patient w/ hx of unprotected sex a/ multiple partners p/w several days of joint pain and tenosynovitis. Arthrocentesis w/ turbid yellow fluid and leukocyte count of 9k
dx? best test to confirm?
culture from joint, rectum, urethra, oral cavity
55M s/p bone marrow transplant w/ high dose corticosteroid treatment p/w fever, cough, chest pain, localized HA, recurrent nasal bleeding
preferred HIV screening
alternative test for those who test negative but have a high clinical suspicion of acute HIV
HIV p24 antigen and antibody screen
Plasma HIV RNA testing
management of patient presenting w/ flu
if presenting <48 hours: oseltamivir (esp if >65, pregnant, have high sk medical conditions such as pulmonary and cardiac disease)
if presenting >48 hours: acetaminophen and symptomatic treatment
5M p/w sore throat, dysphagia, purulent exudates on tonsils and posterior pharynx, and enlarged/tender anterior cervical nodes
diagnosis? tests? treatment?
rapid strep antigen test (RAST) + throat cultures if RAST is negative in children
penicillin or amoxicillin
diphtheria antitoxin ADR
anaphylaxis (made w/ horse serum, thus risk of HSR or serum sickness)
work-up of acute hepatitis C
work-up of resolved hepatitis C
- elevated transaminases
- +HCV RNA (vis PCR)
- + anti-HCV antibodies within 12 weeks
- normal transaminases
- -HCV RNA
- + anti-HCV antibodies
development of rash after taking amoxicillin
rash is immune-mediated, caused by circulating antibodies to penicillin derivatives, forming circulating immune complexes
discontinue abx and observe/supportive treatment
best diagnostic test for confirming a diagnosis of osteomyelitis
patient w/ hx of BCG vaccination and CXR w/ upper lobe fibrosis has a PPD w/ 16mm induration. next step?
isoniazid + B6 x9 months
induration from BCG vaccine rarely exceeds 15mm and significantly decreases over time
upper long fibrosis suggests latent TB
purpose of taking B6 when taking isoniazid
isoniazid can cause peripheral neuropathy and it is prevented by concomitant use of B6
petechial rash begins on the ankles and wrist, spreads to palm, soles, central body
management in pregnant women?
start doxycycline w/o waiting for confirmatory tests
pregnant women: chloramphenicol (since tetracyclines are contraindicated; higher incidence of side effects)
patient presents w/ shingles
infant w/ weight that corresponds to the 55th %ile and a head circumference that is below the 7th %ile
microcephaly, likely 2/2 toxoplasmosis acquired by maternal consumption of undercooked lamb meat during pregnancy
patient p/w necrotizing faciitis, source unknown. what 3 abx should you start and why?
piptazo (or imipinem, meropenem) - GAS + anaerobes
vancomycin - s. aureus
clinca - inhibit toxin formation by staph/strep
supportive treatment and observation
treatment of cryptococcus
amphotericin B + flucytosine x2 weeks (induction tx), followed by fluconazole (consolidcation, maintenance tx)
repeat lumbar punctures if pt starts experiencing HA, blurry vision, N/V as alleviation of the elevated opening pressures
HIV patient w/ cryptococcal meningitis - should you initiate HART therapy at at the same time as initiating amphotericin/flucytosine?
no, can lead to immune reconstitution inflammatory syndrome (IRIS) - paradoxical worsening of infection due to strengthening of the immune system. can result in increased mortality
start ART 4-10 weeks after initiation of antifungal therapy
43M recently returned from India presents w/ persistent fever, retroorbital pain, malaise, intense muscle, joint pain, enlarged liver, and petechial tendencies
increased capillary permeability can lead to hemoconcentration, pleural effusion, an dascites. Significant plasma leakage can result in circulatory collapse/shock
faint salmon-colored macules on trunk and abdomen
typhoid fever, can be associated w/ intestinal perforation.
when to treat w/ PO flagyl vs PO vanco?
