularly in patients with volume depletion or chronic kidney disease.
Orlistat
48
Older patients, > ___ with osteoarthritis who require NSAID therapy to control pain should be considered for____ therapy to manage gastrointestinal toxicity
75....topical NSAID
49
____painful inflammation of the fibrous layers of the eye underlying the episclera and conjunctiva, is often associated with systemic diseases including inflammatory connective tissue disorders and infections.Patients may present with severe, continuous, boring ocular pain that radiates to the surrounding facial areas, redness, photophobia, and tearing. Most commonly affects both eyes and is worst at ____ and has ____*Emergent referral to opthalmologist
Scleritis....night...photobia
50
___ classically presents with burning heel pain and stiffness that worsen with activity and improve with rest. On examination, there is frequently tenderness to palpation approximately 2 to 6 cm proximal to the Achilles tendon insertion on the calcaneus.
Achilles tendinopathy...
51
1. The ___l is a quality improvement method that focuses on eliminating non–value-added activities, or waste, within a system: ie improve waiting times2. This model tends to focus more on quality control in each step of a process rather than on optimizing the overall efficiency of a system (used within the 6 sigma model)3. ___ tend to focus on specific points in a system and are not typically used for studying overall system function and efficiency4. ___ is a quality improvement model that is designed to reduce variation and drive a process toward near perfection; ie reduce infections in the ICU
1. Lean mode2. The Define, Measure, Analyze, Improve, Control (DMAIC)3. PDSA cycles4. Six Sigma
52
To give large volumes of crystalloid fluids what do you utilize?
Large-caliber short-length peripheral IVs (NOT triple lumen cathethers or PICC)Recall, flow of fluid through a catheter is inversely proportional to catheter length and proportional to the radius of the catheter to the fourth power.
53
___ in the form of either a patch or the less expensive cream has been shown in randomized controlled trials to be very effective in treating postherpetic neuralgia and diabetic peripheral neuropathy. Similarly, ___ is an effective topical therapy for neuropathic pain.
Topical lidocaineTopical capsaicin
54
1. What are the long-term vitamin and mineral deficiencies seen post bariatric surgery?2. 40 yo femael s/p bariatric surgery 5 yrs ago p/w c/o fatigue and painless paraesthesias: PE = spasticity and hyperreflexia. Hgb 10, Plt 1000, WBC 2.4: BM biopsy = hypercellular marrow w/ some blasts and ring siderobalsts.MCV 75: dx?MCV 102 w/o the spasticity and hyperreflexia Dx?
1. Vitamin B12, Vitamin D, Copper, and Iron2. Copper deficiency.....B12 deficiency
55
1. Red eye w/ pain and photobia, (+) blurry vision2. (+) red eye w/ constricted irregular pupil, (+) ciliary flush.3. Red eye, slit-lamp shows WBC in aqueous humor on corneal epithelium4. Blurry vision, floaters and genital ulcers
1. Anterior Uveitis (AU)2. AU3. AU4. Posterior-uveitis: pt. w/ Bechet's syndrome
56
1. Pt. w/ A. fib has painless loss of vision. Dx? What will optho exam show?2. Pt. w/ HTN or P. vera or waldenstrom macroglobulinemia p/w sudden painless loss of vision of one eye. Dx? What will optho exam show?3. Eldery pt. p/w blurry vision in the center, but peripheral vision is spared. Dx? What will optho exam show?
1. Retinal artery occlusion: cherry red spot in macula.2. Retinal vein occlusion: multiple hemorrhages3. Macular degeneration: yellow spots (drusen)
57
1. Young woman who has blurring of vision, especially after exercise and regains it gradually. What should you r/o?2. Optin nerve infarction is seen in ____. Tx is ___
1. R/o MS: Do MRI head2. Temporal arteritis: high-dose steroids
58
Pt w/ long-standing DM presents w/ c/o of blurry vision1. Fundoscopy shows aneurysms w/ hemorrhages and exudates. Dx and Tx?2. Fundoscopy shows neovascularization. Dx and Tx?
1. Non-proliferative diabetic retinopathy w/ macular edema: tx w/ tight glc control2. Proliferative DM retinopathy: Tx w/ laser of periphery and tight glc control
59
1. Pt w/ right eye and facial pain w/ n/v/headache and blurry vision; PE mid-dilated pupil that's sluggishly reactive: (+) ciliary flush. Hazy cornea. Dx?2. Decreased vision in left eye + paraesthesias 3. Elderly man w/ progressive loss of central vision; edges of objects are blurry4. Elderly w/ difficulty driving at night time due to glare from oncoming veichles and has difficulty reading door signs of fine print: Dx?
1. Glaucoma2. Optic neuritis3. Macular degeneration4. Cataracts
60
1. Anterior uveitis has ___ color in eye, pain, photophobia, ___ pupil and ___ blurry vision
1. Anterior uveitis has redness in the eye...mid-constrictive pupil +/- blurry vision. Posterior uveitis is normal except that it pt has blurry vision!
61
1. Pt. w/ red eye has a corneal ulcer and pain: dx? tx?2. Pt. whose intubated develops red eye and whtie cornea: Dx?3. Pt. who wears contact lenses; must r/o what?4. AIDS pt w/ blurry vision; fundoscopy shows white cheese, ketchup apperaance. Dx? Tx?
1. HSV-1 keratitis: tx w/ topical trifluridine or ganciclovir2. Psuedomonas keratitis3. Pseudomonas keratitis4. CMV retinitis: Ganciclovir or fosfovir (NOT acyclovir: won't work)
62
1. 45 yo female p/w c/o of severe right eye pain and temporal headache; exam shows conjunctival injection of right eye, 20/200 visionand a mid-dilated, fixed, non-reactive pupil. Dx? Next step?
1. Closed-angle glaucoma: start Pilocarpine drops right away and refer to optho
63
1. ___ is a pustule on eye lid margin; tx is ___2. ___ is a small nodule under tarsus (ie eyelid). Tx is ___
1. Stye: warm compresses2. Chalazion: obstruction of meibomian glands. Tx: Warm compresses
64
1. For surgical clearance, most cases on exam will be "clear for surgery", except those who have ____; do further evaluation with ____2. Pt. on anti-TNF medication goes for majory surgery: when do you stop and when do you resume? Why?3. Pt. post CABG is confused and inattentive; what do you give? What medication is known to cause this?
1. Peripheral vascular disease; likely have CAD; d/ dipyridamole thallium stress test or dobutamine stress test2. Stop before surgery and resume 2-4 weeks after; otherwise can get wound dehiscence3. Key here is attentive; pt is delerious, likely due to, most commonly, meperidine. Give haldol
65
A chronic alcoholic presents to the ER with1. Confusion, ataxia, nystagmus and diplopia. Dx? Tx?2. Anterograde and partial retrograde amnesia and has confabulatory speech. Dx?3. Pt. in ICU on TPN has nystagmus: what should you think?
1. Wernicke's encephalopathy: Tx w/ thiamine2. Korsakoff psychosis3. R/o Thiamine deficiency: TPN is deficient in it
66
Vitamins1. White-grey spots on the conjunctiva.2. Pt. p/w nausea, vomiting, severe constipation and dry mucous membranes: Ca is 11.3, and Phos is 5.2: Dx?3. Pt. presents w/ n/v, headache, dizziness and dry skin; has transaminitis and Ca is 10.7. Dx?4. Diarrhea, dementia, dermatitis, death5. Diarrhea w/ linear vertical whie lines on nails is due to what poisoning?6. Prolonged ICU on TPN has alopecia, heperkeratotic rash, anemia and loss of taste. Dx?
1. Vitamin A deficiency2. Vitamin A toxicity3. Vitamin D toxicity4. Niacin B35. Arsenic poisoning6. Zinc deficiency
67
Best drug to tx alcohol addiction is what?Best screening test for dependce is called ___Best test to establish chronic alcholoism is ____
NaltrexoneBest screening test for dependce is called Screening, brief intervention and referral for treatment (SBRIT): 6 or more is severeBest test to establish chronic alcholoism is: increased carbohydrate free transferrin
68
Pt whose post-surgery and only on IV fluids now POD#3 has prolnoted PT and INR. Dx? Why?..7 days later ahs PTT 65, PT 2.8. Dx?
1. Factor VII Def due to biliary stasis?2. Vitamin K def
69
1. Pts. w/ Mitral Valve prolapse have increased incidence of what psych abnormality?2. Tx of OCD is what?3. Tx for PTSD?4. Young woman has multiple complaints w/ >8 organ systems involved w/ several negative evaluations. Dx and Tx?
1. Panic disorders; best tx is Paroxetine (think Premenstrual d/o and premature ejaculation also)2. SSRI: fluoxetine or TCA cloimpramine + CBT3. CBT first...then SSRI4. Somatic sxs d/o: tx w/ regularly scheduled visits
70
1. Pt. has multiple physical complaints that are non-sensical; doctor shops and needs q month appts. Dx?2. Pt. has weakness of one side of body but normal MRI and is unaware3. Pt. produces signs & sxs deliberately4. Same sxs as #3 but w/ secondary gain
1. Somatic sxs d/o (Somatization)2. Conversion d/o3. Munchausen syndrome (if is a pathological liar about others; its MS by proxy);4. Malingering
71
Depression sxs after the death of a loved one that last <2 months is considered ____
Bereavement
72
Treatments of choice1. Eneuresis2. Panic d/o3. OCD4. Chronic pain +/- depression5. Smoking cessation6. Insomnia
1. Imipramine (TCA)2. Alprazolam (short-term): SSR (long-term)3. Fluoxetine...clomipramine...fluvoxamine...CBT4. Amitryptyline5. Bupropion6. Amitryptyline
73
Tx for bulimia is ___ where as these must be avoided in anorexia
SSRIs
74
1. Pt. has hyperthermia w/ mental status changes, tremors, tachycardia, BP, and hyperreflexia: dx? cause? tx?2. Pt. has above sxs w/ lead pipe rigidity and hyporeflexia. Increased CPK. Dx? Cause? Tx?3. Hyperthermia w/ sustained muscle contraction, HTN, hyporeflexia, increased CPK. Dx? Tx? Cause?
1. Serotonin syndrome: due to SSRI + MAOI or SSRI + linezolid or SSRI + tramadol: d/c meds. Start benzo's + cyproheptadine2. Neurleptic malignant syndrome: tx w/ dantrolene or bromocriptine. Due to antipsychotics/antidopamanergics3. Malignant hyperthermia: start rapid cooling then dantrolene. Due to inhalation anesthetics (esp if fam hx of fever or death on table during anesthesia)
75
Organophsophate poisoning ("Petite farmer on heroin = constricted pupils): what blood test do you do? Tx?
RBC acetylcholinesterase level...Tx w/ remove clothing, activated chorcoal, IV atropine and IV pralidoxime
76
Substance abuseFever, hypertension, tachycardia, mydriasis and hyperreflexia is seen in all of them1. Serotonergic and SIADH (causing hypoNa), and seizure. Drug?2. Aigtated, psychotic, violent, with hallucinations and delusions. Drug?3. Agitated, psychotic but alert with oral mucosa burns, poor dentition and skin pricking. Drug?
1. MDMA: ecstasy2. Bath salts3. Methamphetamine
77
Timed up and go test has patient walk 10 ft turn around and return to sit in same chair. Longer than ____ seconds means pt is at high risk of falls
>14 seconds
78
If an elderly pt has a non-displaced femoral fx then do surgery and ____ as opposed to a sustained displaced femoral neck fx, then do ____ and for intertrochanteric fx do ____
Three parallel pins....total hip arthroplasty (femur + ball + socket replacement)...hip compression screws
79
1. Tx for this incontinence is Wt. loss first, then bladder training, pelvic muscle exercises (Kegels) and lastly oxybutynin or tolterodine2. Tx for this incontinence is Wt. loss first, then kegels (pelvic muscle exercises)3. Post void residual is >100ml, and tx for this is praxosin or finasteride4. Post void residual is >100ml, and tx for this is cholinergics (bethanechol)5. Pt. has urge to urinate very often and often leak urine on her dress and sometimes has small amount of urine loss with coughing or sneezing6. Pt. has incontinence secondary to patients' inability to reach the bathroom due to a physical disability and atonic bladder from a stroke. What incontinence is this?
1. Urge incontinence2. Stress incontinence3. Urethral obstruction4. Detrusor underactivity (overflow incontinence)5. Mixed incontinence6. Functional incontinence
80
Pt. has symptomatic BPH (causing incontinence: urgency, polyuria), but BP is 90/65mmHg. PSA is normal. Best tx?2. Above person w/ BP 140/85mmHg. Tx?3. Pt. w/ BPH + hematuria. Tx?
1. Tamsulosin (Flomax): lowest effect on BP2. Terazosin3. Finasteride
81
TCA's and anticholinergics (such as diphenhydramine) can cause what type of incontinence?
Overflow incontinence
82
1. Pt. has non-blanchabel redness on the sacrum: Dx and Tx?2. Pt. has loss of skin and full thickness tissue, subcutaneous fat is visible, not bone. Dx and Tx3. Pt. has a shallow ulcer that is red pink with a wound bed. Dx and Tx?4. Full thickness loss of tissue; can see bone, tendon or muscle. Dx and Tx?
1. Stage 1 ulcer: Static foam or gel mattress2. Stage 3 Ulcer: debride + Abx prn3. Stage 2 ulcer: tx w/ occlusive or semipermeable dressings that will maintain a moist wound environment4. Stage 4 ulcer: Debridement + abx prn
83
1. Drugs to avoid during pregnancy are ___ anti-epeleptic, ___ anti-BP medication, ___, ___ and ___ antibiotics, ___ immunosuppressant, most antihistamines (except hydroxyzine and chlorpheniramine), radio iodide I-131, methimazole (1st trimester only), and nitroprusside.2. Drugs safe in pregnanyc are Mg sulfate, ___ and ___ anti-epileptics, ___ (4) BP meds, __, ___, ___, and ___ antibiotics, ___ antiarrythmic, CCB, clonidine, PTU, hydroxyzine and chlorpheniramine, ___ (3 anti-coagulants)
1. Valproic acid, ACE inhibitors, ciprofloxacin, doxycycline/tetracyclines and most aminoglycosides, mycophenolate mofetil2. Carbamazepine and levitracetam...labetalol, furosimide, alpha methyl dopa and hydralazine, nitrofurantoin, amoxicillin/ampicillin, gentamycin and flagyl...procainamide...heparin, LMWH and warfarin =5mg (anytime).
84
Pregnant mother gets exposed to1. Hepatitis A2. Hepatitis B3. Measles4. VaricellaWhat do you give for each of the above and when?
1. Immune globulin2. Hepatitis B immune globulin3. Immuneglobulin within 1 week4. Varicella immune globulin within 10 days
85
1. Can you treat Latent or active TB during pregnancy?2. What vaccines to avoid during pregnancy?3. MMR, varicella and zoster (not the recombinant one) are contraindicated in HIV with CD4 count
1. Yes2. MMR, Varicella, oral polio and yellow fever3. 200cells/uL
86
1. Pt. who has anaphylactic reaction to eggs should be given what flu vaccine?2. Can you give the singles vaccine and pneumococcal vaccine at the same visit?3. Can you give digoxin or verapamil to a pregnancy woman?
1. Flublok2. Yes; give in different arms3. Yes
87
1. Pt. w/ Mitral stenosis w/ A. fib should be tx w/ ___, ___ and ___ medications2. MS valvular area of ___ requires no tx, ___ requires beta blocker therapy and ___ requires valvuloplasty
1. Beta blocker, digoxin and anticoagulation2. >1.5sqcm...1-1.5sqcm...<1sqcm
88
1. Pregnancy woman with ASD wants to get pregnant, what do you do ifShunt is < 2:1..... or >2:12. Can pt. w/ MV prolapse or HOCM get pregnant?
1. <2:1: Can get pregnant....>2:1: surgery first2. Yes
89
1. Pregnant pt. w/ S3 and II/VI systolic murmur at apex; W.t.d?2. Causes of DIC in pregnancy are pre-eclampsia, acute fatty liver of pregnancy, ____ embolism, ___ and ____.3. Pt. c/o itching during pregnancy, w.t.d?4. What two medication requirements increase during pregnancy?
1. Functiona heart sound and murmur due to normal volume overload of pregnancy - do nothing 2. Amniotic fluid embolism, dead fetus and abruptio placentae3. Can give hydroxyzine and chlorpheniramine4. Insulin (by 50%) and thyroxine
90
1. What trimester is the best time to fly during pregnancy?2. Women with pulmonary HTN should avoid ____ only OCPs
1. 2nd2. Progesterone
91
1. When is hyperemesis gravidarum seen during pregnancy? Does it have AST/ALT elevation? Does it have itching?2. When is intrahepatic cholestasis seen during pregnancy; does it have increased AST/ALT? Does it have vomiting? What is the tx?3. Does pruritis gravidarum (called mild intrahepatic cholestasis of pregnancy) have vomiting or AST/ALT elevation? What about itching? What trimester is it seen?
