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1

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?

gonococcal arthritis

culture from joint, rectum, urethra, oral cavity

2

55M s/p bone marrow transplant w/ high dose corticosteroid treatment p/w fever, cough, chest pain, localized HA, recurrent nasal bleeding

dx?

invasive aspergillosis

3

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

4

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 

5

5M p/w sore throat, dysphagia, purulent exudates on tonsils and posterior pharynx, and enlarged/tender anterior cervical nodes

diagnosis? tests? treatment?

strep tonsillopharyngitis

rapid strep antigen test (RAST) + throat cultures if RAST is negative in children

penicillin or amoxicillin

6

diphtheria antitoxin ADR

anaphylaxis (made w/ horse serum, thus risk of HSR or serum sickness)

7

work-up of acute hepatitis C

work-up of resolved hepatitis C

acute

  • elevated transaminases
  • +HCV RNA (vis PCR)
  • + anti-HCV antibodies within 12 weeks 

resolved

  • normal transaminases
  • -HCV RNA
  • + anti-HCV antibodies

8

development of rash after taking amoxicillin

management?

mononucleosis

rash is immune-mediated, caused by circulating antibodies to penicillin derivatives, forming circulating immune complexes

discontinue abx and observe/supportive treatment

9

best diagnostic test for confirming a diagnosis of osteomyelitis

MRI

10

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

11

purpose of taking B6 when taking isoniazid

isoniazid can cause peripheral neuropathy and it is prevented by concomitant use of B6

12

petechial rash begins on the ankles and wrist, spreads to palm, soles, central body

diagnosis? management?

management in pregnant women?

RMSF

start doxycycline w/o waiting for confirmatory tests

pregnant women: chloramphenicol (since tetracyclines are contraindicated; higher incidence of side effects)

13

patient presents w/ shingles

management?

start acyclovir

14

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

15

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

16

mono treatment

supportive treatment and observation

17

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

18

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

19

43M recently returned from India presents w/ persistent fever, retroorbital pain, malaise, intense muscle, joint pain, enlarged liver, and petechial tendencies

dengue fever

increased capillary permeability can lead to hemoconcentration, pleural effusion, an dascites. Significant plasma leakage can result in circulatory collapse/shock

20

faint salmon-colored macules on trunk and abdomen

typhoid fever, can be associated w/ intestinal perforation. 

21

pasteurella treatment

amoxicillin/clavulanic acid

22

c. diff

when to treat w/ PO flagyl vs PO vanco?

PO flagyl = when WBC <15k, Cr < 1.5x baseline

all other scenarios = PO vanco

23

HIV patient w/ CD4 counts of: 

400

200

< 400 - candida (oral)

< 200 - JC virus, cryptosporidium, PCP -> bactrim ppx

< 100 - Histoplasmosis, candida (esophageal), toxo

<50 - CMV, MAC, cryptococcus neoformans -> ganciclovir + azithromycin ppx

A image thumb
24

management of individuals exposed to patient w/ TB

PPD, if negative, repeat PPD in 3 months

25

patient undergoes HCV testing and was found to have Anti-HCV antibodies. Next step in management?

confirm diagnosis w/ HCV RNA testing (high specificty)

26

eosinophilia associated w/ eosinophilia

treatment?

intestinal parasitosis, likely 2/2 helminthiasis (ascaris, trichuris, necator, ancylostoma)

tx: albendazole

27

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)

28

sporotrichosis

itraconazole for 3-6 mo

29

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

treatment?

neonatal chlamydia

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

30

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 

31

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

32

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

33

patient w/ gonorrhea is treated w/ ceftriaxone, but returns to clinic w/ persistent urethral discharge.

diagnosis? treatment?

likely coinfection w/ chlamydia trachomatis

treatment: all patients diagnosed w/ gonorrhea should be treated w/ ceftriaxone AND azithromycin OR doxycycline

34

What is the J<3nes criteria for rheumatic fever?

treatment?

joints (migratory arthritis)

<3 (heart)

nodules (sub-cu)

erythema marginatum

sydenham chorea (aka Saint Vitus Dance - emotional lability and irregular, rapid jerking movements of face/hand/feet)

trmt: pencillin

35

most common complication of acute otitis media

another episode of otitis media

36

patient p/w signs and symptoms of infectious mono

diagnostic test

in patients w/ suspected mono but negative test

monospot

EBV specific antibodies (VCA and EBNA)

37

mono treatment

when is steroids indicated?

bed rest and symptomatic treatment (NSAIDs, tylenol)

steroids when airway obstruction is imminent (SOB when recumbent)

38

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

39

best diagnostic test to confirm osteomyelitis

MRI

40

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

41

what is a common manifestation of constipation in young chldren?

enuresis due to reduced bladder capacity

42

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)

43

patient w/ HIV has a brain biopsy that demonstrates oligodendrocytes w/ intranuclear inclusions, demyelination, and astrogliosis.

diagnosis? treatment?

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

44

pneumococcal vaccines recommendations

19-64: PPSV23 or sequential PCV13 + PPSV23 (for high risk patients)

>65: sequential PCV13 + PPSV23

45

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

46

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

47

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)

48

What is IRIS after HIV treatment?

paradoxical worsening of pre-existing infections in HIV+ individuals 

49

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

50

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)

51

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 

52

3 year old p/w lump in arm pit, 3 day history of decreased appetite and fever. has kitten at home

diagnosis? treatment?

bartonella/cat scratch disease

azithromycin

53

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

54

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?

urethritis

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

55

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.

Diagnosis?

Treatment?

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)

56

antibiotics appropriate for treating UTI in pregnant women

Cephalexin

amoxicillin 

amoxicillin-clavulanate

nitrofurantoin

57

recent immigrant from africa p/w dysuria, frequency, and anemia

diagnosis?

schistosomiasis

58

marker of high HepB infectivity

marker(s) of chroinc HepB infection

HBeAg

HBsAg w/ anti HBe and IgG anti-HBc

59

risk of developing chronic hepatitis after an acute hepatitis B infection

5%

60

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

dx? tx?

mucormycosis

amphotericin B

61

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