ID and Pulm Flashcards
1
Q
What is the next step after a PPD is positive?
A
rule out active TB - chest xray
check LFTs to get a baseline for thinking about giving isoniazid
2
Q
What are the diagnostic criteria for spontaneous bacterial peritonitis?
A
paracentesis with PMN > 250 or total WBC >500 in the ascitic fluid
gram stain is helpful if positive, but not is negative (can’t rule out)
3
Q
How do you dx cryptococcal meningitis?
A
hx of HIV with CD4 <100
cryptococcal antigen test >90%
India ink test will be positive in 50-70%
4
Q
How do you treat lyme disease with advanced disease? (heart block)
A
IV ceftriaxone
5
Q
Why don’t we give patients with a fib heparin before starting warfarin?
A
because they don’t already have a clot burden, so warfarin necrosis doesn’t happen (pt unliekly to have protein C or S deficiency)
6
Q
How do you treat cryptococcal meningitis?
A
IV amphotericin then flucytosine for 2 weeks, then oral fluconazole until CD4 > 100 or 3 months
*make sure HIV pts also on HAART
7
Q
What organisms commonly cause cellulitis?
A
staph (MSSA ) or group A strep (S. pyogenes)
8
Q
What is the treatment for Hepatitis C?
A
check genotype
check viral load - tx if elevated RNA viral load
interferon with ribavarin
if type 1: also give sofosbuvir or simeprevir for 12 wks
9
Q
What vital change can you see with OSA?
A
HTN
10
Q
How do you treat osteomyelitis?
A
- GET A BONE BIOPSY to ID organism
2. Start antibiotics (no empiric coverage, only targeted treatment)
11
Q
How do you treat osteomyelitis with MSSA?
A
IV oxacillin or nafcillin or cefazolin for 6-12 wks
12
Q
How do you decide if a pt with penumonia needs to be hospitalized?
A
CURB-65 (1 pt for each) Confusion Blood urea nitrogen >19.6 RR >/= 30 Systolic BP <90 or Diastolic BP <60 Age >/=65 If 2 positive or greater -> hospitalize
13
Q
What is the most common cause of an asthma exacerbation?
A
Viral infections
14
Q
What antibiotic do you use if patient is allergic to vancomycin?
A
daptomycin
15
Q
What tests do you get to look for a pulmonary embolism?
A
lytes, EKG, chest xray, D-dimer, ProBNP, lactrate, ABG, pulse ox
CT Angio “gold standard”
*V/Q scan if renal failure or contrast allergy
16
Q
What is the differential for bradycardia with heart block?
A
- hypothyroidism
- Lyme Disease
- Beta-blocker or calcium channel blocker
- Ischemic heart disease
17
Q
What is the natural hx of spontaneous bacterial peritonitis?
A
70% will recur, if take prophylactic antibiotics it goes down to <20%
18
Q
What are the hallmark signs of legionella?
A
- atypical pneumnonia
- hyponatremia due to SIADH
- diarrhea
19
Q
What organisms can cause subacute bacterial endocarditis?
A
strep -50-60% mostly viridans, bovus assoc with GI neoplasm (get a GI study)
staph - 30%
enterococci 5-10% (strep species - cocci in pairs and chains)
20
Q
How do you dx meningitic TB?
A
CSF stain/culture
LP - looks like viral w/ elevated protein and low glucose
Meningeal biopsy
21
Q
What abx do we use to treat MSSA?
A
nafcillin or oxacillin, could also do a first gen cephalosporin (cefazolin)
22
Q
What would a CT show with necrotizing fasciitis?
A
gas formation within the fascia
23
Q
What diseases are assocaited with erythema nodosa?
A
Sarcoid, IBD, TB, lymphona, fungal infections, bacterial infections
24
Q
How do you dx urinary tract infection?
A
increased WBC and nitrate positive and bacteria +
25
What must be consdiered in young patients with emphysema involving the base of the lung and liver abnormalities?
alpha-1-antitrypsin deficiency
26
How do you treat uncomplicated UTI?
1. trimethoprim-sulfamethoxazole (3 days)
2. fosfomycin (1 dose)
3. nitrofurantoin (5 days)
27
What organisms do you have to consider with community acquired pneumonia?