PO flagyl = when WBC <15k, Cr < 1.5x baseline
all other scenarios = PO vanco
HIV patient w/ CD4 counts of:
< 400 - candida (oral)
< 200 - JC virus, cryptosporidium, PCP -> bactrim ppx
< 100 - Histoplasmosis, candida (esophageal), toxo
<50 - CMV, MAC, cryptococcus neoformans -> ganciclovir + azithromycin ppx
management of individuals exposed to patient w/ TB
PPD, if negative, repeat PPD in 3 months
patient undergoes HCV testing and was found to have Anti-HCV antibodies. Next step in management?
confirm diagnosis w/ HCV RNA testing (high specificty)
eosinophilia associated w/ eosinophilia
intestinal parasitosis, likely 2/2 helminthiasis (ascaris, trichuris, necator, ancylostoma)
viral meningitis or encephalitis in the US pediatric population Is usually due to:
enteroviruses or arboviruses (ie eastern equine encephalitis, western equine encephalitis, St. Louis encephalitis, Colorado tick fever, California encephalitis)
itraconazole for 3-6 mo
6 w.o. infant w/ that developed nasal congestion that turned into a series of short, dry coughs; previously healthy except conjunctivitis at 12 days of age
transmitted via vaginal contact; develops conjunctivitis at 5-14 days followed by staccato cough and pneumonia at 4-12 weeks
CXR usually shows hyperinflated lungs w/ no focal infiltrates
2 weeks of PO erythromycin
Management of infants born to others w/ hepatitis B infection
Hep B Ig + vaccine within 12 hours of birth
2nd vaccine btwn 1-2 mo
3rd vaccine at 6 mo
assess Hep B serology titers at 9 mo
why is injecting topical anesthetics like lidocaine not helpful in treating cellulitis pain?
areas of infection typically have an acidic environment; local anesthetics are basic compounds and can become neutralized in infectious acidic environments, thereby rendering them ineffective
chlamydia treatment non-pregnant vs pregnant women?
treatment of their partners
nonpregnant women: doxycycline 100mg bid x7d or azithromycin 1g x1 dose
pregnant women: erythromycin 500mg tid x 7d
partners: azithromycin 1g x1 dose
patient w/ gonorrhea is treated w/ ceftriaxone, but returns to clinic w/ persistent urethral discharge.
likely coinfection w/ chlamydia trachomatis
treatment: all patients diagnosed w/ gonorrhea should be treated w/ ceftriaxone AND azithromycin OR doxycycline
What is the J<3nes criteria for rheumatic fever?
joints (migratory arthritis)
sydenham chorea (aka Saint Vitus Dance - emotional lability and irregular, rapid jerking movements of face/hand/feet)
most common complication of acute otitis media
another episode of otitis media
patient p/w signs and symptoms of infectious mono
in patients w/ suspected mono but negative test
EBV specific antibodies (VCA and EBNA)
when is steroids indicated?
bed rest and symptomatic treatment (NSAIDs, tylenol)
steroids when airway obstruction is imminent (SOB when recumbent)
management of patient w/ infected PICC line
management of patient w/ AML on chemotherapy, p/w infected PICC line
patient: start vanco
patient w/ AML on chemo: start vanco + cefepime (patient w/ neutropenia or sepsis should receive GN coverage as well)
in both instances - remove the PICC line
best diagnostic test to confirm osteomyelitis
common pulmonary pathogens present in CF patients
treatment for patient experiencing severe pulmonary exacerbation (i.e. they have evidence of pneumonia)?
s. aureus, p. aeruginosa
tobramycin, ticarcillin-clavulanate, vancomycin
what is a common manifestation of constipation in young chldren?
enuresis due to reduced bladder capacity
Patient presents w/ HA, forgetfulness, blurry vision; found to be HIV+ and RPR+. What is the next step in management?
LP - evaluate whether his HA, forgetfulness, and visual changes are due to neurosyphilis.
Must exclude neurosyphilis before starting therapy for syphilis (penicillin IM), as the treatment for neurosyphilis is different (penicillin IV)
patient w/ HIV has a brain biopsy that demonstrates oligodendrocytes w/ intranuclear inclusions, demyelination, and astrogliosis.