1. 1st trimester; Yes >2xULN. No itching2. 2nd or 3rd trimester: Yes but <200 ULN: no vomiting; Tx/ w/ cholestyramine, ursodeoxycholate or early delivery if fetal distress (+)3. No AST/ALT elevation or vomiting: (+) itching. 2nd or 3rd trimester
92
1. 40 yo female has dysfunctional uterine bleeding (abnormal uterine bleeding w/o a specific cause): what do you give?2. What do you give for post-coital contraception3. Pt. on OCPs missed 3 days of pills and had no sexual activity during that period: w.t.d?
1. Mydroxyprogesterone acetate for 10-12 days2. Start Levonorgesterl within 72 hrs: this inhibits ovulation, but if already ovulated, blocks implantation.3. Take only the most recently missed pills and use another method of contraception for 1 week
93
1. OCPs are contraindicated in patients w/ CAD, HTN, ___ headaches, breast cancer, chornic hepatitis, hx of DVT, and smokers >___ yo.2. What abx cause OCP failure? What anti-seizure meds cause OCP failure? What supplements? What immunocuppressants?
1. Migraines w/ aura...>35 yo (use progesterone only)2. Rifampin....Topiramate, primidone (metabolized to phenobarb), hbarbiturates, carbamazepine and phenytoin....St. john's wort...tocilizumab
94
Woman on fertility tx presents w/ SOB, and abdominal distension: US show sascites and enlarged ovaries w/ increased number of ovarian follicles. Dx?
Hyperstimulation syndrome (affects women taking injectable hormone medications to stimulate the development of eggs in the ovaries....happes due to too much hormone medication in the system)
95
1. Covers hospitals, skilled nursin ghomes, home-health, and hospice services2. Covers some cost of prescription medications3. Covers healthcare personnell, and labs tests and durable medical equipment4. Covers benefits from part A, B, and D through medicare advantage plans (managed care plans)5. Supplemental insurance plans to help cover deductibles and co-insurance costs of Medicare Parts A and B, as well as preventive and other health-related services
1. Medicare Part A2. Medicared Part D3. Medicare Part B4. Medicare Part C5. Medigap
96
1. Pt w/ breast cancer makes an advanced directive and desires DNR; son moves in w/ her recently. She deteriorates and ends up in ER. Son says she told him that she doesn't want to be DNR and wants you to intubate the mother. W.t.d?2. Pt. w/ hemiplegia after a stroke makes her son durable power of attorney; she wants colonoscopy. Son says, no wait for me and I will decide. W.t.d?3. Whom can overright an advanced directive if patient becomes incapacitated?4. Who takes presedence: living will or durable power of attorney for healthcare?
1. Refer to ethics committee2. Tell the son, you will take consent from the mother and proceed accordingly3. Assigned surrogate or healthcare proxy (also known as durable power of attorney for healthcare)4. Durable power of attorney/healthcareproxy/surrogate
97
1. Pt. w/ attempted suicide brought to the ER refuses treatment. Threatens to sue. W.t.d?2. Pt. w/ meningococcal meningitis and wants to leave AMA. What do you do?3. Pt. w/ AWMI, whose mentally competent, refuses admission even after you explain consequence. W.t.d?
1. Treat: pt is in a pathological mental state2. Hold against will for public welfare3. Give nitrates, beta-blockers, ASA, ace inhibitor and arrange for home visiting RN
98
1. Pt. w/ COPD from smoking comes for a visit; you advise quitting; he says, he wants to, but doesn't have a quit date. W.t.d?2. Leading cause of mortality for age group 10-24 is what?3. Leading cause of preventable premature deaths in the US are due to waht?
Begin varenicline, a partial neuronal alpha-4, beta-2 nicotinic receptor agonist (know this)2. MVA>homicide>suicide3. Cigarette smoking
99
1. Marathon runner collapses; on PE she's ataxic (key), hypotensive, tachycardic, flushed with dry skin; Temp is 105F. Dx?Key differences btw heath exhaustion and stroke are what?
Heat stroke (NOT heat exhaustion): key is ataxia = mental status changeHeat exhaustion is opposite: pt is sweating, cool to touch, has a rapid weak pulse (strong pulse in heat stroke) - no altered mental status (no passing out, etc)
100
1. No DM, 10yr ASCVD risk >/=10.5%: best stain therapy? (<75yo)2. DM + LDL 80-189; best statin therapy? (40-75yo)...LDL >190? Tx?3. LDL >190: best statin therapy? (>19yo)4. ASCVD: CAD, PAD, TIA or stroke: >75yo: Tx? <75yo: Tx?
1. High intensity statin2. Moderate intensity statin....high intensity statin if >1903. High intensity statin4. >75yo: Moderate intensity...<75yo: High intensity
101
1. A. High intensity statins are rosuvastatin and atorvastatin at ___ doses2. B. Moderate intensity statins are rosuvastatin and atorvastatin at ___ doses, and simvastatin and pravastatin at ___ doses3. 62 yo DM male and HTN has Chol 268 and LDL 190, HDL 142. Tx?4. 68 yo w/ DM and ESKD on HD has legpains on atorvastatin 40mg; next step?5. 76 yo w/ DM and CVA: Tx?6. CHF pt. on atorvastatin w/ muscle aches; normal CPK. Next step?7. 50 yo w/ DM and LDL 130. Tx?
1. Rosuvastatin: 20-40mg...Atorvastatin: 40-80mg2. Rosuvastatin: 5-10mg...10-20mg...simvastatin: 20-40mg, prvastatin 40-80mg3. A (B/c LDL is >189: If less then choose B)4. D/c; no decrease in mortality in pts w/ DM or CHF5. B: age is 76yo!6. D/c7. B
102
The most common heritable hyperlipidemia is familial combined HLD. What is the best test for it?
Apoprotein B
103
1. Decreased LDL receptors + tendon xanthomas2. Decreased LPL and familial CII...same + chylomicrons - eruptive xanthomas -- all these can cause ____3. Abnormal ApoE + palmar xanthomas
1. Type IIa LDL2. VLDL type I, IV....and V - also all cause pancreatitis.3. Type III IDL: palmar xanthomas***Type I, IV and V are the same; all have eruptive xanthomas
104
1. Best tx for HLD in pregnancy?2. Pt. on statin c/o of myalgias; CPK 1900. You d/c; repeat in 3 mo, CPK 1925; muscle biopsy shows necrotizing muscle fibers w/ NO inflammation and NO vacuoles. Dx?3. When do you d/c a statin? vs. decrease its dose?
1. Colesevelam: safe, but not most potent2. Statin induced myopathy 2/2 200/100: anti-3 hydroxy-methylglutaryl coenzyme A reductase HMGCR)3. D/c if LFT's >5x ULN....Decrease dose if LFT's are >3-5x ULN; otherwise, continue dose and monitor
105
For patients taking low doses of prednisone ____, stress dosing of glucocorticoids typically is not required, even before high-risk surgical procedures (such as intrathoracic surgery).
<10 mg/d
106
True or FalseScreening for cervical cancer can be stopped in women age 65 years and older who have had three consecutive negative Pap smears or two consecutive negative Pap smears plus human papillomavirus test results within the last 10 years, with the most recent test performed within 5 years.
True
107
Side effects of Isotretinoin?
In addition to teratogenicity, serious side effects include pseudotumor cerebri (especially if used with tetracyclines), depression and psychosis, pancreatitis, marked hypertriglyceridemia, hearing loss, night vision loss, and skeletal abnormalities.
108
Beefy red tongue is seen in what deficiencies?
• Beefy red tongue (glossitis) is seen in pernicious anemia and various B vitamin deficiencies. It can also be associated with glucagonomas.
109
Macroglossia is seen in what diseases?
Macroglossia (big tongue) is associated with multiple myeloma, primary amyloidosis, lymphoma, hemangioma, acromegaly, hypothyroidism, angioedema, and Down syndrome.
110
Geographic tongue, thought benign, is associated with what autoimmune disease?
Psoriasis
111
Oral hairy leukoplakia seen in patients with HIV / AIDS is usually benign itself, what virus causes it?
EBV
112
Bald tongue is atrophy of the lingual papillae associated with what diseases?
Pellagra, iron deficiency anemia, pernicious anemia
113
Treatment for Rosacea
Topical Flagyl, azelaic acid, or sulfur/sulfacetamide preparations, or if severe, oral tetracycline
114
Treatment for contact dermatitis
Topical corticosteroids, burrow's solution; if severe, give po steroids
115
Treatment for intertrigo
Topical antifungals (ketoconazole, miconazole, etc), and drying agents (antifungal powders, aluminum sulfate powders, or corn starch).
116
Treatment for Seborrheic Dermatitis
Topical antifungals such as ketoconzazole +/- Low-potency topical corticosteroids; can use tacrolimus or sulfur/sulfacetamide cleansers/lotions Go to tx is topical antifungal
117
Antibiotic to use for refractory moderate-to-severe acne?
Bactrim
118
Treatment for Hidradenitis Suppurativa
1% topical clindamycin and intralesional steroidsIf refractory, consider Adalimumab (TNF alpha inhibitor)
119
Hyperpigmented Gingiva is seen in what autoimmune disease?
Addison's Disease
120
Oral Hairy leukoplakia, seen in HIV/AID patients as white plaques on side of tongue are caused by what Virus?
EBV
121
Strawberry tongue is associated with what diseases?
Scarlet Fever, Kawasaki Disease, and Toxic Shock Syndrome
122
What drugs are known to cause photosensitivity?___, ___ and ____ antibiotics, ____ anti-arrythmic, ____ cholesterol medication, ____ diuretic, and ____ heart medication
Tetracyclines, floroquinolones, sulfunoamides, amoidarone, statins, furosimide, and diltiazem.
123
This drug causes hypersensitivity syndrome (rash, lymphadenopathy, and hepatitis): also causes something with the gums?
Phenytoin: gum hyperplasia.
124
What drugs are known to cause Drug reaction w/ eosinophilia syndrome (DRESS)?
Allopurinol and anticonvulsants
125
All types of psoriasis can be worsened by what?
Beta Blockers, infections (virus and strep pharyngitis), sunburn, and lithium
126
What is a known trigger of Guttate psoriasis?
Streptococcal pharyngitis
127
Sudden withdrawal of what medication is known to cause pustular psoriasis?
Corticosteroids
128
Diffuse systemic sclerosis affects face, trunk, upper arms and thighs and is associated with what type of antibodies? What diseases do these people develop?
Anti-topoisomerase I antibody (Scl-70) or anti-polymerase RNA III antibodies. Develop scleroderma renal crisis and interstitial lung disease
129
Lofgren syndrome
Acute sarcoidosis that presents with EN, bilateral hilar adenopathy, fever, arthritis and uveitis; it is self-limiting
130
What is Lupus Perino? What is the treatment?
A type of sarcoidosis that has skin changes ranging from violaceous (purple) lesions on the tip of the nose and earlobes to large purple nodules/tumors on the face and fingers. It has a slow onset and almost never resolves! It is associated with chronic disease and extrapulmonary involvement.Treatment for cutaneous sarcoidosis: topical steroids, intralesional steroid injections, antimalarials and MTX.Tx of pulmonary sarcoidosis: Corticosteroids
131
Erythema nodosum is most commonly seen in what diseases? What is the MCC of EN in the world?
Sarcoidosis, inflammatory bowel diseases, drugs (sulfa and penicillins), infections (TB, strep and deep fungal).MCC of EN in the world is: streptococcal infection
132
If you only see cutaneous dermatomyositis, what is it called? How is it treated?
Amyopathic dermatomyositis.Treatment: Hydroxychloroquine
133
Pyoderma gangrenosum is most commonly see in inflammatory bowel disease. What other diseases can you see this in?
RA, MM
134
Sweet syndrome aka acute febrile neutrophilic dermatosis: idiopathic or associated with underlying disease (e.g. AML). What is the treatment?
Corticosteroids, potassium iodide, dapsone or colchicine - all 1st line
135
Porphyria cutanea tarda is seen in patients with what? It is a hereditary or acquired blistering disease caused by excess circulating porphyrins. Up to 50% of patients with sporadic PCT have ____ infection. Clinically, patients present with vesicles and bullae on sun-exposed skin, most commonly on the face, dorsal hands, and scalp. Skin fragility (tearing with minimal trauma) is common. Other features include hyperpigmentation, milia (tiny inclusion cysts), hypertrichosis, and alopecia.
HIV, HCV and hereditary hemochromatosisHepatitis C
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HSV resistant to acyclovir should be given what?
Foscarnet
137
For most fungal infections (candida), what should your prescribe: topical or oral treatment?
Topical treatment will treat almost all infections (clotrimazole, miconazole, and terbinafine (lamisil).
138
Tinea unguium (onychomycosis) can be treated with either topical or oral antifungal agents. How long is topical treatment?
48 weeks w/ eg: ciclopirox 8%
139
Can you treat tinea capitis w/ topical antifungals?
No: must always be treated with oral antifungals: griseofulvin, terbinafine, fluconazole, or itraconazole
140
KOH prep reveals spaghetti meatball appearance. What is it? What disease does it cause?
Malasezzia furfur or globosa.It causes tinea versicolor (hypo/hyperpigmented lesions depending on patient's skin tone/color)
141
What is the treatment for head lice?
Spinosad (overexcites CNS of head lice), Malathoin (pesticide), topical ivermectin (strongest drug; one application)Benzyl alcohol lotion (has no neurotoxic pesticides; safe in children >6 months and; needs 2nd treatment 7 days later)OTC premetherin cream + lotion (<50% effective 2/2 to resistance)1% lindane shampoo (2nd line due to neurotoxicity)
142
Treatment for Scabies?____ topical cream, ___ oral medication___ and ___ are safe in pregnancy and young children
Treat with 5% permethrin applied to all areas of the body from the head down and washed off after 8–14 hours. A second dose in 7 days is recommended.Use oral ivermectin for severe or recalcitrant cases with a repeat dose in 2 weeks.Lindane has CNS toxicity, so do not use during pregnancy, in infants, or in young children.Permethrin (category B) can be used in pregnancy.Precipitated sulfur is also considered safe in pregnancy, but may be less effective.Wash all linens in hot water.
143
Glucagnomas (alpha-cell tumors) cause what?
secrete excessive amounts of glucagon and can cause a beefy red tongue (think GLucagonoma = GLossitis), angular cheilitis, and a necrolytic migratory erythematous rash. Patients with glucagonomas may develop the 4 Ds: diabetes, DVT, depression, and dermatitis. Weight loss is characteristic.
144
What cancers metastasize to the skin?
Lung, breast, GI & melanoma
145
Nikolsky sign: Slight lateral pressure on the skin causes sloughing of the epidermis. It is positive in what diseases?
Pemphigus vulgaris, toxic epidermal necrolysis (TEN), and staphylococcal scalded skin syndrome (SSSS). It is negative in bullous pemphigoid
146
How does bullous phemphigoid differ from pemphigus vulgaris?
Bullous phempigoid rarely involve the mucosa.
147
What drugs precipitate bullous pemphigoid? Treatment is what?
Furosemide, ibuprofen, captopril, and penicillamine. Therapy includes topical (mild disease) and systemic corticosteroids and immunosuppressants.
148
Dermatitis herpetiformis, seen in celiac's, can be treated with what antibiotic?
Dapsone
149
When can a woman on isotrentoin become pregnant?What is required of them before they can use it?
When she stops taking it and waits at least 1 month.2 negative pregnancy tests and is on 2 forms of birth control prior to use. She must undergo a pregnancy test prior to obtaining a prescription, every time.
150
_____ is a safe and effective treatment for moderate-to-severe hidradenitis suppurativa, resulting in a significant decrease in abscesses and inflammatory nodules within the first 12 weeks of treatment.
Adalimumab
151
Scaling and redness, specifically on the eyebrows, nasolabial folds, and sides of the chin, are characteristic of _____. The redness and scaling are a response to commensal yeasts in the skin, and topical ____targets them.
Seborrheic dermatitis. Ketoconazole
152
_____ is a medical condition involving inflammatory cells in the anterior chamber of the eye. It is a leukocytic exudate, seen in the anterior chamber, usually accompanied by redness of the conjunctiva and the underlying episclera.Blood in the anterior chamber is ____
HypopyonHyphema
153
_____ consists of ongoing, slowly progressive, scaly infiltrative papules and plaques or atrophic red plaques on sun-exposed skin surfaces. Other chronic lesions may be____appearing. Most patients with this type of lupus, particularly those whose lesions are only on the head and neck, do not have systemic disease_____ may be associated with systemic lupus erythematosus but may also occur independently without systemic involvement. The rash is papulosquamous or annular, spares the ___, and usually ___.
Chronic cutaneous lupus erythematosus (also known as discoid lupus erythematosus)... hypertrophic or verrucousSubacute cutaneous lupus erythematosus....face, and usually does not scar.
154
____ which may develop from extensive alcohol use, ____ or _____ , presents with skin fragility and small, transient, easily ruptured vesicles in sun-exposed areas such as on the hands.