1. pneumococcal pneumonia
2. haemophilus
3. atypicals (legionella, chlamydia, mycoplasma)
4. TB
28
How do you work up elevated liver enzymes?
hepatitis serologies
MRI can show increased iron
sonography shows fat infiltration
29
How do you change management with red man syndrome from vancomycin?
slow the infusion
30
How do you treat mixed flore necrotizing fasciitis?
vancomycin, daptomycin, tigacycline, ceftaroline, linezolid (to cover MRSA)
+
imipenem/meropenem, pip/tazo, ticarcillin/clavulinate, cefepime w/ metronidozole (to cover gram neg, including pseudomonas and anaerobes)
+
clindamycin (for toxin production)
31
What must you consider in a pt with meningitic symptoms and a low DC4 count?
cryptococcal meningitis
32
What are the 2 types of asthma?
1. Intrinsic (nonallergic - 50%)
| 2. Extrinsic - (allergic 20%)
33
How do you treat HIV with CD4 < 200?
prophylaxis for penumocystis jiroveci: tmp/smx (*if allergic, dapsone or atovaquone)
34
Who needs a booster for the pneumococcal vaccine (PPSV23)?
anyone who received it prior to age 60 at age 65.
those at risk of fatal infection
NO ONE gets more than 1 booster
35
What is the possible serious side effect of nafcillin or oxacillin? What do you do?
Allergic interstitial nephritis (fever, rash, acute renal failure) Confirm dx with urine eosinophils. Stop agent
36
How you you empiracally tx eikenella (human bites/mouth)?
amox + clauv
37
What do you do if a pt isn't responding to treatment in3-5 days for pyelonephritis?
Get a CT to look for an abscess - drain it!
38
What is the difference between HSV 1 and 2?
HSV 2 is harder to treat and tends to recurr more.
| *they can both cause oral/genital lesions, but general HSV 1:oral, HSV 2: genital
39
How do you ddx OSA?
sleep study is dx and tx - split night nocturnal polysomnography w/ CPAP titration with apnea hyponea index > 15
40
Colon cancer screening recs for 1st degree relative with colorectal cancer <60 yo or many first degree relatives with it
Whatever happens first
* age 40 or age that is 10 yrs prior to the age at which the youngest relative was dx
* colo every 5 yrs
41
What are the classic symptoms of active TB?
weight loss
fever
cough, sputum
night sweats
42
What are the criteria for home O2 for emphysema?
PaO2 = 55 or sat <88%
pt has cor pulmonale and PaO2 <60
If on 6 min walk test, they desat on exertion
43
How do you treat a pt with lyme dz with the classic rash?
give doxycycline, don't send titers (too early for them to be positive)
44
How do you test and dx active TB?
chest xray with cavitary lesion in RU lobe, respiratory sputum x3 sample for acid-fast bascillus stain and culture (NO PPD - not helpful in active TB)
45
What are the 3 indications for daptomycin?
MRSA skin and soft tissue infection, right-sided endocarditis, and bacteremia due to line sepsis
46
Side effects of necleoside reverside transcriptase inhibitors?
general malaise, vomiting, nasuea
47
How to treat patients with advanced cancer who have a PE?
they need to be treated with LMWH (not warfarin) long term
48
How do you treat gram negative osteomyelitis?
can use oral ciprofloxacin! Awesome - get the bone biopsy so that it is possible to do this!
49
When do we use thrombolysis in pulmonary emobolism?
shock!
| tPA if sys BP < 90 or decr >40 from baseline or MAP <70
50
What might you see on ABG with OSA?
elevated bicarb - chronic hypoxemia that is compensating
51
Cervical cancer screening recs
Pap test from 21-65 every 3 years (regardless of sexual activity)
* can do Pap +HPV q5 yrs from 30-65
* may need after 65 for high risk women
52
What are pts with asbestos exposure at risk for?
1. Lung cancer
If normal risk is 1, + tobacco =10x risk, +tobacco and asbestos = 75x risk
2. much lower risk, but also, mesothelioma
53
Which antibiotics cover pseudomonas?
```
cefepime
ceftazidime
pip/tazo
ticarillin/clavulanate
imipenem/meropenem (NOT ertapenem) *use for PCN allergy
Aztreoonam * use for PCN allergy
aminoglycosides
ciprofloxacin
```
54
What is the work up for pneumonia?
chest xray, sputum gram stain, sputum culture, pulse ox, CBC, blood cx
55
What travelers should get a polio vaccine?
if going to developing country, get a booster or if never vacinnated - get the whole 3 shot series (all inactivated).
56
How do you treat syphilis?
1 dose of penicillin for primary, secondary, and early latent
3 doses of late latent
14 days IV penicillin for neurosyphilis
*if allergy to penicillin, must sensitize them
57
What is a consideration about how to give rabies vaccines?
Give IM if also getting malaria prophylaxis bc chloroquine can blunt the response with the intradermal form of the rabies vaccine
58
How do you treat Pelvic inflammatory disease?