PML - progressive multifocal leukoencephalopathy - causes rapidly progressive focal neurologic deficits w/o evidence of increased iCP
HAART therapy - regression of PML has been well documented
pneumococcal vaccines recommendations
19-64: PPSV23 or sequential PCV13 + PPSV23 (for high risk patients)
>65: sequential PCV13 + PPSV23
T/F patients s/p 9 mo isoniazid now p/w PPD 11mm induration with CXR demostrating small calcified granuloma in RUL require an additional 9 months of isoniazid
F - asymptomatic complaints w/o CXR evidence of active TB who have been treated previously for active TB or LTBI need no further TB treatment
management of patient w/ abnormal CXR or normal CXR w/ suspected TB
to confirm if there is ACTIVE TB, get suptum studies for AFB smears + cultures
IGRA + PPD can't differentiate between latent and active TB
What 3 situations should HIV post-exposure prophylaxis should be implemented as the immediate first step?
when patient refuses testing
test results are pending
HIV status of patient is unknown
ppx should be started <72 hours after exposure (ideally 1-2 hours)
What is IRIS after HIV treatment?
paradoxical worsening of pre-existing infections in HIV+ individuals
HIV patient w/ hemiparesis, ∆s in vision, speech, and gait
PML - caused by JC virus, predominately involves WM but may affect brainstem and cerebellum; does not cause mass effect
patient w/ 1 wk hx of fever, skin rash, fleeing joint pain w/o swelling, redness, or change in ROM; found to be HBsAg+
serum sickness - can develop in the prodromal phase of HepB infection, due to circulating immune complexes (type III)
patient s/p exlap for perforated appendix now p/w swinging fever, dry cough, pain in R shoulder, and WBC 14k. Best diagnostic test?
Abd US - look for subphrenic abscess
3 year old p/w lump in arm pit, 3 day history of decreased appetite and fever. has kitten at home
bartonella/cat scratch disease
what is ecthyma gangrenosum?
How does that differ from pyoderma gangrenosum?
ecthyma gangrenosum - commonly seen in immunocompromised patients w/ Pseudomonas bacteremia; manifestations include rapid evolution of ≥1 skin lesion from erythematous macule to pustule/bullae and then into a non-painful gangrenous ulcer
pyoderma gangrenosum - commonly seen in pts w/ IBD or an arthritides; lesions begin as an inflammatory nodule, pustule, vesicle, and quicly evolve to ulcers. quite painful
presence of many PMNs on urethral swab
two types of bugs that can cause this and their respective treatment?
management of patients who fail initial treatment?
gonorrhea - typically seen w/ multiple GN diplococci; tx: ceftriaxone
chlamydia - typically, no organisms are seen; tx: azithromycin
consider trichomonas as the cause of urethritis; tx: flagyl
HIV patient w/ CD4 count <85 p/w 7 days of fever, dry cough, progressive SOB w/ minimal exertion. Induced sputum analysis is negative for Pneumocystis.
Pneumocystis jirovecii Pneumonia (PCP)
the diagnostic sensitivity of the induced sputum is 50-90%, therefore negative results in HIV patients w/ suspected PCP necessitates further testing (i.e bronchoalveolar lavage - high sensitivity of 90-100%)
bactrim + corticosteroids (indicated during the first 2-3 days of abx trmt (or when Aa gradient ≥35 mmHg and/or PaO2 <70% on RA) due to organism lysis, which stimulates an inflammatory response that can lead to intubation and/or death)
antibiotics appropriate for treating UTI in pregnant women
recent immigrant from africa p/w dysuria, frequency, and anemia
marker of high HepB infectivity
marker(s) of chroinc HepB infection
HBsAg w/ anti HBe and IgG anti-HBc
risk of developing chronic hepatitis after an acute hepatitis B infection
patient w/ DKA develops foul nasal discharage and pain in R paransal area, exam demonstrates inflamed nasal mucosa and a black discoloration in the antero-inferior aspect
treatment of patients who come into contact w/ patients who has meningococcal meningitis
rifampin - bid x2 days (avoid in patients taking OCPs)
cipro - single dose
ceftriaxone - single dose