Porphyria cutanea tarda....Hemochromatosis, or hepatitis C virus infection
155
Most patients on stable doses of isotretinoin who have mild, expected changes in laboratory studies _____ monthly surveillance laboratory testing.
None! Do not need monthly surveillance.
156
Severe atopic dermatitis: Tx is what?
Medium-potency glucocorticoids: Triamcinolone ointment
157
___ and _____ are rated FDA pregnancy category B and is safe to use for mild comedonal and inflammatory acne during pregnancy
Azelaic acid cream and topical erythromycin
158
____ are benign firm brown or reddish papules that most commonly occur on the lower extremities. They extend deeper into the skin and exhibit the “dimple sign” when squeezed.
Dermatofibromas
159
____ are flat brown macules that occur on sun-exposed skin of older persons, particularly the face and dorsal hands rather than the trunk. They resemble large freckles
Solar lentigines (“liver spots”)
160
1. This type of rash has the characteristic findings include erythematous papules coalescing into plaques, often with some pruritus, and no accompanying systemic symptoms after a drug.2. In ______, patients develop an exanthem rash on the face, trunk, and extremities, and they often have facial edema. Due to systemic inflammation, patients may have fever, lymphadenopathy, and, in severe reactions, hypotension. Tx with ____.
1. Morbilliform Reaction2. Drug reaction with eosinophilia and systemic symptomsTx w/ steroids and d/c drug (MC allopurinol, sulfonamide abx and anticonvulsants)
161
1. Erythema infectiosum is seen in 2. Erythema marginatum is seen in 3. Erythema migrans is seen in 4. Erythema multiforme is most commonly seen in 5. Erythema nodosum is seen in
1. Parvovirus B19: "Fifth disease"2. Rheumatic fever3. Lyme disease4. HSV...also Mycoplasma5. Rheumatic fever, sarcoidosis, inflammatory bowel disease, etc.
162
Erythrasma is a scaly, reddish-brown rash that most frequently occurs in the inguinal or axillary areas caused by Corynebacterium minutissimum. The rash will fluoresce a ____ when illuminated with ultraviolet light from a Wood lamp.
Coral red color
163
1. White flakes on chest, upper arms and scalp: cause? what should you work up in these patients? Dx? And Tx?2. Associated with asthma and rhinitis: Increased IgE; found on flexural surfaces: Dx and Tx?
1. Seborrheic dermatitis; due to Pityrosporum; check HIV. tx w/ topical antifungal or topical steroids2. Atopic dermatitis; tx w/ hydrants, emollients....hydrocortisone
164
Female w/ severe acne wants accutane; what do you do prior to prescribing it?
Start OCP and another method of contraception during the treatment and 1 month after completing therapy
165
1. Macroglossia is associated with amylodoisis, ____ cancer, acromegaly, and ___ syndrome, hypothyroidism, angioedema2. Erythema multiforme ('targetoid lesions) is caused by ___ virus, ___ bacteria, ___ anti-epileptic, and ___ antibiotics and ___ pain medicaiton3. Pt. has recurrent erythema multiforme; what do you do?
1. Multiple myeloma, down syndrome2. Recurrent HSV, Mycoplasma, phenytoin, PCN and sulfa abx, and NSAIDs3. R/o HSV: tx/ w/ prophylaxis acyclovir - lifetime
166
1. Tx for SJS (<30%) and TEN (>30%)2. Pt. has generalized erythema, exfoliating dermatitis w/ bullae, you do punch biopsy and it shows a cleavage plane in the stratum corneum, this is due to ____....what if it shows in the stratum germinativum, then its due to ____
1. IVIG and steroids.2. Infection....TEN due to drugs: start IVIG
167
1. Rapid tapering of steroids can cause ____ psoriasis2. This psoriasis can be seen after a sore throat (usually due to group A strep: pyogenes)3. Pt on infliximab presents with erythrodermic itchy skin; cause? Tx?
1. Pustular2. Guttate psoriasis3. Psoriasis 2/2 to anti-TNF therapy; d/c it.
168
Red painful nodules (erythema nodosum) on the shins +1. Genital ulcers. Dx2. Diarrhea. Dx3. Hilar adenopathy. Dx
1. Bechet syndrome2. Ulcerate colitis3. Sarcoidosis
169
What is the vitamin deficiency?1. White spots on conjunctiva w/ night vision loss: Dx?2. Bleeding gums + perifollicular hemorrhages3. Angular cheilitis4. Atrophic glossitis w/ cheilitis and hyperpigmentation of skin5. Gum hypertrophy can be caused by ___ anti-epileptic, ___CCB, and ____ immunosuppressant.6. Eczematoid red rash on whole body + alopecia: pt. usually on TPN
1. Vitamin A deficiency2. Vitamin C deficiency3. Riboflavin deficiency (B2)4. B12 deficiency5. Phenytoid, nifedipine, and cyclosporine6. Zinc deficiency
170
1. Pt. has a while defined reddish lesion on axilla or groin or toe webs that lights up under wood's lamp: turns red. Dx? and Tx?2. Erysipelas is caused by ____ and recurrent ____ infections. If fever, what should you r/o?3. For verrucuous warts on hands; tx is ____. In the genitals, the tx is ___4. Smooth umbilicated papules that are seen common in HIV patietns are due to ____ and usually located on the ____ and tx with ____
1. Erythrasma; Gram + corynebacterium. Tx w/ oral erythromycin2. Strep and if recurrent its staph; if fever, do Echo to r/o endocarditis.3. Topical salicylic acid....topical imiquoid4. Poxvirus....eyelids....cryotherapy - molluscum contagiosum
171
1. Pt. has an erythematous, annular, scaly rash with central cleaning AND an advancing red border: Next step? Dx? Tx?2. Pt. c/o of a bald patch; o/e you see black dots (broken hair follicles); Under wood's lamp, it lights up bright green fluorescence. Dx? Tx?3. Pt. in summer, after tanning, finds untanned areas. Exam shows hypopigmented patches; next step? dx? tx?
1. Do scraping w/ KOH, which will likely reveal septate branching hyphae = tinea. Tx w/ topical azole (terbinafine or ketoconazole)2. Tinea capitis...Tx w/ PO meds: griseofulvin or terbinafine or ketoconazole3. Scarping w/ KOH: will see yeast-like ball and sticks or meatball and spaghetti on microscopy: dx is tinea versicolor (caused by malassezia furfur). Tx is reassurance + topical antifungal cream or selenium sulfide
172
1. The depth of this cancer determines prognosis; it's seen in patients with multiple sunburns in childhood, especially those who are on immunosuppressants. What is it?2. This is seen usually after age 60yo in sun-exposed areas and gradually, over years, becomes bigger and is pigmented. Dx? Tx?3. ___ is recommended for patients with melanomas of 1- to 4-mm thickness to provide accurate staging, as metastasis to regional lymph nodes is the most important prognostic factor in patients with early-stage melanoma.
1. Melanoma: <0.76mm is a good prognosis: think ABCD2. Lentigo maligna; refer for biopsy - its a precursor to melanoma3. Sentinel lymph node biopsy
173
High SPF lotion/cream helps protects against which of the following:Solar (actinic) keratosis and squamous cell carcinoma, melanoma or basal cell carcinoma
Solar keratosis and squamous cell carcinoma!
174
AA male has patchy loss of hair on arms and legs, coalescing to discrete patches/plaquies/nodules on trunk and buttocks + severe pruritis.Biopsy shows clusters of atypical lymphocytes in the epidermisDx?What is this called if you see lymphocytes with hyperchromatic and convoluted nuclei (cerebriform nuclei) in the blood smear?What is the Tx?
Mycosis FungoidesSezary Cells/syndromeTx: Topical nitrogen mustard or psoralen PUVA
175
1. Pt. has red to violet telangiectasias on lips, tongue and extremities. Dx? What should you r/o in this patient?2. Pt. has pigmented lesions on lip and mouth. What should you r/o?
1. Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Syndrome)2. Peutz-Jegher's syndrome: colonoscopy = hamartomas = increased malignancy risk
176
1. Pt. has beefy red tongue w/ skin rash w/ central clearing (necrolytic migratory erythema) on the perineum, perioral areas w/ chelitis: Dx?2. Pt. has multiple oral ulcers and large loose bullae and denuded skin: Dx? Abs will be positive to ___ proteins. Pt. has a positive ___ sign. These are intraepidermal3. >60 yo patient has tense bullae that don't rupture easily: have IgG + C3 and eosinophil deposits at the ___ junction: Dx? Tx?4. Pt. has tense, nonpruritic blisters in sun exposed areas. Causes? Tx?
1. Glucagonoma: islet cell tumor2. Pemphigus vulgaris...demoglein 1 & 3; Nikolsky sign - pressure applied on a blister results in its extension.3. Bullous pemphigoid: Dermal-epidermal junction. Tx w/ oral tetracycline or steroids4. Dx: Porphyrea cutanea Tarda: Hep C, Hemochromatosis, alcoholism, OCPs. Tx: Phlebotomy, anti-malarials (hydroxychloroquine)
177
1. Pt w/ recurrent itching, wheezing, SOB, dizzines w/ hypotensive episodes, abdominal pain and diarrhea. O/E: +/- hepato-splenomeagly. Dx? Next step?2. An elevated eosinophil count (>1500/µL [1.5 × 109/L]) without a secondary cause and evidence of organ involvement are diagnostic of ___3. ___ is characterized by urticaria pigmentosa, a unique identifying clinical finding. Urticaria pigmentosa findings include pruritic yellow to red or brown macules, papules, plaques, and nodules; these pts key complaints are GI
1. Systemic mastocytosis....Do serum tryptase2. Hypereosinophilic syndrome3. Systemic mastocytosis with eosinophilia
178
1. Frost bite, when grade 1 (affects fingers) and grade II (blue finger tips) put in warm (100F) water (NOT hot), for grade III and IV, do ___, if abnormal, give ____.2. Day # 2: If blisters seen, what should you do? What to do if you see blisters w/ hemorrhagic fluid?
1. Assess perfusion by doing technitium-99 bone scan: If decreased, give tPA + heparin then re-assess w/ scan.2. Drain and debride....drain only, do NOT debride
179
Hypersensitvity reactions:1. Allergic bronchopulmonary aspergillosis2. Hypersensitivity Pneumonitis3. Rh incompatibility and ABO incompatibility4. Arthus reaction and serum sickness5. SLE, PAN, RA, Hep B6. PPD, Poison ivy, nickel7. Latex8. Hyperacute graft rejection9. Acute or chronic graft rejection10. Allergic rhinitis/urticaria11. Wheal and flare
1. Type 12. Type 33. Type 24. Type III5. Type III6. Type IV7. Type IV, but can be type I8. Type II9. Type IV10. Type 111. Type 1
180
1. Best test for someone w/ allergic rhinitis, ocular itching exacerbated by pollen2. Best test for someone w/ latex allergy for dx?3. Pt has allergy to ASA. What NSAID can you use?4. What medications are contraindicated in patients with sulfa allergies? ____ type of NSAID, ___ BP med, ___ migraine med, and ___ anti-epileptic5. Pt. who develops itching and swelling in the mouth after eating avocado, or kiwii, or ____ have latex food allergy syndrome
1. RAST (radioallergosorbent test is a blood test using radioimmunoassay test to detect specific IgE antibodies: quantitative)2. RAST3. Sodium or choline salicylate4. Celecoxib, Hctz, sumatriptan, zonisamide5. Pineapple
181
1. Pt. gets urticaria when exposed to heat or hot shower. Dx?2. Pt. stung by bee/wasp = bronchospasm, urticaria, flushing; hypotension.What do you give: IV epi vs. subQ epi, vs. diphenhydramine vs. steroids?3. Can you give immunoglobulins (IVIG) to a patient with IgA deficiency?
1. Cholinergic urticaria syndrome2. SubQ epinephrine3. No! IVIG has IgA antibodies = worsen the reaction!
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1. Patient has recurrent angioedema with each episode, lasting 1–3 days. Unlike angioedema/urticaria caused by immediate hypersensitivity reactions,this is not associated with urticaria or itching. Even minor trauma from dental procedures can precipitate attacks! Attacks may include laryngeal obstruction and very often affect the GI tract, causing severe abdominal pain. Dx? W/u? Tx? And long-term management?2. Patients are particularly susceptible to invasive infections with encapsulated bacteria (such as meningitis and septicemia): Deficiency is in what? These patients are at increased risk of what autoimmune disease?3. Pt has severe pyogenic bacterial infections: Deficiency is in what complex?4. Deficiency in this results in increased Neisseria meningococcal/gonococcal infections (especially meningitis or septicemia). Dx? Screen with what?5. What is the best screening test for complement deficiencies? Why?
Hereditary angioedema: check C4 (will be low) if so, check C1H-inhibitor functional assay: this is C1 esterase inhibitor deficiency. Tx is FFP (SubQ epi does not work in this situation). Best long-term management = Danazol (increases C1-inhibitor levels)2. C1, C2 or C4 (MC is C2)-- SLE3. C3 complement4. C5 to C9 complement deficiency: Screen with CH505. CH50...b/c CH50 assay measures the total complement hemolytic activity of the classical pathway
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1. Which hypersensitivity rx benefits from immunotherapy? How long does it take to have this effect? What medication should be avoided when patients are underoing this?What type of reaction is ABPA - can you give immunotherapy to those patients? Is hypersensitivity pneumonitis IgE mediated?
Only IgE-mediated reactions benefit from immunotherapy treatment. Avoid beta-blockers as they can interfere w/ epinephrine if tx is needed ABPA is IgE mediated AND immune complex deposition : DO NOT give them immunotherapy - will worsenHyperesensitivity pneumonitis is NOT IgE mediated.
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1. Are there any contraindications for giving live or inactive vaccines to patiets w/ complement deficiencies?2. What vaccines can you not give in patients w/ phagocyte dysfunction?3. What vaccines can you not give in patients w/ a B-cell deficiency? (These are typically not given in the US)
1. No contraindications: can give all vaccinations2. Do not give live oral typhoid vaccine and BCG: can give all other live vaccinations3. Live influenza, Yellow fever, smallpox, oral polio, oral typhoid and BCG - you can give other live vaccines such as MMR, varicella, zoster
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When giving measles and varicella containing vaccinations, how long should you wait if patient has had: 1. IVIG2. Whole Blood3. Plasma/Platelets/PRBCs4. Immunoglobulins of measles or varicella or hep A or Hep B or Tetanus
1. 8-11 months2. 7 months3. 6 months4. Range from 3mo to 6mo
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Theophylline levels are increased by what drugs?
ciprofloxacin, clarithromycin, zileuton, allopurinol, methotrexate, estrogens (OCPs), propranolol, and verapamil
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Theophylline levels are decreased by what drugs?
Various antiepileptic drugs, rifampin, St. John’s wort, and smoking (which is more of an issue when patients stop smoking and theophylline levels subsequently increase on the same dose)
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Theophylline decreases levels of these two drugs when co-administered. What are they?
Phenytoin and Lithium
189
Silicosis is exposure to what occupations?
Making Brick, glass, ceramics, metal. Also sandblasting, and mining.
190
Asbestosis is exposure to what occupations?
Factory workers, industrial workers, insulators
191
Byssinosis (organic dust) exposure occurs in what occupations?
Cotton dust, hemp dust or flax dust
192
Beryllium exposure occurs in what occupations?
Worker's in high-tech electronics, alloys, ceramics, nuclear industry and pre-1950 fluorescent light manufacturing
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Long-term oxygen therapy is indicated if patients with COPD meet the following criteria: (1) chronic respiratory failure and/or severe resting hypoxemia, defined as an arterial PO2 less than or equal to ___ mm Hg (7.3 kPa) or oxygen saturation less than or equal to ___ breathing ambient air, with or without hypercapnia; and/or (2) if there is evidence of pulmonary hypertension, peripheral edema suggesting right-sided heart failure, or polycythemia, in combination with an arterial PO2 less than ____ mm Hg (8.0 kPa) or oxygen saturation less than ____ breathing ambient air.
1. 55mmHg2. 88%3. 60mmHg4. 88%
194
_____ are the drug class of choice for treatment of non–neuropathic pain in critically ill patients, including mechanically ventilated adult patients in the ICU, and should be given in an interrupted fashion when needed.
Opioids
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According to the referenced study, the most appropriate treatment for this patient with idiopathic pulmonary arterial hypertension (PAH) is to add oral ____ to the current regimen of ambrisentan and tadalafil.
Selexipag: it resulted in a significant reduction in the combined endpoint of death or complications in patients with pulmonary arterial hypertension, both in patients on other therapies and in patients who had not yet been treated.
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For acutely ill patients who are hemodynamically unstable, supporting all respiratory effort with the ____ mandatory ventilation setting to minimize risk for ventilator-induced lung injury is recommended as the best strategy for initial mechanical ventilation. ____ ventilation, in which a breath is delivered according to a preset inspiratory pressure, has been associated with ventilator-induced lung injury; therefore, ____, in which ___ and ___ flow are designated, is the preferred breath control method as the initial strategy for ventilation of critically ill patients.