Ceftriaxone (single dose) AND
| azitrhomycin or doxycycline for 14 days to cover chlamydia
59
How do you treat Calcium channel blocker overdose?
Give calcium
60
How do you prescribe RIPE tx for active TB?
RIPE x 2 months (or whenever you get the resistance pattern back)
RI x 4 more (or combo that the TB is sensitive to)
(TOTAL has to be 6 months)
61
What complication do you need to think about when treating spontaneous bacterial peritonitis?
hepatorenal syndrome
- give IV albumin if Cr is >1.5 to mitigate
- DO NOT GIVE diuretics or do a large volume paracetesis unless pt is having respiratory distress
62
What are the side effects of TMP/SMZ?
sulfa allergy - inhibits folic acid synthesis (myelosuppresion - thrombocytopenia)
Renally cleared - if given in renal failure can drop pt's platelets
type 4 RTA (can't secrete K and get hyperkalemia)
63
What are the most common causes of hypoglycemia in adult diabetic pts?
change in dietary habit
increase in metabolic demand (increased activity)
medication overdose
new onset renal failure
64
How do you treat small abscesses without surrounding erythema?
I & D (no need for Abx unless risk factors present- old/young, immunosuppressed…etc)
Always drain abscesses!
65
What organisms need to be covered in peritonitis?
E. Coli and Strep pneumoniae
| *do not need to cover anaerobes bc not an intraabdominal infection (just the fluid not open to the gut)
66
If you get a positive PPD, what is the next step?
chest xray
67
How do you treat pneumocystis pneumoniae?
Bactrim - first line (tri/sulfa)
*if allergic to sulfa - IV pentamidine (lots of side effects) or clindamycin with primaquine or atovaquone
give prenisone if P02 < 70 or A-a gradient >35
68
Side effects of interferon?
severe depression and SI *can give an SSRI in addition
69
What is a measure that you can use to follow sarcoidosis lung disease?
PFTS (restrictive pattern (decr FEV and FVC, but ratio normal to high because they can move air in and out just fine, just small lung volumes d/t interstitial dz)
70
How do we use ritonavir for HIV treatment?
It is a protease inhibitor but not good on it's own - so it is always given in a low dose in addition to another PI.
71
How do you work up interstitial lung disease?
Chest xray, EKG, PFTs, ECHO (if worried about pulm HTN and right sided heart failure)
72
What follow up needs to be done with PE?
lower extremity u/s for DVT/find the source
73
Recommendations for breast cancer screening
starting at 50 mammogram every 1-2 yrs
| *if multiple first degree relatives consider prophylactic tamoxifen
74
What are the most common bacterial food poisonings?
Campylobacter and Salmonella
75
What feature should make you think about covering MRSA in cellulitis?
if purulent!
| * on exam - will probably also give a risk factor
76
Is the PPD always positive in active TB?
No = negative 25% of the time because the system is overwhelmed and can't mount a response
77
What travelers should receive rabies vaccines?
travel to india, mexico, asia (where rabies is common in domesticated animals)
78
What is a side effect of foscarnet?
acute tubular necrosis (Hydrate!!!!)
79
What travelers should get the typhoid vaccine?
travel to developing countries with prolonged exposure to food and water
80
When do patients get heprain induced throbocytopenia?
3-5 days on heparin for naïve pts
| sooner in pts who have been exposed to heparin before
81
What other tests should you send when you are thinking about sarcoidosis?
cxray, rule out TB with PPD and lupus with ANA, elevated 24 hr Ca may be high, tissue dx with lung biopsy if worried it could be lymphoma
82
What pathology is seen on cardiac biopsy in rheumatioc heart disease?
pancarditis - myocarditis with aschoff bodies
83
How to diagnosis disseminate gonococcal infection?
Hard to dx: do urine test (nucleic acid amplicafication - same as for uretritis)
84
What physical finding in an asthmatic patient should make you think twice about using aspirin/NSAIDs?
nasal polyps - can have an asthma exacerbation when taking aspirin/NSAIDs
85
When to do a TTE vs TEE for infective endocarditis?
Significant valvular regurgiation
Risk factors for perivalvular abscess
-new conduction delay (abscess could be causing this)
-aortic valve endocarditis
persistent bacteremia or fever despite appropriate therapy
86
How do you differentiae between OSA and primary snoring?
no cessation of breath in the primary snoring
87
How do you treat strep endocarditis?
penicillin G or ceftriaxone for 4 weeks
88
What is the current recommendation for screening smokers for abdominal aortic aneurysms?
screen male smokers >65 yo once with U/S
89
How do you tx symptoms of emphysema/COPD?
tx symptoms with inhaled bronchodilators (ipratropium and tiotropium)
if severe - tx with inhaled corticosteroids also
90
What do you need to do in addition to antifungals to treat cryptocaccal meningitis with high opening pressures?
daily LPs to decrease the CSF pressure
91
How do you treat osteomyelitis with MRSA?
vancomycin for 6-12 wks
92
What is the gold standard to dx sarcoidosis?
bronchoscopy with biopsy showing noncaseating granulomas (though that is not pathopneumonic for sarcoid, it could be other things - the clinical picture also has to fit)
93
How do you dx asthma?
clinical and PFTs (showing reversible obstruction)
94
How do you dx pleural TB?
```
plueral fluid stain/culture
adenosine deaminase
macobacterium TB PCR
Quant gold on fluid
Pleural biopsy (gold standard)
```
95
How do you treat necrotizing fasciitis?
Clindamycin - to inhibit exotoxin production
| Penicillin - to kill replicating cells by inhibiting cell wall synthesis
96
Do you treat asymptomatic pts found to have hilar lymphadenopathy concerning for sarcoid?
NO! only tx with steroids if have symptoms
97
Side effect of gentamicin
acute tubular necrosis (DON’T USE IN RENAL FAILURE)
98
What are side effects of pyrazinamide and ethambutol?
Gout
| Ethambutol - also optic neuritis (why we don't use in kids)
99
How does disseminated lyme disease present neurologically?
cranial nerve palsy (bell's palsy like), aseptic meningitis, radiculopathy
100
How do you treat MRSA pneumonia?
Ceftriazone + azitromycin + vancomycin/linezolid/clindamycin
or
Ceftaroline + azithromycin
*can never use daptomycin (neutralized by surfactant)
101
how do you treat pts with uremia who are bleeding?
desmopressin
102
What does an xray show in active TB?
Apical lesions
103
What is the work up for severe asthma attack?
1. Arterial blood gas (only for severe to see how they are doing)
2. PA and lateral chest xray (look for secondary pneumothorax/pneumonia)
3. Peak flow (baseline to help see if treatment is working)
4. Influenza nasal swab, sputum culture and grain stain
104
How do you confirm interstitial lung disease?
Bronchoscopy with lavage and BIOPSY!
105
What is the most common cause of viral encephalitis?
Herpse Simplex Virus Type 1
106
How do tx chronic hepatitis B?
tenofovir, - goal to treat HBsAg pos to HBsAg neg
107
What is the most common cause of chronic cough?
post-nasal drip (but always think about asthma)
108
How do you treat gas gangrene (clostridium perfringens from deep wounds or heroin use injected into tissue)?
penicillin + clindamycin
109
How do you dx HSV?
Clinical if classic presentation or HSV PCR if unsure
| DO NOT USE Tzanck prep anymore
110
What is the ddx for pulmonay nodule?
1. malignancy (bronchogenic carcinoma, pulm metastases, carcinoid tumors)
2. benign (granulomas, hamartomas, resolving infection, rhuem nodule, AV malformation, old trauma, rounded atelectasis)
111
What bacteria most likely causes navtive valve subacute endocarditis?
streptococci (50-60%) - mostly viridans
112
What is the side effect of rifabutin?
uveitis and activates p450 system
113
What antibiotic can we use for gram negatives that are producing carbapenemases?
Tigacycline
114
Risk factors for OSA?
```
older age
male
obesity
craniofacial abnormalities
upper airway soft tissue abnormalities
smoking
family hx of OSA
```
115
How do you treat moderate persistent asthma?
long acting beta-2 agonist (salmeterol) + glucocorticoids (fluticasone)
116
Common side effect of linezolid?
thrombocytopenia
| serotonin syndrome in combo with SSRIs
117
How do you treat cryptosporidiosis?
Nitazoxanide
118
Tx for MSSA endocarditis
4-6 wks IV abx (nafcillin or oxacillin) + gentamicin x1 wk for synergy
119
How do you treat hospital acquired penumonia?
Give 2 agents for pseudomonas + MRSA
| ex. cefepime, gentamicin, vanc
120
What antiretroviral should never be given in pregnancy?
efavirenz
121
What population is more infective in TB (kids or adults)?
ADULTS! Because they get the cavitary lesions in their lungs.
122
What is a side effect of tenofavir?
fanconi syndrome
123
How do you tell is someone with chronic hep B is infectious?
If surface antigen posiitive -> infectious
124
How do you treat resisent HSV?
foscarnet
125
What is the differential for elevated liver enzymes?