Volume-controlled continuous...Pressure-controlled...Volume control...tidal volume and inspiratory flow
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1. A large (>2 cm), symptomatic, primary spontaneous pneumothorax may be initially managed with high-flow supplemental oxygen and ____2. Insertion of a ___-bore thoracostomy tube (<14 Fr [4.7 mm]) is indicated as initial treatment for larger (>2 cm) _____ pneumothoraces in patients who are symptomatic
1. Needle aspiration2. Small...secondary
198
The combination of ____ with ____ has been shown to improve FEV1, alleviate symptoms, and reduce exacerbations in patients with moderate to severe COPD.
Long-acting muscarinic agents with long-acting β2-agonists (LAMA + LABA)LAMA + ICS is NOT superior - ICS = increased pneumonias
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Obesity hypoventilation syndrome is characterized by fatigue and daytime somnolence in patients who are ____, and the diagnosis is confirmed by arterial blood gas testing showing ____ with an arterial PCO2 greater than ____ (in OSA this is normal; key difference between the two). Pulmonary function testing typically shows a ____ without ____, with a decreased FEV1 and FVC but preserved ____.
Obese (BMI >30)....daytime hypercapnia....45 mm Hg (6.0 kPa). Restrictive pattern....obstruction...FEV1/FVC ratio.
200
Congenital bilateral absence of the vas deferens is a common cause of obstructive azoospermia and is frequently associated with ____. Sperm production, however, is normal!
Cystic fibrosis
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A complicated parapneumonic effusion has pH of ____ and glucose of ____ and should be first treated with ____ and if that fails, then ____.If the above criteria aren't met, it's an uncomplicated parapneumonic effusion, so tx is ____.
<7.2, glucose <60.....pleural fluid drainage via tube thoracostomy....if it fails, then consider pleural decortication or video-associated thoracoscopic surgery.IV antibiotics; it'll resolve on its own
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1. The mainstay of management for acute respiratory distress syndrome is a lung-protective ventilator strategy, with ___ and ___, even if this results in hypercapnia and a lower pH 2. In patients with severe acute respiratory distress syndrome, current recommendations are to use a ____ that achieves adequate oxygenation with an FIO2 of less than ____ and does not cause hypotension. Then do prone positioning - it takes longer to help with oxygenation.
1. Low tidal volume (6 mL/kg of ideal body weight) and low plateau pressure (<30 cm H2O)2. Positive end-expiratory pressure level....0.6
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Criteria for ARDS include hypoxemia with ____ on chest xray and PaO2 to FiO2 ratio of ____.
Bilateral pulmonary infiltarates....less than or equal to 200 (< / = 300 is Acute lung injury)
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What happens to the FEV1, FEV1/FVC, TLC, DLCO and RV in: 1. COPD2. Asthma3. Restrictive Intrathoracic lung disease4. Restrictive extrathoracic lung disease
1. Decreased...Decreased....Increased....Decreased....Iincreased 2. Decreased.....Decreased.....Increased....Normal/increased....Increased 3. Increased....Normal/Increased....Decreased....Decreased....Decreased 4. Decreased....Normal....decreased....Normal....increased
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What is the disease: FEV1 (80%), FEV1/FVC (90%), TLC (94%), DLCO (86%) is normal. When reading these, always look at TLC first and then DLCO.1. FEV1 (58%), FEV1/FVC (65%), TLC (108%), DLCO (65%)2. FEV1 (55%), FEV1/FVC (92%), TLC (55%), DLCO (64%)3. FEV1 (56%), FEV1/FVC (72%), TLC (102%), DLCO (88%)4. FEV1 (58%), FEV1/FVC (90%), TLC (60%), DLCO (85%)
1. COPD: Obstructive disease2. Restrictive Intrathoracic disease (e.g. Pulm fibrosis, etc)3. Asthma: Obstructive disease4. Restrictive Extrathoracic lung disease (Chest cage: Kyphosis, obesity and spondylitis. Neuromuscular: M. gravis, guillan bare syndrome and muscular dystrophy)
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DLCO is 140% of predicted, normal FEV1/FVC and TLC. What is the dx?Asthma vs. COPD vs. Obesity vs. Spondylitis vs. Alveolar hemorrhage vs. Bronchitis
Alveolar hemorrhage
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DLCO is normal in asthma and ____
Carbon monoxide poisoning
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Extrathoracic and intrathoracic restrictive lung disease have the same values except that the DLCO is ____ and RV is _____ in extrathoracic vs. intrathoracic lung disease.
Extrathoracic lung disease: DLCO is normal and RV is increased (meaning they don't use a lot of their lungs due to their body habitus)Intrathoracic lung disease: DLCO is decreased and RV is decreased
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To dx asthma you do PFTs with bronchodilator challenge: an increase of in FEV1 of ___ diagnoses it....But if you don't see any reversal but still suspect it you should do a ____ test and a drop in FEV1 of ____ will diagnoses it
>12%.....methacholine challenge test...>20%
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The FEV1 is ___ in the following situations for asthma:1. >80% w/ < 2 night awakenings per month2. 60-80%3. <60%4. >80% w/ >2night awakenings per month
1. Mild intermittent asthma2. Moderate persistent asthma3. Severe persistent asthma4. Mild persistent asthma
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1. Can you give leukotriene inhibitors to mild persistent asthma (key is >2night time awakenings per month and >2 attacks per week)?2. What about ASA sensitive asthma?3. What affect will they have on moderate and severe persistent asthma? 4. Leukotriene receptor antagonists are: ____, leukotriene synthesis inhibitor: _____
1. Yes2. Yes3. Allow dose reduction of inhaled glucocorticoids4. Montelukast.......end in lukast5. Zileuton....
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Pt w/ perennial vasomotor rhinitis and nasal polyps develops asthma and has allergy to NSAIDS. Dx is what? Tx is what? What can you give these ppl for pain control?
1. ASA sensitive asthma...avoid ASA and start leukoterine inhibitors (montelukast, zafirlukast, zileuton)....for pain control No COX-1 inhibitors...can give codeine-based analgesics or sodium or choline salicylates
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A patient continues to have cough and SOB w/ wheezing after a viral URI. Methacholine challenge test is positive: Dx and Tx?
Post-viral hypersensitivity....give INH steroids: budesonide once daily
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Pt. w/ chronic nonproductive cough and a negative methacholine challenge test may have what? How do you dx it?
Non-asthmatic eosinophilic bronchitis: sputum for eosinophils
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1. At what stage of asthma do you add LABA?2. Pts w/ asthma who have a high serum IgE should be given what?3. Pts. with severe persistent asthma uncontrolled can be given what along with INH steroids+ Laba, + Leukoterine inhibitor and SABA prn?4. Pt. whose on all of the above that pt. 3 is on but also PO steroids with a high eosinophil count - what can you offer them?
1. Moderate persistent Asthma2. Omalizumab (Anti-IgE)3. Tiotropium4. Mepolizumab or benralizumab (IL-5 inhibitors)
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Mast cell stabilizers: coromolyn sodium can be added at what stage of asthma tx?
Mild persistent
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Pt w/ exercise induced asthma who does not improve with SABA - what can you give them?
ICS or coromolyn Na (mast cell stabilizer) or leukotriene inhibitors (the....lukast's)
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Pt w/ steroid dependent asthma has productive cough w/ brownish mucus plugs, wheezing; has a parakeet. Is on INH triamcinolone, albuterol and mast cell stabilizer (cromolyn Na); Prednisone now at <20mg/day: WBC: 15% eosinophils and IgE >200; XR chest - fleeting pulmonary infiltrates. Dx? Tx?
Dx: Allergic bronchopulmonary aspergillosisTx: Increase steroids dosage
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Hypersensitivity pneumonitis can be seen in Farmers, pet bird owners, those working with air conditioning systems or ___, ___, ___ and ____ medications. What causes this? What will the CD8 to CD4 count be in BAL? What will be the IgE and eosinophils be? Tx? PFTs will show what type of pattern?
Mtx/nitrofurantoin/rituximab/tacrolimusOrganic dust w/ thermophilic actinomycetes causes thisCD8>CD4 (opposite of sarcoidosis)IgE normal and eosinophilsTx; Remove offending agentPFTs: Restrictive pattern
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Pt. from central america is dx w/ asthma and despite tx continues to have cough and wheezing. CBC shows eosinophilia only and XR chest shows round infiltrates. What is the most likely Dx? Tx is what?
Strongyloides infection: Loeffler's syndrome!Tx: Thiabendazole
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If you have asthma + vasculitis; what disease should you think of?
Churg-strauss: Eosinophilic granulomatosis w/ polyangitis
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Dry cough with eosinophilia and peripheral infiltrates and high ESR. Dx and Tx?
Chronic eosinophilic PNATx: Glucocorticoids
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FEV1 is __ in the following GOLD criteria and also list treatments1. GOLD 12. GOLD 23. GOLD 34. GOLD 4
1. >/= 80%: Tx SABA +/- short acting anticholinergic (ipratropium) OR Laba2. <80% Tx: Laba or Lama (tiotropium) +/- pulm rehab3. <50% Tx: ICS + Laba: those w/ chornic bronchitis or increased exacerbations, add roflumilast (PDE-4 inhibitor) + pulm rehab4. <30% Tx: ICS + Laba +/- long-acting anticholinergics (tiotropium) +/-roflumilast
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Indication for oxygen in patients w/ COPD isA resting PaO2 of ____ or an SaO2 of ____ when breathing ambient airOr a resting PaO2 of ____ or an SaO2 of ____ in patients w/ evidence of corpulmonale (polycythemia + clinical right heart failure: LE edema, etc)
A resting PaO2 ≤ 55 mmHg or an SaO2 ≤ 88%,Or a resting PaO2 ≤ 59 mmHg or an SaO2 ≤ 89% in a patient with evidence of cor pulmonale
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Lung transplant criteria are:PCO 2 greater than_____, PAO 2 less than ____, and an FEV1 and DLCO of less than ____of predicted
50mmHg....60mmHg....20%
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Paraneoplastic syndromes are associated with the pulmonary neoplasms. Be familiar with these associations!1. Squamous cell carcinomas: central, cavitary, and ___2. Small cell carcinomas: central, neuroendocrine,___ and ___.Large cell carcinomas: peripheral, ____Adenocarcinomas in situ:____ smoking (and can masquerade as a pneumonia)
1. Hypercalcemia2. SIADH, dermatomyositis3. Scar carcinomas4. Not associated with
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____ consists of clubbing, painful periosteal hypertrophy of long bones, and symmetrical arthralgia of the large joints.Radiographs of the long bones show thickening and hypertrophy of the periosteum.This disease occurs most commonly as a paraneoplastic syndrome associated with ____ of the lung. Resection of the primary tumor may relieve the symptoms
Hypertrophic pulmonary osteoarthropathy (HPOA)...Adenocarcinoma
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COPD hypoxia is due to ____ and so will respond to oxygen. If it does not you should think of ____
V/Q mismatch...another cause of the hypoxia
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Pt w/ COPD exacerbation and non-hypercapenia should be tx with ____ to decrease mortality and intubation as opposed to pt. w/ COPD exacerbation w/ hypercapnia, whom shoud be treated with ___ to decrease inbuation and mortality
HFNC 100% FiO2@ 50L/min.....BiPAP
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Should you give oxygen to a patient with COPD who desaturates to 88% when playing golf?
No! Recall the criteria for oxygen: if it was =88% while resting, then yes!
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Does Pulmonary Rehab improve FEV1 compared to pre-rehab values?
No!
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What has shown to decrease mortality in COPD patients?Infuenza vaccine vs. pneumococcal vaccine
Influenza vaccine!
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OCPs increase levels of which key asthma medication?
Theophylline
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Pt. has bronchiectasis (tram lines on xr chest), sinusitis, infertility +/- sinus inversus. Dx? How do you screen and confirm dx?
Dyskinetic cilia syndrome aka Kartagener's syndromeScreen: Inhaled NO testConfirm: Biopsy of sinus or bronchi
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Causes of bronchiectasis include cystic fibrosis, ___ (has to do w/ immunoglobulins), pneumonia, ABPA, ___ (related to liver disease), and ____ (aka kartenger syndrome). How do you dx each?
Cystic fibrosis: Sweat chlorideHypogammaglobulinemia: immunoglobulin titers: IgG/A/MPneumonia: Hx of pneumoniaABPA: Elevated IgE and eosinophils in pt. w/ hx of asthma and fleeting b/l infiltrates or Ab's to aspergillusAlpha-1 antitrypsin deficiency: antitrypsin levelDyskinetic cilia syndrome: Inhaled NO test
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This bacteria is the leading cause of mortality in patients with CF? Tx?
Burkholderia Cepacia: Tx w/ bactrim.
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Pt. w/ migratory infiltrates but NO asthma, but has either RA, post-lung transplant or carcinoid tumor. Dx is what? And Tx?
Cryptogenic organizing pneumoniaTx: Glucocorticoids
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Patients with IPF will have inisidous onset of dry cough, dyspnea, clubbing, cyanosis and CT showing of ____ is key. What two medications have shown to decrease rate of FVC decline?
Honeycombing....pirfenidone and nintedanib
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HRCT w/ tree in bud (TIB) appearance in the following patterns mean what:1. Random TIB pattern2. Widespread pattern3. Consolidation pattern4. Dependent areas and pt. has esophageal abnormality
1. Mycoplasma Avium Cellularlae or Miliary TB2. ABPA3. Aspiration bronchiolitis4. Aspiration bronhciestasis
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Sandblasting, stone/granite cutting - think ____. XR will involve ____ and pt. has increased incidence of ___ infection. XR chest will also show ____ calcifications w/ hilar LNs.
Silicosis...Upper libe fibrosis: Myobacterium tuberculosis....egg shell calcifications
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Langerhan cell histiocytosis (histio. X) is associated with ____. Tx is what?
Smoking...Quit!
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Premenopausal woman on OCPs presents with sudden onset SOB: CXR reveals pneumothorax and honeycomb appearance diffusely. Pt. has an effusion: what will be prominent in it? Dx is what?
Lymphangioleiomyomatosis. Chylous effusion.
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Pulmonary HTN has IV types: which ones require anti-coagulation with coumadin?
1. Type 1 Pulmonary Arterial HTN (many causes) and Type IV (chronic thromboembolic cause)
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Type 1 PAH is due to ____Type 2 PH is due to ____Type 3 PH is due to ____Type IV PH is due to ____
Type 1 is PAH (not PH): Many causes: idiopathic, HIV, congenital heart disease, shistosomiasis, etcType 2: Left heart diseaseType 3: Lung disease +/- hypoxia: obstructive and restrictive diseases, sleep-disorders, high altitude, alveolar hypoventilationType 4: Thromboembolic cause
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Pt. has split second heart sound, loud pulmonic component, pansysotlic murmur at left sternal border, left parasternal heave, and tall R waves in V1 and V2. Dx is ____. You do Echo and it shows RV dilatation and moderate TV regurgitation: Next step is _____. If patient responds to vasodilators you can give ___ and ___. If no response, give ___ or ___.If pt. has moderate to severe disease you can give ____, then ___ + above.
Pulmonary Hypertension....Do right heart cardiac catheterization w/ vasodilator testing: if pt. responds, give nifedipine or diltiazem, if no response, can give PED5 inhibitors (Sildenafil/tadalafil), or endothelin receptor antagonists (bosentan or macitentan or ambrisertan, etc).If moderate to severe disease give selexipag...then IV epoprostenol
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Age x ___ gives you normal D-dimer. For example and 80 yo's normal D-dimer is ___ as opposed to a 30 yo.
Age x10...800.....300
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Indications for greenfield filter (IVC filter) are ___, contraindication to anticoagulation, ___ post anticoagulation and cirrhotic patient with PT INR >___ w/ DVT (recall FVIII is made by endothelial cells and liver makes protein c & s....low c & s with increased factor VIII = hypercoagulable state b/c c & s inactivate factor VIIIa and Va)
PE ...emboli....3.5
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Do you anticoagulate patients with fat emboli (post trauma/fractures: key is petechiae seen over chest) and do you tx w/ steroids?
No and No!
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For hip or knee replacement you must give DVT prophylaxis with LMWH for ____ or warfarin for ____ weeks or fondaparinux for ___ weeks.
4 weeks...4-6 weeks....4-6 weeks.
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Chronic sinusitis is defined as sxs for > ____ weeks. Tx is with ____ for ____ weeks.Acute exacerbation of chronic sinusitis is tx w/ ____ for ____ weeks.
>4 weeks: augmentin for 4 weeks.Augmentin for 2 weeks
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Centor score of 0-1 do nothing, 2-3 rapid strep. And 4-5 do rapid strep w/ culture and possible antibiotic use based on clinical scenario.It consists of ___, ____, ____, ____, age: 3-14 is 1, 15-44 is 0, and >/= 45 is -1
Fever >100.4F, exudative or tonsillar swelling, tender/swollen anterior cervical lymphadenopathy, absence of cough
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Spontaneous pneumothorax in a smoker, you should think of ____.
Pulmonary Langerhans cell histiocytosis
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The only two medications for IPF are ____ and ____.Glucocorticoids are only used for exacerbations and are of questionable efficacy.
Nintedanib (tyrosine kinase inhibitor) and pirfenidone
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Normal TLC with decreased DLCO is seen in what?
Pulmonary arterial hypertension
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In patients with pulmonary arterial hypertension and a negative vasoreactivity test (positive is decrease in pressure by 10 or more), ___ are not beneficial and ___ or _____ are preferred.
Calcium channel blockers...phosphodiesterase-5 inhibitors (sildenafil, tadalafil)...endothelin receptor antagonists (bosentan, ambrisentan)
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1. Fever, dysphagia, muffled voice with stiff neck and woody induration of hypopharynx2. Fever, dysphagia, neck pain with brawny edema of the hypopharynx and SCM tenderness3. Hot potato or muffled voice, fever, difficulting opening mouth and uvula deviation with drooling secretions4. Sore throat, odynophagia, fever, muffled voice and hoarsness with respiratory distress with drooling secretions
1. Ludwig's angina2. Lemierre's disease (IJ vein thrombosis).3. Peritonsillar abscess4. Epiglottitis
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In the elderly fluoroquinolones can cause QTc prolongation, tendon rupture, ___, ___ and ___
Paraesthesias, aortic aneurysms and dissection and prolonged hypoglycemia!
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Influenza outbreak in a nursing home; what do you do?
Vaccine + oseltamivir for 2 weeks....takes 2 weeks for vaccine to form protective antibiotic response....if no vaccine them oseltamivir for 6 weeks
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Pt. exposed to a patient with mult-drug resistant TB; this new patient is asymptomatic but PPD is 5.5mm. What is the best tx?
Pyrazinamide + ethambutol or Pyrazinamide + quinolone for 6 months
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PPD of >5mm is positive in patients with: HIV, recent contact of patient with TB, ___ w/ old TB scar, ___ recipients, ____ , ___ and ____ medication use.
XR chest....organ transplant recipients....prednisone >15mg, anti-TNF alpha users (e.g. infliximab, etanercept, adalimumab, cetrolizumab) and those on -mab drugs (ecluzimab, etc)
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Pleural fluid exudate will have fluid:serum protein ratio of ____ and fluid to serum LDH ratio of ____: Total protein and LDH in transudate vs. exudate will be ____
Exudate: >0.5......>0.6Exudate Total protein: >3g/dLExudate total LDH: >200Transudate less than all of above.
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Patient with OSA or obesity hypoventilation syndrome fails CPAP or BiPAP: what do you do next?What if a patient is intolerant of CPAP or BiPAP?
Fail = Volume assured pressure support as long as there's no heart failureIntolerant: hypoglossal nerve simulator for apnea reduction
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The key difference btw OSA and obesity hypoventilation syndrome is ___. Tx for OSA vs. OHS?
PCO2 is normal in OSA but increased on OHSTx for OSA: CPAPTx for OHS: BiPAP
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Tx for Narcolepsy? What if they have cataplexy?
Narcolepsy: Methylphenidate, or modafinil (expensive)Cataplexy: Sodium oxybate
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Pt. w/ CHF has episode of hard breathing for several seconds followed by no breath for several seconds at night time - NO snoring. Dx is what?
Cheyne stokes w/ central sleep apnea
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1. Lung nodule that is: ≤4mm: Low-risk vs. high risk2. >4 to 6mm: Low-risk vs. high risk3. >6 to 8mmg: low-risk vs. high-risk4. >8mm: low-risk vs. high-riskHigh risk: Age (older than 50 years of age confers higher risk), history of past or present smoking, and other risk factors for lung cancer, such as environmental or occupational exposures (for example, asbestos and radon), a diagnosis of COPD, a history of radiation therapy, and possibly a family history of lung cancer.
1. Low risk: no follow-up needed...high-risk: follow-up CT at 12 months; if unchanged, no further follow-up2. Low-risk: Follow-up CT at 12 months; if unchanged, no further follow-up...High-risk: Initial follow-up CT at 6 to 12 months then at 18 to 24 months if no change3. Low-risk: Initial follow-up CT at 6 to 12 months then at 18 to 24 months if no change...High-risk: Initial follow-up CT at 3 to 6 months then at 9 to 12 months and 24 months if no change4. Follow-up CT at around 3, 9, and 24 months; dynamic contrast-enhanced CT, PET, and/or biopsy...High-risk: same as for low-risk patient
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1. ____ is pulmonary hypertension in the setting of portal hypertension, typically associated with liver cirrhosis. 2.____ is a disorder caused by dilated small vessels in the pulmonary vasculature resulting in shunting of blood in a pt w/ liver disease whose hypoxic. ____ is not a defining feature. Intrapulmonary shunting is confirmed by the appearance of contrast (bubbles from agitated saline) in the left heart following injection into a peripheral vein.
1. Portopulmonary HTN2. Hepatopulmonary syndrome...Pulmonary hypertension
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___ is a self-limiting form of sarcoidosis characterized by acute arthritis, bilateral hilar lymphadenopathy, and erythema nodosum.Tx sxs w/ ____
Lofgren syndrome...NSAIDS...colchicine or LOW dose prednisone
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Patients with ___ deficiencies may present with recurrent, invasive meningococcal or ___ infections
Late complement component (C5 to C9)...gonococcal
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In patients with apparent malignant superior vena cava syndrome, a ____ should be established, whenever possible, before treatment is begun.
Histologic diagnosis
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Asthma Tx:Step 1 is ___Step 2 is ___Step 3 is ___Step 4 is ___Step 5 is ___Step 6 is ___
Step 1: SABA prnStep 2: Low-dose ICSStep 3: Low-dose ICS + LABA or Medium-dose ICSStep 4: Medium dose ICS + LABAStep 5: High-dose ICS + LABAStep 6: High-dose ICS + LABA + PO corticosteroids
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0. Hypoxemia: A-a gradient is elevated in all except ____ & decreased ____ ventilation1. V/Q Mismatch: PNA, COPD, Asthma: alveolar, interstitial or pulmonary vascular (PE) diseases. Do these respond to 100% oxygen? 2. R-to-L intrapulmonary shunting within the lungs: Examples are pneumonia,ARDS, etc. Does this respond to 100% oxygen? no response to 100% oxygen3. Decreased alveolar ventilation (e.g. hypoventilation due to opioids): Drugs. The A-a gradient is ____4. Decreased diffusion: ILD & emphysema w/ tachycardia: with tachy, there's increased blood flow through the lungs, and hence less time for diffusion: A-a gradient is ____5. High Altitude: Low Alveolar O2: A-a is ____6. Low mixed venous oxygen: too much extracted in tissues or a low CO (heart failure); can exaggerate all other causes of a low PaO2; will cause hypoxic vasoconstriction and hence anatomic ____ shunt. Will this respond to 100% oxygen?
0. High altitude...alveolar1. Yes2. No3. Normal4. Increased5. Normal6. R-to-L...No response to 100% oxygen
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Uncomplicated cystitis: Treat with a 3-day course of ____. Or 5 day course of ____.
TMP/SMX, fluoroquinolone, or cephalexin. Or macrobid for 5-7 days.
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Complicated cystitis or uncomplicated pyelonephritis: treat with ____.
Fluoroquinolone, TMP/SMX, or beta-lactam depending on culture and sensitivity data.
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Complicated pyelonephritis and/or hospitalized patients: Treat with ____.
Fluoroquinolone, ceftriaxone, beta-lactam + beta-lactamase inhibitor (augmentin, unasyn, zosyn), or ampicillin + aminoglycoside for 7−10 days unless bacteremic.
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Relapses are commonly due to a persistent nidus of infection (e.g., stones, abscess, urethral/ureteral/bladder diverticula, obstruction) in the urinary. What do you do to evaluate relapses?
To evaluate relapses perform CT of the abdomen and pelvis with contrast or renal ultrasound.
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Reinfection is sometimes related to sexual activity. If so, give very low-dose prophylaxis (e.g., TMP/SMX 1/2 single-strength (SS) tablet, nitrofurantoin 50 mg) before or after sexual activity. When do you treat these as a UTI vs giving low-dose prophylaxis?
If there is no sexual activity and < 3 episodes a year, treat UTIs as they occur.If ≥ 3 episodes a year, consider chronic low-dose suppression for 6 months.
278
What is the treatment for Mucormycosis sinusitis in a diabetic patient? Organism looks like ____ on biopsy
Radical Surgical Debridement, with Amphotericin B and when stable, switch to posconazoleFilaments w/ branching at rt. agnles
279
When should you consider CT or MRI in patients with recurrent sinusitis?
When there are >3 episodes/year
280
1st and 2nd line treatments for sinusitis?
1st line: Augmentin2nd Line: Doxy or floroquinolone
281
Patient with GABHS (S. Pyogenes) have a penicillin allergy, what do you give?
Azithromycin
282
1. Pharyngitis w/ Maculopapular rash is caused by what 2 viruses?2. Pharyngitis w/ diffuse erythema is caused by _____ & ____.3. Pharyngitis w/ erythema multiforme is caused by ____.4. Pharyngitis w/ vesicular rash is caused by ____.
1. HIV & Epstein Barr Virus2. Strep Pyogenes (GABHS) or arcanobacterium haemolyticum3. Mycoplasma pnuemoniae4. Coxsackie virus
283
What organism causes Epiglotittis and what's the treatment?
H. Influenza; tx w/ Ceftriaxone
284
1. Treatment for purulent cellulitis?2. Tx for nonpurulent cellulitis
1. Bactrim or Doxy2. Clindamycin or caphelexinIf unsure: Bactrim + caphalexin
285
1. Treatment for mild nonpurulent cellulitis? 2. Moderate? 3. Severe?
1. Clindamycin or caphlexin 2. IV ceftriaxone 3. Vancomycin and Zosyn
286
Erysipleas is caused by what organism?
Streptococcus
287
Necrotizing fasciitis is caused by what organisms?
Group A Strep, Group B Strep, Staph, Vibrio vulnificus or clostridium species
288
Treatment of Pasturella Multicoda caused by dog or cat bite?
Augmentin
289
An alcoholic man with liver disease who has exposure to salt water or fish and comes in with sepsis, confusion, and bullous skin lesions. Another case is a person with liver disease who eats oysters or goes to the beach. What organism is responsible and how do you treat?
Vibrio vulnificus. Tx w/ ceftriaxone or tetracycline/gentamicin or doxycycline
290
This organism causes nonhealing skin ulceration in people who work with fish tanks. The Infection can present as a single granuloma, but the organism often invades the lymphatics and can cause a series of lesions along the lymphatic drainage similar to the lesions seen in sporotrichosis or bartonella henselae. Lesions tend to localize in the distal extremities because the organism does not grow well at body temperature. What organism is it and what's the treatment? How long do you treat for?
Myobacterium Marinum. Treat w/ Clarithromycin + either ethambutol or rifampin and continue tx for 1-2 months after ulcers have resolved
291
1. Septic arthritis treatment should be how long? 2. What is the organism and treatment for: Gram positive cocci vs. Gram negative bacilli?
1. 3 weeks iV amd then 2 weeks PO2. Staph aureus - vancomycin and gram negative bacilli tx w/ ceftriaxone
292
Neutropenic patient with a symmetric maculopapular rash is infected by what organism?
Candida and has candidemia
293
What organism causes a superimposed infection on varicella?
Strep. Pyogenes - can cause toxic shock syndrome
294
Food poisoning what's the difference between Staph vs. B. cereus?
Staph incubation period is 1-6hrs and causes primarily a vomiting illness as opposed to B. cereus which causes a vomiting illness for the first 1-6 hrs and then diarrhea from 8-16hrs
295
Norovirus comes from what?
Clams and oysters - cruise ships!
296
Salmonella Typhi colonizes what & causes what disease? What's the treatment?
Gallstones, causes acute diarrhea. Tx w/ Floroquinolone or ceftriaxone
297
Tx for Campylobacter Jejuni bacteria?
Floroquinolone or macrolide (preferred)
298
Always treat shigella, no matter what - what's the treatment?
Floroquinolone
299
Yersinia is treated with what?
Bactrim, tetracycline or ceftriaxone
300
Vibrio acute diarrhea is treated with what?
Doxycycline or ceftriaxone
301
Complicated severe C. Diff is defined as what and treated w/ what?
Hypotension, toxic megacolon, ileus.Tx w. PO and rectal vanco, and IV flagyl
302
What is moderate disease with C. diff? And what do you treat it with?
WBC >15000 or increase in creatinine by 50% from baseline. Tx w/ PO vancomycin
303
At what size do you drain a liver abscess and at what size do you put place a catheter?
Drain of <5cm, place cathether if >/=5cm
304
What group of patients w/ ascites should be given spontaneous bacterial prophylaxis and what antibiotic(s) should be used?
For patients who have ascitic fluid protein < 1.0 g/dL, variceal bleed, or a prior episode of primary peritonitis.Use ciprofloxacin or TMP/SMX
305
Young person presents w/ strokes, what should you consider?
Secondary (meningovascular) syphilis
306
What are the 3 stages of tertiary syphilis?
Gummatous, cardiovascular (ascending aorta aneurysms), & neurosyphilis
307
1. For syphilis, which antibodies are negative in 1/3 of patients w/ primary syphilis but also tertiary syphilis? Why?2. Which Ab's are always positive and when do they become positive?
1. VDRL and RPR - negative in 1' syphilis b/c not enough time to make them, but also 3' syphilis, b/c these IgM antibodies burnout.2. MHA-TP and FTA-ABS; IgM Ab's, seen in 2-4 weeks and stay positive for the whole life
308
For syphilis, LP is indicated when you suspect neurosyphilis, but also, at what RPR titers should you do it?
>/= 1:32
309
What is the treatment for Primary, secondary, and early latent syphilis:
Benzathine PCN G 2.4 MU IM x 1
310
What is the treatment for Late latent, latent of unknown duration, and non-neurologic tertiary syphilis?
Benzathine PCN G 2.4 MU IM every week x 3
311
What is the treatment for Neurosyphilis? What if pen allergy?
PCN G 18–24 MU IV divided every 4 hours or continuous infusion for 10–14 days. Or Ceftriaxone 2g/day x 10-14 daysIf allergic; Put in ICU, desensitize and tx.Repeat spinal q6 months until WBCs are normal
312
What abx's can you give for syphilis for penicillin-allergic patients?
Ceftriaxone is an alternative for PCN-allergic patients, but cross-reactive allergies may occur.
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The following antibiotic can be given for syphilis for penicillin-allergic patients except those whom are pregnant or have neurosyphilis.
Doxycycline
314
Chancroid, caused by this organism, is known to cause painful genital ulcers lymphnodes that can drain. What is the treatment?Microscopy will show ___
Haemophilus Ducreyi. Tx w/ 1g Azithromycin x1 OR ceftriaxone (125mg) IM x1 OR ciprofloxacin 500mg BID x3 days or erythromycin 500mg PO TID x7 daysSchools of fish or box care appearance: It is a gram negative bacteria
315
1. Lymphogranuloma venereum causes a painless genital ulcer followed by tender inguinal lymphadenopathy (2-6 weeks later) +/- rectal scarring; what organism causes this? What's the treatment?2. Pt has terrible looking painless ulcers: (+) lymphnodes. O/E: ulcer looks like carcinoma. Dx? Organism? Microscopy will show ___. Tx?
1. Chlamydia trachomatis. Tx w/ Doxycycline for 21 days2. Granuloma inguinale by klebsiella granulomatis. Microscopy will show donovan bodies: bipolar saftey-pin in cytoplasm (safety pin is also yersinia: plague, southwest desert)Tx w/ Doxy for 21 days or bactrim/erythromycin
316
The CDC recommends empiric treatment of PID in a sexually active woman with pelvic and/or lower abdominal pain if she also has any one of the following minimal clinical criteria? There are 3.
□ Cervical motion tenderness □ Uterine tenderness□ Adnexal tenderness
317
When do you admit a patient with chlamydia pelvic inflammatory disease? What is the treatment?
When a patient fails outpatient therapy, is pregnant, has sepsis, or has a tuboovarian abscess or has decreased PO intake due to vomiting.Inpatient treatment: Cefoxitin or cefotetan IV and doxycycline IV/PO OR IV or Clindamycin and gentamicin IV (use the latter, if you think anaerobes caused this)
318
What is the outpatient treatment for pelvic inflammatory disease?
Cefoxitin or Ceftriaxone IM x1 + doxycycline +/- flagyl (if suspecting anaerobes as the cause) for 14 days
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1. Cervicitis is characterized by an ____ and is caused by ____.2. What do you give for Cervicitis? Do you treat the sexual partner?3. Vaginitis refers to inflammation of the vagina and is caused by infections such as ____ and ____ or by noninfectious conditions such as atrophic vaginitis or vaginal irritation
1. Inflamed, friable cervix...it is caused by chlamydia and gonorrhea2. Azithromycin 1g PO x1 + Ceftriaxone 250mg IM x1 and treat the sex partner3. Candidiasis and trichomoniasis
320
What color is the discharge for gonococcal urethritis & is it painful?
Always painful & clear.
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What is the treatment for gonococcal urethritis vs. nongonococcal urethritis?
Gonococcal urethritis: Ceftriaxone & azithromycin x1Nongonococcal urethritis: 1 dose PO azithromycin or 7 days of Doxy 100mg PO BID
322
What is the best test to diagnosed N. gonorrhea as the cause of septic arthritis?
Take specimens for testing from genital sources: 85% yield, otherwise it's only 15% yield
323
Epididymitis in <35 yo is due to STI's, but >35 are due to what organism? And what's the treatment?
<35 yo: Chlamydia or gonorrhea; Azithro + Ceftriaxone IM>35yo: E. Coli. Tx w/ floroquinolone
324
What HPV strains cause cervical cancer and what cause genital warts?
16 and 18 = cervical cancer11 and 6 = Genital Warts
325
What organisms that cause diarrhea are known to have fecal leukocytes?
Shigella—along with Salmonella, E. coli O157:H7, Campylobacter, and Yersinia—causes an invasive gastroenteritis resulting in fecal leukocytes being noted in the stool.
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1. Rotavirus causes ____ type of diarrhea.2. Cryptosporidia (from fresh produce such as raspberries from mexico) causes ____ type of diarrhea3. Giardia causes _____ type of diarrhea.
1. Secretory diarrhea2. Protein-losing enteropathy3. Malabsorptive diarrhea
327
What antibiotics should be given to close contacts of someone who was just diagnosed with Serotype B menningococcal meningitis?Which of those are indicated in pregnancy?
Rifampin, ciprofloxacin or ceftriaxone. Pregnancy indication is ceftriaxone
328
Out of the three causes of vaginitis, which one has a pH <5.0?Candida vs. Trichomonas vs. Gardanella?
Candida pH <5, the other 2 >5
329
What is the treatment for bacterial vaginosis from gardanella?
Flagyl x7 days or intravaginal cream x5 daysAlternative: Tinidazole or clinda PO or 2% intravaginally x7 days
330
What is the treatment for Candidiasis in pregnant women?
Topical clomitrazole or miconazole; PO meds can cause still births!
331
Tx for candida?Should patients in the ICU w/ a urinary catheter who are asymptomatic be tx for candiduria?
150mg PO fluconazole x1No; only tx of symptomatic, or those who are neutropenic or those undergoing urologic procedures
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Does BV produce a discharge?
No
333
What is the organism that produces a thin, frothy, yellow-green, foul-smelling discharge with a positive whiff test? And what is the treatment? Do you check for clearance?
Trichomonas. Flagyl 2g PO x1 or tinidazole 2g PO x1Check for clearance w/ repeat NAAT testing in 3 months
334
What is the treatment, in order, for the following patient:1. Bacterial meningitis w/ (+) focal neurological deficits2. Bacterial meningitis w/ (-) focal neurological deficits
1. Stat blood cultures-->IV dexamethasone + IV antibiotics (vanc and ceftriaxone, (if age >50, add ampicillin for Listeria)-->CT head---->If negative, Lumbar Puncture2. Stat blood cultures--->IV dexamethasone + IV antibiotics--->Lumbar Puncture
335
When do you start dexamethasone for Pneumococcal meningitis & how long do you continue it for?
15-30mins prior to giving antibiotics...continue for 4 days
336
1. Who should get prophylaxis if they are exposed to someone w/ Neisseria Meningitis?2. What medication do you give:2a. Non-pregnant adult? and 2b. Adolescent: >/=15 yo2c. Pregnant adult and children <15 yo3. Those being tx w/ neisseria meningitis are placed on ___ precautions and these are discontinued when ____
1. Household contacts, daycare workers and ONLY the healthcare workers exposed to oral secretions (i.e. the anesthesiologists who intubates the patient, etc)2a. Rifampin; if contraindicated, then cipro: if on OCP; change contraception method while on rifampin2b. Rifampin2c. Ceftriaxone3. Droplet....24 hrs of abx have been given
337
Should a patient who is successfully treated for meningitis caused by N. Meningitidis, be given prophylaxis? Why or why not?
Yes; penicillins don't kill the bacteria, which resides in the nares.
338
CSF lymphocytic pleocytosis w/ high protein and very low glucose is caused by what organism?
Myobacterium Tuberculosis
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1. Which fungi and bacteria cause aseptic meningitis?2. What medications cause aseptic meningitis?3. What type of pleocytosis do you see initially in CSF for aseptic meningitis?
1. Nocardia, cryptococcus, lyme disease and myobacterium tuberculosis2. NSAIDs, bactrim and OKT3 Abs (graft vs. host dz)3. Initially Neutrophilic pleocytosis!
340
Fever, back pain & radiculopathy is what____ . What LP show?
Epidural abscess, MC by staph. LP will be consistent with aseptic meningitis.
341
1. What is the empiric treatment for brain abscess?2. What if the patient had a recent neurosurgical procedure?
1. PCN (if allergic, use ceftriaxone) + flagyl (to cover for aerobes & anaerobes)2. Above + Vancomycin (for MRSA) & Cefepime or ceftazidime or meropenem (for pseudomonas)
342
What diseases do you only give PPSV23 (pneumococcal polysaccharide)?
Chronic heart disease (including CHF and cardiomyopathies) Chronic lung disease (including copd, emphysema), cigarette smokersAlcoholism, chronic liver disease,and diabetics
343
Rabies presents 1-3 months after exposure w/ encephalitis, ascending paralysis, etc.1. How do you diagnose it?2. Bites from what animals are considered high risk?3. What do you give for post-exposure prophylaxis?
1. PCR of oral secretions or CSF antibodies2. Bats, racoons, foxes & skunks3. Human rabies immune globulin (HRIG) injected in the tissue around the wound, with the remainder given IM & also give vaccination. If person has been previously vaccinated, only give booster vaccine, not HRIG
344
An abnormal protein, 14-3-3, may be present in the CSF and EEG shows bi or triphasic sharp wave complexes. What disease is it?
Prion Disease
345
Staph, followed by veridians strep and enterococci are the most common organisms causing NVE.What additional organisms can cause native valve endocarditis (NVE)? What antibiotics are these organisms susceptible to?
AACEK:Aggregatibacter aphrophilus, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingaeThey are all susceptible to Penicillins - ceftriaxone x4 weeks!
346
1. What is the difference between early prosthetic valve endocarditis vs. late PV endocarditis?2. Empiric Abs for PV endocarditis3. Empiric Abx for NV or IVDU endocarditis4. What do you do if #2 or 3 grows PCN sen strep vs. PCN res strep?5. What to do if PV endocarditis grows MSSA vs. MRSA?
1. Early occurs in <2 months and is hard to treat - think S. Epi . Late happens >2 months - caused by same organisms of NVE2. Vanco + rifampin + gentamycin3. Vancomycin + gentamycin4. If cx grows PCN sen strep: con't Cef or PCN G....if PCN resistant stre: Cef alone or PCN G + gentamycin5. PV w/ MSSA: Naf + Rifampin + Gentamycin...MRSA: Vanco + Rifampin + Gentamycin
347
What do you do when you have a patient who develops a new heart block or bundle branch block after insertion of prosthetic valve?
Replace the valve - there's a serious infection going on
348
How do you draw blood cultures for patients w/ Endocarditis?
Draw 3 sets:if patient is stable, do them 8 hrs apart. If unstable, get them 1 hr apart.
349
What organisms cause culture negative endocarditis?
Coxiella Burnetti, Bartonella, Tropheryma whipplei, legionella species, chlamydia psittaci, fungi.Also AACEK organisms
350
What is the test of choice to diagnose NVE vs. PVE?
NVE: TTEPVE: TEECan do TEE for both TTE only picks up PVE 17-69%
351
How do you diagnose endocarditis?
1. Pathologic evidence (vegetation or intracardiac abscess - confirmed by histological examination) OR2. 2 Major criteria (2/3 positive blood cultures: coxiella only needs 1 + evidence of endocardial invovlement: abscess, new regurgitation (not change in murmur intensity) or valve dehisicence)3. 1 Major + 3 minor OR4. 5 minor criteria: Predisposing condition (IV drug user, or valve disease), Tmax >100.4F, vascular phenomenon (janeway lesions, etc), immunologic phenomenon (Osler nods, roth spots, acute glomerulonephritis - recall normal complement systemic) and positive blood cx not meeting the major criteria
352
How long should you treat Native valve endocarditis vs. Prosthetic Valve endocarditis?
All NVE are treated for 4 weeks. Exceptions:Right or left sided-staph endocarditis: 6 weeks, but can treat for 2 weeks if it's uncomplicated right sided MSSA endocarditis and an aminoglycoside is addedProsthetic valve is generally treated for 6 weeks
353
What patient's and what procedures require endocarditis prophylaxis?
High risk patients:1. Congenital Heart disease:1a. Unrepaired cyanotic CHD, including palliative shunts and conduits 1b. Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure1c. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization) 2. Prosthetic Cardiac Valve3. Hx of infective endocarditis4. Cardiac Transplant recipient w/ valvular disease2. Dental Extraction, periodontal procedures, root canal and dental implants.Rrespiratory procedures that cut through mucosa (such as tonsillectomy) or bronchoscopy w/ incision.
354
What is the backbone of treatment for HIV?
2 NRTI's or NNRTI's and 1 drug from another class (can be a protease inhibitor, or integrase inhibitor).NRTI backbones are as follows: Tenofovir + emtricitabine OR Abacavir + lamivudine + 1 drug from any of the followingIntegrase inhibitors: Elvitegravir, Dolutegravir or RaltegravirBoosted protease inhibitor:Darunavir
355
What is the medication for pre-exposure prophylaxis for HIV?
Daily Tenofovir-emtricitabine
356
Needle stick transmission is 0.33% or 1 in 300 and from mucous membrane secretions is 0.09% (1 in 1,100) - what is post-exposure prophylaxis treatment for HIV? & at what intervals do you check them for HIV?
Same as HIV treatment: 2NRTI's (Tenofovir + emtricitabine ORAbacavir + lamivudine) + integrase inhibitor (ends w/ avir) or protease inhibitor darunavir) - tx for 4 weeks.Baseline, 6, then 12 weeks, then 6 months
357
How is HIV transmitted?
ONLY via bloody fluids, and ONLY if these have been injected or penetrate non-intact skin or mucous membranes
358
What medication(s) is/are contraindicated in pregnant women with HIV? When do you give continuous IV zidovudine to these women?
Contraindicated: EfavirenzWith respect to labor and delivery, give all HIV-infected pregnant women whose viral load is > 1,000 copies/mL zidovudine as a continuous infusion during labor in addition to their current ART therapy.Deliver babies by C-section.
359
PCP is 2nd most common infection (after bacterial PNA) in AIDS patients whose CD4 count is <200. What medications can you give to treat?Bets blood test for this?
Mild-to-moderate disease: tx w/: Bactrim: if allergic give Clindamycin + primaquine or atovaquoneSevere disease: Pentamidine (this kills pancreatic beta cells - can also cause renal failure, hyponatremia, and diarrhea) If PaO2<70mmHg on RA or AA gradient >/= 35, give GlucocorticoidsBest blood test: Serum Beta-D-Glucan
360
When do you do PCP prophylaxis, with what and for how long?What do you give if patient is allergic to bactrim?
1. CD4 count <200 - give bactrim DS daily or 3x/week. Discontinue when CD4 remains >200 for >/= 3 months on ARTIf allergic to bactrim: give dapsone or atovaquone
361
How do you Tx TB in a patient with HIV?
RIPE therapy for 2 months followed by Rifampin + INH for 4 months. However, a 7-month continuation phase of isoniazid and rifampin is recommended in patients who do not receive pyrazinamide during the initial phase, in patients receiving once-weekly isoniazid and rifapentine whose sputum cultures are still positive at the end of the initial treatment phase, and in patients with cavitary pulmonary tuberculosis whose sputum cultures are positive at end of the initial phase of treatmentIf positive PPD if +5 or greater, INH for 9 months
362
What is the organism that causes: presents as disseminated infection causing a wasting syndrome with fever, weight loss, night sweats, lymphadenopathy, hepatosplenomegaly, diarrhea, and abdominal pain in a patient with HIV? How do you treat this?
Myobacterium Avium CellularleTreatment: Clarithromycin OR azithromycin + ethambutol + rifabutin (or rifampin) for disseminated disease
363
Can you give Acyclovir to treat CMV?
No. Only val or gancyclovir
364
The most common presentation is a subacute meningitis or meningoencephalitis that is very different than bacterial meningitis. Subtle signs of decreased mental status, personality changes, and memory loss may be the only manifestations and are due to increased intracranial pressure, not invasion of the organism. -- What organism is this? What is/are the go to medication(s) for treatment initially?Should you start HIV meds right away?
Cryptococcous in an AIDS patient. Amphotericin B + Flucytosine for 2 weeks, then fluconazole for >1yrStart HIV meds after cryptococcous is treated for 5 weeks. Otherwise, increase in T-cells = worsening ICP during immune reconstitution syndrome
365
India ink stain is used to Dx what organism?What about methamine silver stain?
Indian ink stain - CryptococcousMethamine silver stain - PCP
366
What do you give to treat Toxoplasmosis Gondi infection in an AIDS patient? What if patient is allergic to initial tx?
Pyrimethamine and Sulfadiazine (w/ folinic acid; to prevent anemia from pyrimethamine) If ALLERGIC Give Clindamycin
367
When do you give primary prophylaxis for Toxo in AIDS patients & with what?
CD4 <100, same regiment as PCP: Bactrim DS 1 tab daily or 3x/week & d/c when CD4 >100 for >/=3 months on ART
368
HIV patients w/ chronic diarrhea can be caused by Cyclospora and Cytoisospora, cryptosporidium, microsporidia, or bacteria (salmonella, shigella and campylobacter).How do you treat them? *Note all these can cause alcalculous cholecystitis
◊ Treat Cyclospora and Cystoisospora with TMP/SMX.Cryptosporidium has a variable response to nitazoxanide.Microsporidia responds to albendazole.Treat Salmonella, Shigella, and Campylobacter with ciprofloxacin
369
What is the oral antibiotic treatment for a patient with febrile neutropenia? If admitted, what do you give? If fever lasts >5-7 days, what should you add?
Augmentin + Cipro or moxifloxacinAdmitted: can give cefepime, a carbapenem (imipenem or meropenem) OR zosynAn echinocandin - specifically Capsofungin (echinocandins end in "fungins)OR add voriconazole (esp if pulmonary infiltrates - treats aspergillus us: voriconazole is the drug of choice for invasive aspergillosis)
370
What are the indications for removing a central line?
Remove if CLABSI is associated with severe sepsis, hemodynamic instability, metastatic infection (e.g., meningitis, osteomyelitis, endocarditis), suppurative thrombophlebitis, or blood cultures remain positive more than 72 hours after appropriate antibiotic therapy. Also remove if blood cultures are positive for:Staph Aureus, P. Aeruginosa, fungi or myobacteria.
371
What is the empiric treatment for CLABSI? How long do you treat these?
Empiric Tx: use vancomycin, unless patient has risk for gram negative organisms (femoral line, has colonization of gram negative organisms or neutropenia or severe sepsis)Give antifungal w/ echinocandin, if femoral line, on TPN, hematologic malignancyTreat CLABSI for 2 weeks, unless it's Staph infection, then tx for 4-6 weeks
372
1. Toxic shock syndrome diagnosed when one has fever, hypotension and what else?2. Which organism causes bacteremia and which doesn't? When do these organisms normally cause this?3. Next step in tx?
1. Sun-burn like rash, and involvement for 3 or more organ systems2. Strep presents in <24 hrs and is (+) bacteremiaStaph presents >24 hrs later and is (-) bacteremia3. Surgical debridement and abx
373
A patient with chicken pox develops toxic shock syndrome - what organism caused it?
Strep Pyogenes!
374
Treatment for Staph Toxic Shock syndrome? Treatment for Strep TSS?
Staph: start w/ Vancomycin...change to naficllin or 1st generation cephalosphorin (if MSSA)....with mild can use Doxy or bactrimStrep: Any penicillin.Always add Clindamycin for anti-toxin effect
375
What antibiotics do you give for Eneterococci infections:Mild to moderate vs. Severe
Mild-to-moderate: Pen G, Ampicillin or VancomycinSevere: Add gentamicin for synergy
376
1. Treatment for listeria is Ampicillin - what do you give if allergic?2. Tx/ for confirmed Listeria meningitis is ampicillin + ____ (for synergism)
1. Bactrim, vancomycin or chloramphenicol2. Gentamicin
377
Corynebacterium diphtheriae causes diphtheria, an upper respiratory infection with a gray-white pharyngeal pseudomembrane, hoarseness, sore throat, and a low fever (< 101.0° F [38.3° C]). In addition, toxin production causes myocarditis with heart failure and polyneuritis.What is the treatment of choice?
Erythromycin...2nd line is penicillin. Always give diptheria anti-toxin along with the antibiotic
378
Corynebacterium jeikeium (JK) is a multidrug-resistant strain that colonizes and infects neutropenic patients and/or bone marrow transplant patients, where it causes IV catheter–related infections. What is the treatment of choice?
Vancomycin
379
This organism causes pharyngitis in adolescents with a desquamative scarlatiniform rash and lymphadenitis. What is the treatment?
Arcanobacterium haemolyticumTx: Erythromycin, penicillin or tetracycline
380
Bacillus Anthracis is known to cause Cutaneous, Pulmonary and GI anthrax. What is the treatment of choice until susceptibilities are known?
Ciprofloxacin, meropenem and linezolid
381
B. cereus usually causes a GI infection, but can cause endopthalmitis, especially in contact lens wearers, after trauma. What is the treatment?
Vancomycin
382
Treatment of choice for Clostridium species (except C. Difficile)
Penicillins, cephalosporins or clindamycin
383
Like vibrio vulnificus, this organism typically causes, diarrhea (similar to that of B. cereus), but can also cause rapidly progressing cellulitis. What is it and what is the treatment?
C. Perfringens. Tx w/ Pencillin, or cephalosporin or clindamycin
384
Most chronic meningitis' are lymphocytic, which organism can cause chronic neutrophilis meningitis? What is the treatment?This organism causes ___cavity in the lungs
Nocardia Asteroides. Tx is Bactrim...If sulfa allergy, use minocyclineThin-walled
385
What three organisms cause nodular skin lesions along lymphatic channels? And what are their treatments?
Nocardia Brasiliens (Tx w/ bactrim) Mycoplasma Marinum (clarithromycin + ethambutol or rifampin) andSporothrix Schenckii (self-limiting but can tx w/ itraconazole if disemminated, DM or transplant: use Amphotericin B)
386
What is the treatment for Actinomyces israelli (think yellow-sulfur granules & lumpy jaw)
PCN or ampicillin...2nd line is tetracycline
387
Tennis shoe cellulitis and/or osteomyelitis is caused by what organism?
Pseudomonas Aeruginosa
388
When suspecting Pseudomonas Aeruginosa infection, always treat with 2 antipseudomonals until susceptibilities are known. List all those that cover it.
Carbapenems (except ertapenem), Aztreonam, Fluoroquinolones, Aminoglycosides, Ceftazidime and Cefepime (4th generation), Ceftolozane/tazobactam and Ceftazidime/avibactam (6th generation cephalosporins), and Piperacillin/tazobactam
389
Yersinia Pestis (reservoir is rodents) aka plague and tularemia present similarly (adenopathy after hunting), except that the geographic locations are different. Where do you found Yersinia vs. Tularemia? Where do you find Ehrliciosis and Anaplasma?
Desert Southwest for plagueArkansas, Missouri, and Oklahoma for tularemiaEhrliciosis and Anaplasma: Arkansas and Missouri
390
Bipolar staining ("safety pins") gram negative rods from a suppurated lymph node in a patient from desert in the southwest US?What is the treatment?
Yersinia PestisTx: Aminoglycosides (also drug of choice for tularemia) - Gentamicin (streptomycin not available anymore) 2nd line choices are tetracycline, doxycycline, or quinolones.
391
This organism, seen in ___, missouri and ____ causes sudden onset of fever, chills, myalgias, arthralgias and an irregular ulcer w/ regional suppurative lymphadenopathy in a hunter.What is it and what is the treatment?
Arkansas, Missouri and Oklahoma.Tularemia Francisella.Tx is Aminoglycoside(s) - Gentamicin....or Tetracycline (if not severely ill)
392
Treatment for Klebsiella?
3rd generation cephalosphorins, fluoroquinolones, carbapenems...if resistant to carbapenems, give colistin, tigecycline, or aminoglycosides or 6th generation cephalosphorins or aztreonam
393
TB Drugs: RIPE1. Rash and hepatitis is caused by which drug(s)?2. Peripheral neuropathy is caused by which drug(s)?3. Hyperuricemia is caused by which drug(s)?4. Retrobulbar neuritis is caused by which drug(s)?5. Orange body fluids is caused by which drug(s)?
1. All 4 drugs2. Ethambutol and INH3. Pyranizamide4. Ethambutol5. Rifampin
394
What drugs are used to treat Candidemia and most other forms of invasive candidiasis?
The "fungins"....echinocandins (caspofungin, anidulafungin, and micafungin) are considered the therapy of choice for candidemia and most other forms of invasive candidiasis.
395
In which patients is a TST +5 considered positive?
In patients who are: immunosuppressed, including those who are taking tumor necrosis factor α inhibitors (e.g infliximab, adalimumab, cetrolizumab and entanercept) or the equivalent of at least 15 mg/d of prednisone for 1 month or longer. Other's are those with: HIV infection, organ transplants, fibrotic changes on chest radiograph consistent with old tuberculosis, and recent contacts of a person with active tuberculosis.
396
Next step if TST is positive? And what are the next steps
Get an XR chest....and if positive, Tx with RIPE....if Negative, Tx with INH + B6 for 9 months
397
What are 2 tests for C. Diff and what do they specify?
Stool Enzyme Immunoassay - checks LDH which is prevalent in C. Diff. If negative, no further testing, if positive, do stool C. Diff PCR for confirmation
398
1. Do you treat asymptomatic babesiosis?2. What medications do you use for mild-to-moderate vs. severe disease?3. When is an excahnge transfusion indicated?
1. No - f/u repeat testing in 3 months to make sure it's cleared - most people will clear it2. Mild-to-moderate: Atovaquone + Azithromycin.....Severe: Clindamycin + Quinine3. When patient has severe anemia and >10% parasetemia
399
What antibiotic is indicated for ESBL organisms (mostly are Klebsiella species and E. Coli)?What antibiotic is known to induce this plasma mediated resistance?What do you give if pt. is growing ESBL klebsiella and is resistant to imipenem?
Carbapenems: meropenem or doripenemCephalosporinsCeftazidime + avibactam (Avicaz)
400
What is the treatment of choice for coccidioidal meningitis?
Fluconazole
401
The rash of this pathogen begins as small red dots on the pharyngeal and buccal mucosa with centripetal spreading to the hands and face, followed by the arms, legs, and feet; the rash progresses in synchronous fashion, from macules to papules to vesicles and pustules before crusting over. What is it?
Smallpox
402
When do you see a negative tuberculin skin test (TST) in patients who actually have TB? I.e. False negative.
Physiologic causes of false-negative TST results include active tuberculosis infection, HIV infection, use of immunosuppressive agents (such as glucocorticoids), kidney injury, lymphoproliferative disorders, and recent vaccination with live virus.
403
Patients who have more than one recurrence of Clostridium difficile infection should be treated with what medication and for how long?
Oral vancomycin given at tapered doses over 6 to 8 weeks.
404
You find cryptococcous in the lungs. What's the next step? How is it treated?
Do a LP to r/o meningitis; recall it's meningitis is very subtle. Tx w/ fluconazole for 6-12 months (Echnicidans have no function against this)
405
How do you interpret Lyme enzyme immunoassay, and if positive, subsequent westernblot results of IgM and IgG for Lyme arthritis?
The initial test, an enzyme immunoassay (EIA), is exquisitely sensitive but not specific. If the result of this test is negative, no further evaluation is necessary. When the EIA finding is positive or equivocal, a more specific Western blot test is recommended for confirmation. A negative Western blot result is interpreted as a negative serologic result. A positive result must be further interpreted with respect to acuity of symptoms. When symptoms are present for less than 1 month, an isolated positive IgM Western blot result may be diagnostic of acute infection. However, symptoms present for more than 1 month provide ample time for IgG seroconversion. A positive Western blot IgM result without associated positive IgG result in a patient with more than 30 days of symptoms should be interpreted as a false-positive result.
406
What do you give for treatment for inpatient PID vs. outpatient PID?
Inpatient PID: 2nd generation cephalosphorin (Cefoxitin or cefotetan) + IV doxyOutpatient: 1 dose of IM Ceftriaxone + Doxy 14 days +/- flagyl
407
Outbreaks of Yersinia enterocolitica have been traced to consumption of what foods? Yersinia gastroenteritis is clinically indistinguishable from other forms of inflammatory diarrhea and is most commonly identified in young children. It does not cause grossly bloody stools. In some cases, diarrhea may be absent with bacteria localizing to lymphoid tissue in Peyer patches and associated mesenteric lymph nodes. This presentation may mimic appendicitis clinically.
Pig intestines
408
A TST reaction of 10-mm or larger induration is interpreted as positive which patients?
In patients who use injection drugs, are recent arrivals from countries with a high prevalence of tuberculosis, or reside in homeless shelters
409
Those who have a positive TST and negative XR chest - you give them INH + B6 for 9 months, what else can you give them to treat this latent TB?
Other possible treatment regimens for LTBI include a 12-week regimen of directly observed once-weekly isoniazid and rifapentine OR Four months of daily rifampin therapy is acceptable for patients with LTBI that is suspected to be resistant to isoniazid or who cannot take isoniazid.
410
What is the blackbox warning of fluoroquinolones?
Peripheral Neuropathy, CNS side effects, tenidinitis, tendon rupture & worsening of myasthenia gravis
411
Treatment for a patient who has pneumonia with a reticulonodular pattern from Mississippi and Ohio River basins and the basins near the Great Lakes and along the St. Lawrence River. Sputum shows broad-based yeast.What is the organism and what is the treatment?
BlastomycosisMild-to-moderate: ItraconazoleSevere: Amphotericin B Treatment lasts 6 to 12 months
412
Mississippi and Ohio river valleys - bat and bird droppings. Immunocompetent patients typically have a self-limited, flu-like illness with or without mild pulmonary infiltrates.This can present with interstitial pneumonia, palate ulcers, and splenomegaly. It occasionally causes upper-lobe cavitary pneumonia similar to that seen in TB.What is it? What will sputum gram stain show? What is the treatment?Best test to detect this?
Histoplasmosis: narrow-based buds:Mild: No txMore severe but localized histoplasmosis can be treated with itraconazole.Disseminated disease requires amphotericin B (either deoxycholate or liposomal formulations), followed by itraconazole.To detect: use Urine or serum Ag - can cross react w/ blastomycosis (broad-based buds)
413
This is found in: Southwest US (Cali, Arizona, parts of Texas) andNorth Mexico.It causes a self-limiting flu-like illness +/- arthralgias/myalgias.This and and allergic bronchopulmonary aspergillosis are the only 2 fungal diseases that cause peripheral eosinophilia.What is it? What do you see under microscope?What is the treatment?
Coccidiodiomycosis immitis.Will see spherules under the microscope.Treatment: chronic or mild to moderate: treatment with fluconazole, itraconazole, or ketoconazole is common.Severe: Amphotericin B
414
Fluoroquinolones should NOT be taken with what?
Antacids, milk, ice cream or other high calcium foods - all inhibit absorption
415
If you have had rheumatic fever or carditis due to GAS, how long are prophylactic antibiotics required, if at all?
Rheumatic Fever: 5 yearsCarditis: 10 years
416
Which organisms can be spread via respiratory droplets from a person with necrotizing pneumonia and is useful as a bioterrorism agent because of this characteristic?
Yersinia Pestis - PlagueTx w/ streptomycin or gentamicinThis is also the treatment for Tularemia!
417
1. Which malaria agent is the drug of choice for prophylaxis of a pregnant woman traveling to high-risk, chloroquine-resistant malaria areas and can be used in all trimesters?2. What malaria agent clears the liver stage of P. vivax or ovale3. For severe malaria (e.g. cerebral malaria) use ____
1. Mefloquine2. Primaquine3. IV artesunate
418
Treatment of choice for RMSF - can present as pancytopenia, also hyponatremia and transaminitis.
Doxycycline
419
Drug or choice for listeria in pregnancy is ampicillin. What is the 2nd line drug and at what weeks of pregnancy can you not use it, why?
Bactrim - don't use after 32 weeks --->increased risk of hyperbilirubinemia and subsequently kirnectirus
420
19-64 yrs of age: who gets PPSV23 vs PCV13?
Patients 19–64 years old should receive only the PPSV-23 vaccine if they are at increased risk because they smoke, have CHF, COPD, cirrhosis or are alcoholics.PCV-13 followed by PPSV-23 should be given to all patients ≥ 65 years of age.In addition, patients 19–64 years of age should only receive both vaccines if they are at very high risk due to CSF leak, cochlear implants, asplenia, CKD, nephrotic syndrome, immunocompromised, lymphoma, leukemia, myeloma, or disseminated cancer.
421
Missouri,” “tick bite,” and “pancytopenia" - what should you think of?
Ehrlichiosis
422
Uncomplicated cutaneous anthrax should be treated with what antibiotics?
A fluroquiniolone (ciprofloxacin, levofloxacin, moxifloxacin) or doxycycline and should be reported to local health authorities.
423
Bactrim can increase your creatinine without affecting GFR, but it can also cause life threatning elevation of what electrolyte, especially in HIV patients and the elderly?
Potassium
424
What is characterized by sudden high fever, frontal headache and retro-orbital pain, myalgias and arthralgias, severe lower back pain, and rash that appears as the fever abates in a person returning from the caribbean?
Dengue Fever
425
This infection causes severe joint pain and stiffness. Other distinguishing features include high fever, which often recurs after a brief afebrile period (“saddle-back fever”); more significant polyarticular and migratory joint pains involving the small joints of the hands, wrists, and ankles; and much less thrombocytopenia.
Chikungunya
426
What is the treatment of choice for coccidioidal meningitis, because it offers a good response rate and a favorable safety profile. Eosinophils in the CSF are seen in up to 70% of patients with coccidioidal meningitis.
Fluconazole
427
Patients with uncomplicated community-acquired pneumonia who are suspected of having infection with drug-resistant Streptococcus pneumoniae should be treated empirically with what?Factors that increase the risk for DRSP include age greater than 65 years, alcoholism, immunosuppression, certain medical comorbidities (COPD, chronic liver or kidney disease, cancer, diabetes, functional or anatomic asplenia, chronic heart disease), and recent (within the past 3-6 months) antimicrobial therapy with a β-lactam, macrolide, or fluoroquinolone antibiotic.
A respiratory fluoroquinolone or a β-lactam plus a macrolide or beta-lactam + doxycycline.Those healthy without risks for DRSP can get monotherapy with a macrolide (Azithromycin) or doxycycline
428
The most common antibiotics used for OPAT (outpt. parenteral therapy) require weekly laboratory monitoring. Please list what you should monitor weekly for:Nafcillin and OxacillinCarabapenemsBeta-LactamsAntipseudomonal penicillins
Nafcillin and Oxacillin: Monitor for bone marrow suppression with a complete blood count (CBC) and liver enzyme tests. Kidney function testing with a serum creatinine level (not K)Carbapenems: Same as aboveBeta-lactam antibiotics: CBC and creatinine**Check CBC and creatinine for most**Antipseudomonal penicillin: Serum K
429
Asymptomatic bacteriuria should be treated in patients who are pregnant, and ____ is safe to use in the third trimester of pregnancy. ______ should not be used in pregnant patients near term because it may cause hyperbilirubinemia and kernicterus in the newborn.
AmoxicillinTrimethoprim-sulfamethoxazole
430
Frequent infections with an autoimmune disease such as vitiligo, RA, pernicious anemia, etc., you should think of what disease?
Common Variable Immunodeficiency
431
Although diagnosis of herpes simplex virus (HSV) infections can be made clinically___ and ____ testing can provide results in less than 24 hours and can differentiate between HSV1, HSV2, and varicella infections, which is important when treating immunocompromised patients.
Direct-fluorescent antibody and polymerase chain reactionWhen you have to choose btw the two, choose PCR, especially for genital herpes.
432
____ is the next best choice when MRI with contrast, the study of choice in evaluating for acute or chronic osteomyelitis, is contraindicated.
Contrast-enhanced CT
433
1. ___ and ___ precautions are indicated to prevent spread of infection in patients with disseminated zoster infection or those who are immunocompromised with localized zoster infection.2. Patients with localized zoster who are not immunocompromised can be managed with ____3. Other organisms transmitted via the airborne route include those causing tuberculosis, ___ and ___
1. Airborne and contact2. Contact precautions alone3. Measles, and chickenpox.
434
What CSF finding is very specific for early bacterial meningitis: will have low glucose and high protein (as would late meningitis)
CSF to serum glucose ratio of <0.4
435
Pt p/w headache of 2 days duration: felt dizzy and now lethargic. (+) meningeal signs. 7th episode in the last 6 yrs. CSF reveal granular cells (monocytes). Dx? Tx?
Mollaret's meningitis: benign and recurrent due to HSV2Tx: Supportive only: antivirals have no benefit
436
Normal CSF glucose is ____ and normal CSF protein is ____
40-80.....15-45
437
Do you treat the following situations?1. Asymptomatic bacteruria in pregnancy?2. Asymptomatic bacteruria in DM +/- foul-smelling urine?3. Asymptomatic bacteruria in post-transplant?4. Asxs funguria w/ foley?5. Asa bacteruria w/ foley?
1. Yes: Augmentin x7 days2. No!3. Yes4. No!5. No!
438
Complicated UTI w/ ESBL: Tx w/ ____
PO Fosfomycin
439
Pregnant patient w/ Pyelonephritis is admitted, and has severe allergy to penicillins. What do you give?
Aztreonam
440
Elderly p/w dysuria and increased frequency: (+) tender prostate. Dx? Tx?
Dx: Acute prostatitis: MC is E. ColiTx w/ Bactrim or Cipro for 4-6 weeks: Bactrim in elderly due to cipro SE's
441
Female has dysuria for >1 week: no fever or flank pain. O/E: No cervical motion tenderness. Urine: No bacteruia, but WBC's 20/hpf = (+) pyuria. Dx? Dx test? How long will this test be positive for after tx? Tx?
Dx: Chlamydia: Test: Urine nucleic acid: NAAT. Will stay positive for 3 weeksTx: Azithromyicn or doxy
442
Male presents w/ urethral discharge while on spring break:1. Sxs onset within a 2- 6 days2. Sxs onset after 1-4 weeksCause of above?3. Pt. w/ urethral d/c after sexal exposure >1 week ago and was tx w/ Ceftriaxone and Azithromycin: still has d/c while stripping the urethra. Dx? and Tx?
1. Gonorrhea: "early"2. Chlamydia: "Fashionably late"3. Mycoplasma genitalium. Tx: Moxifloxacin
443
Pt dx w/ epididymitis, what is the dx if:1. Age <35 yo. Tx?2. Age >35 yo. Tx?
1. Chlamydia or Gonorrhea. Tx: Ceftriaxone + Doxy...if thinking enteric organissm (MSM) do ceftriaxone + levaquin2. E. Coli or enterobacter. Tx: Levaquin
444
Tx genital herpes 1st episode for ___ days, 2nd episode for ____ days. >___ episodes/yr require continuous prophylaxis
10 days....5 days...>4
445
Pt dx w/ syphilis is started on PCN; couple of hrs later, pt. has headache, fever, myalgias: BP 90/70mmHg and HR 104. What is the dx? Tx?
Jarisch-Herxheimer reaction due to dying spirochetes: bed rest + supportive care, + ASA and con't PCNf
446
1. Tx for 1' lyme disease2. Tx for early disseminated lyme disease (can present as heart block, bell's palsy, aseptic meningitis)True or false3. If a tick is on the skin for <24 hrs, you should treat?4. What about for >36hrs: do you treat?
1. Doxycycline...or Amoxicillin2. IV PCN/ceftriaxone--->Doxy/amox3. False: Do not treat; observe4. True: Treat w/ dox x1 dose, but in an endemic area: full-tx
447
True or FalseBest imaging study for Necrotizing Fasciitis is CT w/ contrast.
False: MRI
448
Liver disease pt after being exposed to water w/ cellulitis and 1. Hemorrhagic bullae and necrosis: Think ____2. Swollen leg and septic: Think ___
1. Vibrio Vulnificus2. Aeromonas hydrophilia
449
Best medication for post-herpetic neuralgia is ___
Desipramine > gabapentin
450
Herpes zoster isolation1. Single Dermatome2. >2 dermatomes3. Herpes zoster w/ single dermatomal rash + sxs:3a. <72 hrs. What do you do?3b. >72 hrs3c. >72 hrs in HIV3d. >72 hrs in on steroids or Anti-TNF3e. >72 hrs age >50yo
1. Contact2. Contact and airborne3a. Treat w/ val/acyc or famciclovir3b. Supprotive care3c. Tx w/ valcyclovir3d. Treat3e: Only tx if new lesions appear
451
Pregnant 34 yo mother and father brings her 5yo daughter who has chicken pox. Son about to get chemo for leukemia. What do you for1. Child w/ the immune deficiency2. Pregnant mother3. Father whose healthy
1. Give Varicella Zoster Immunoglobulin VZIG2. Check titers; If low, give VZIG3. Check titers, if negative: give vaccine
452
1. Pt has fever, malaise, sore throat and vesicular lesions on tongue, buccal mucosa...later on dorsum of hands and feet. Dx?2. Pt. has pustules on palms after a petting zoo. Dx?3. Pt. from southwest US or yosemite national park has sudden resp failure, pulmonary edema and increased Hct. Dx?
1. Coxsackie A virus2. Monkey pox3. HANTA virus
453
1. Tx for bartonella hensealae (cat scratch disease)2. Tx for bacillary angiomatosis (silver stain wil show warthin starry organisms)
1. Doxy/macrolide (azithro or erythromycin)2. Doxy/marcolide (azithro or erythromycin)
454
1. Homeless patient w/ HIV: CD4 <150 p/w/ severe itching and exocriations w/ transaminitis and a holosystolic murmur. Blood Cx neg. Dx?
1. Bartonellosis endocarditis 2/2 bartonella quintana (Trench fever)
455
1. Plasmodium falciparum is resistant everywhere except parts of caribbean, ____ america and near east2. Prophylaxis for P. falciparum resistant organisms is is: ____ or ____ as opposed to sensitive areas is ____3. Tx for P. falciparum resistant organisms is ___ or ___ or ___ or ___4. Tx for sensitive P. falciparm is ___
1. Central America2. Mefloquine 1 week prior to departure and 4 weeks after arrival OR atovaquone/proguanil 1 day prior to departure and up to 1 week after arrival for resistant areas. For sensitive areas: Chloroquine3. Tx for resistant areas: quinidine sulfate + doxy OR atovaquone/proguanil OR quinidine gluconate + clinda OR artemisinin-amodiaquine4. Sensitive Tx: Chloroquine + primaquine
456
Post-renal transplant patinet is ill several months after transplant:1. Ground glass intranuclear inclusions in urine: think of ____2. Intracytoplasmic inclusion bodies: think of ___
1. BK (human polyoma virus nephropathy)2. CMV
457
1. Tx for strenotrophomonas maltophilia or cepacia bulkhoderia?
1. Bactrim
458
True or FalseAnthrax1. Person-to-person transmission does occur2. Isolation is required3. Prophylaxis has shown to be effective one day after exposure
1. False: It does NOT occur2. False: Isolation is NOT required3. True
459
Patient goes hunting and presents w/ ulcers, fevers, chills, myalgias and PNA. Dx? What was he exposed to?Tx?
Tularemia: Ulcers + galnds = Ulceroglandular feverExposed to RabbitsTx: Streptomycin for 7-10 days
460
A rancher w/ fever, culture negative endocarditis: (+) cryglobulins and negative Hep C. Dx?
Q Fever: Coxiella Burnetti. Tx w/ doxy
461
Pt presents w/ fevers, myalgias and petechial rash after returning from a rafting trip from puerto rico or costa rica. He is icteric and has mild transminitis and elevated Total bili. Dx?
Leptospirosis: tx w/ doxy
462
1. Pt. gets this from contaminated soil and animal products: it can be caused by rickettsia and can be inhaled causing atypical PNA. What is it?2. Gram negative coccobacilli that is transmitted via skin contact (butcher of meat) or aerosolized: has splenomegaly, hepatitis, w/ fever and drenching sweats. Dx?3. This is seen in sweage workers and can cause fever, hepatitis, jaundice with conjunctival suffusion (slowly spreading redness) and liver hemorrhage. Dx?4. This is seen in a fisherman or fish handler; pt has burning or throbbing pain w/ erythematous lesion on finger5. Tx for all of above is what?
1. Coxiella Burnetti: Q fever2. Brucellosis3. Leptospirosis4. Erysipelothrix5. Doxycycline
463
40 yo immigrant from turkey or middle east has an enlarged liver. Dx?
Hydatid cyst 2/2 echinococcus granulosus
464
1. Airborne precautions must ben placed for ___ virus >2 dermatomes, ___ virus w/ outbreaks, ____ virus w/ lesions in different stages, ___ virus from ME and ___ bacteria2. Following get standard + droplet3. Following get standard + contact
1. Herpes zoster virus (also contact)...Measles...varicella (also contact)...MERS (also contact), Myobacterium tuberculosis2. Neisseria...influenza...plague3. MRSA, VRSA/VRE, C. Diff, Scabies.
465
Nurse w/ needlestick exposure of HIV patient; what do you do?
Do a baseline HIV elisa....then start Tenofovir+ emtricitabine + dolutegravir: ie treat as she has it.4 weeks later, repeat HIV test: If neg., d/c meds
466
What are the prophylaxis medications to use when CD4 count is <200?
Bactrim or dapsone or atovaquone
467
1. Best statin for HLD for HIV; what must be avoided?2. Best drug for inuslin resistance in HIV?3. Best INH steroid in HIV asthmatics?4. Best HIV medication along with Hep C therapy?
1. Pravastatin or atorvastatin....Avoid simvastatin!2. Metformin3. Beclomethasone4. Integrase inhibitor: dolutegravir
468
This medication boosts levels of HIV meds and can cause benign creatinine elevation. What is it? It will boost levels of CCBs, BB and statins too
Cobicistat
469
When can you stop checking for Viral load and T- cells in a patient with HIV? (normally you check q 2-3 months for 2 yrs, then annually)Viral load should be undetectable within 3-6 mo after treatment ;if not, what do you think is going on?
When CD4 cell count is >250 and viral load is suppressedPatient is non-adherent to medications
470
What antibiotic decreases levels of protease inhibitors and should be avoided in these patients w/ HIV?
Rifampin...change to rifabutin (causes less decrease of PI's)
471
Pt is dx w/ HIV and TB concurrently. When do you bring ART if1. CD 4 T-cells are <502. CD 4 T-cells are >50
1. Within 2 weeks2. Within 8 weeks
472
Patients w/ HIV you cannot use Live vaccines if CD 4 count is
<200....can't use oral polio or yellow fever vaccines
473
Causes of pseudotumor cerebri are obesity, vitamin A toxicity and what else?
Steroids, oral contraceptives, tamoxifen, isotretinoin, nitrofurantoin, Danazol, minocycline, levothyroxine, and tetracyclines.
474
What is the treatment for pseudotumor cerebri?
Acetazolamide (1st line)...if it fails, then optic nerve sheath fenestration...and as a last resort, lumboperitoneal shunt
475
The least likely tumor to metastasize to the brain is which of the following:Breast, lung, melanoma, lymphoma, renal, or prostate?
Prostate
476
What are all the causes of infranuclear palsy of the face?
Bell's palsy, acoustic neuroma, Ramsay Hunt syndrome, Lyme disease, sarcoidosis, and Guillain-Barre syndrome.
477
What is the differential diagnosis of ptosis miosis anhidrosis of one side of the face? This is also known as horner syndrome.
Pancoast tumor, internal carotid artery dissection. so if the patient is a smoker do a chest x-ray. If patient has trauma of the neck do CTA
478
What is the differential diagnosis for a patient with ptosis and dilation with lateral deviation of the ipsilateral eye? Where is the lesions? What is the next step?
Brain Berry aneurysm. Lesions in the posterior communicating artery. Next step is either to do a CT angiogram or MRA of the brain.
479
This syndrome is characterized by dizziness, diplopia, dysarthria. Also sudden weakness of legs leading to drop attacks. What is it? What is the treatment? What is the best test to diagnose?
Vertebrobasilar syndrome. Treatment is aspirin.Diagnose with MRI of posterior cranial vessels.
480
What are the five risk factors for patients who have TIA and are at a higher risk for stroke?
Diabetes, hypertension (BP>140/90mmHg), age greater than 60 years, speech disturbance without weakness, duration of TIA for greater than 60 minutes, focal weakness with the TIA. The last two are two points each the rest are one point each. Anyone with three or more are at higher risk.
481
1. Carotid ultrasound shows greater than 70% stenosis in a patient with TIA. What is the next step?2. What do you do if there's a > 90% stenosis in a patient with TIA?3. What do you do if it's <50% stenosis?
1. Carotid endarterectomy plus aspirin or plavix or aspirin-dipyridamole.2. Place a stent and give aspirin plus plavix for 90 days and then long-term aspirin or plavix or ASA-dipyridamole.3. Aspirin or plavix or ASA-dipyridamole
482
Patient has TIA on ace inhibitor, aspirin 81 mg and statin. What is the next best step?
Add plavix.
483
1. Patient with TIA is less than 80 years old, does not have diabetes or previous stroke and is not taking any oral anticoagulants. Until what time can you give these patients TPA? A recent trial showed that giving TPA (altepltase) within this time frame is beneficial for those with large ischemic strokes.2. Patients of any age whether they're on aspirin or aspirin plus plavix can we given TPA until what time of onset of TIA?
1. 4.5 hrs2. 3 hrsIn other words patients of any age who present within 3 hours to get TPA.
484
Exclusion criteria TPA?
Do not give TPA if systolic blood pressure is greater than 185 or diastolic blood pressure is greater than 110. do not give TPA if patient had a stroke or serious head trauma in the previous 3 months or major surgery within 14 days. Do not give TPA to patients who are using novel oral anticoagulants or direct thrombin inhibitors. Do not give TPA if PT is greater than 15 seconds, platelet count less than a 100,000, glucose less than 50 or greater than 400.
485
Goal BP for patient with hemorrhagic stroke vs. ischemic stroke?
Hemorrhagic: BP <140mmHgIschemic: BP <180/105mmHg
486
What is the threshold to treat HTN in a patient with ischemic stroke and contraindication to tPA?
BP >220/120mmHg
487
Treatment for cyanide poisoning due to IV nitroprusside or IV nitrates?
Hydrocobalamin (IV & IM form of B12)
488
Where is the stroke?1. Urinary incontinence, c/l leg/foot weakness w/ sensory loss2. Acalalculia, agraphia, lt-rt disorientation, finger or tactile agnosia, paraesthesias3. Aphasia4. Spatial Neglect/Unable to dress5. Ipsilateral 3rd nerve palsy (weber's syndrome), homonymous hemianopia, contralateral sensory abnormalities.Parietal & temporal lobe strokes are due to blockage of what artery?
1. Anterior cerebral artery2. Dominant Left Parietal Lobe3. Temporal Lobe4. Non-dominant parietal Lobe (right)5. Posterior cerebral arteryParietal & temporal lobe strokes are due to MCA.
489
Stroke in this artery causes Lateral Medullary Syndrome (Wallenberg syndrome)
Posterior inferior cerebellar artery
490
Patient has ipsilateral loss of pain & temperature from face with contralateral loss of pain and; temperature on body and loss of lacrimation, taste of ant. 2/3 of tongue, also w/ vertigo, nystagmus, nausea, vomiting, fal to the same side, hoarsness and dysphagia....and contralateral weakness. Where's the stroke?
PICA - Lateral Medullary Syndrome aka wallenberg syndrome If fall to the left side: It's left lateral medullary syndrome, etc ^ can happen due to vertebral artery dissection
491
Patient has hamiparesis w/ involuntary shaking movements, unable to move tongue, or bulbar muscles or throat muscles -- essentially has quadrapalegia. Only can move eyes. Where's the CVA? What caused it?
Basilar artery stroke. Can happen from rapid Na correction: central pontine myelenosis
492
Broca's (can comprehend - stutters), wernicke's ( can't comprehend - word-salad) & conductive aphasia (can't repeat or comprehend) can happen due to CVA in which artery?What about global aphasia and "Pure word blindness".
Middle cerebral arteryGlobal aphasia: MCA or Internal carotid arteryPure word blindness: Posterior cerebral artery - occipital lobe cva
493
For a subarachanoid hemorrhage, CT head has >90% sensitivity at what time period? What about Lumbar puncture?
<6hrs for CT head & >6hrs for LP.
494
Patient with worst headache of their life, CN III palsy, n/v, etc, has neg CT head & LP. Next step? Why? Tx/
Do MRA to r/o acute reversible cerebral vasoconstriction syndromeAmlodipine
495
Vertigo: only horizontal nystagmus that is inhibited. Is it central or peripheral? Causes of peripheral vertigo
Peipheral! central can be horizontal or vertical and is not inhibited. Labyrinthitis,and meniere's disease - all have hearing loss....vestibular neuronitis does NOT have hearing loss. And benign proxysmal positional vertigo
496
Pt has vertigo, tinnitus & progressive hearing loss. What do you do next?
MRI of the head to r/o Acoustic Neuroma of schwan cells
497
Patient with vertigo develops sudden onset dizziness, dysarthria, diplopia, ataxia and weakness What could it be?
Vertebrobasilar insufficiency
498
The cholinesterase inhibitors, donepezil, galantamine & rivastigmine, used to treat dementia, have been associated with what key side effects?
Syncope, bradycardia w/ increased pacemaker placement & hip fractures
499
Patient with dementia, parkinsonian sxs of bradykinesia and postrual instability, but NO resting tremor. Also has visual hallucinations & extreme rigidity. What is it? What will histopathology show?
Dementia with Lewy BodiesHistopathology will show Cytoplasmic inclusion bodies of alpha-synuclein protein in the subcortical tissue.Alzehimer's dementia has delusions NOT hallucinations - this is when you don't see anything & saw something is there, as opposed to delusions - you see something & say it's something else.
500
Patient has loss of interest, disinhibition: urinates on neighbor's lawn and is hypersexual. What type of dementia is this?
Frontotemporal dementia