1. chronic viral hep (B or C)
2. drug-induced hepatitis
3. wilson's dz, hemochromatosis, autoimmune hepatitis
4. choledocholethiasis
5. Fatty liver
6. celiac sprue
126
When does getting the BCG shot cause a positive PPD test?
It might cause a mild PPD reaction in the first 5-7 yrs, but it will not cause a positive test in adulthood!
*can always confirm with quantiferon
CONSIDER A POS PPD AS LATENT TB (whether or not the pt got BCG at some pt!)
127
What is the coverage for ciprofloxacin?
gram negatives. NO gram positive coverage.
128
How do you treat an HIV pt with CD4<100 who has a ring enhancing lesion on CT?
Assume toxoplasmosis, start pyrimethamine with sulfadiazine and repeat CT in 2 weeks to confirm improvement/diagnosis (if doesn't shrink do brain biopsy for CNS lymphoma
129
How do you treat immune reconstitution inflammatory syndrome?
Stop antiretrovirals and treat the underlying infection and tx symptoms
130
How do you treat GERD?
give PPI for a short period of time (1-2 wks) and see if it improves
131
When can you not give HIV pts live vaccines?
when CD4 < 200
132
Do not send lyme serologies with non-specific symptoms!
need specific symptoms (rash, polyarthritis, bell's palsy…etc)
133
How to treat traveler's diarrhea
if non-febrile, ok to take loperimide. Use fluoroquinolone or azithromycin for pts with bloody diarrhea
134
What are pulmonary complications of TB?
hemoptysis, penumothorax, bronchiectasis, extensive pulm destruction, lung cancer, chronic pulmonary aspergillosis
135
How do you treat giardiasis?
metronidazole
136
What are the most common bacteria causing necrotizing fasciitis?
Group A strep or polymicrobial
137
What 2 types of abscesses do not get drained?
1. Lung - tx with clindamycin or penicillin
| 2. Liver - tx with metronidazole (enteromebous enterylitica)
138
Ddx of obstructive sleep apnea
OSA
primary snoring
poor sleep hygeine w/ insuff sleep
hypersomnias - narcolepsy, neuro d/o (thalamus/hypothalamus dysfx, alzheimers)
139
What is the most common cause of prosthetic valve endocarditis?
staph in first 2 months, then strep viridans
140
What is the goal o2 sat in COPD pts?
90-92%
141
What medications can lead to hypoglycemia?
insulin and sulfonylureas (esp in renal failure because renally cleared and stick aroun dlonger in body)
142
What is the mechanism of acyclovir?
inhibit polymerase that makes viral DNA
143
Liver enzyme ratio that suggests alcoholic liver disease?
AST/ALT >2 and always under 500
144
What testing is needed for cellulitis dx?
none! Clinical! Can do an u/s to r/o DVT in lower extremities
145
Ho do you treat enterococcal endocarditis?
beta-lactam abx (penicillin or ampicillin) + gentamicin for entire 4-6 wks
146
With a GI bleed, what can the BUN give you a clue about?
The location of the bleed. If high BUN, upper GI bleed bc blood is getting reabsorbed as it travels through the gut causing the BUN to increase *do an upper endoscopy first, if pt hypotensive and high BUN!!
147
Malaria prophylaxis for pregnant women
chloroquine
148
How do you treat a severe asthma exacerbation?
1. Nebulizer with bronchodilator and anti-cholinergic (albuterol + ipratropium)
2. supplemental oxygen if hypoxemic
3. IV glucocorticoids (Methylprednisone) (for a few days, the switch to oral to complete 10-14 days)
149
How do you test for cryptococcal?
india ink and serum cryptococcal antigen titer and fungal cultures
150
Why is aortic stenosis associated with angiodysplasia?
turbulent flow is destroying vWF and platelet disruption which leads to bleeding of the AVMs, so neeed to replace aortic valve to prevent futher bleeding
151
What are 2 variants of asthma that you should keep in mind?
cough variant asthma (think about with chronic cough esp worse at night)
exercise-induced asthma
152
With antibiotics, when treating pts with heart disaese and prolonged QT interval should be avoided?
macrolides and fluoroquinolones
153
What vaccines do new HIV pts need?
pneumococcal pneumonia
hep a and b
flu
154
When worried about mengitis - who needs a head CT before the LP?
papilledema, confusion, focal deficits, seizures, severely immunocompromised (HIV or transplant)
*signs of mass effect, increased ICP
155
When do you avoid imipenem?
brain injuriy/seziures
| *lowers seizure threshold
156
How do you treat HSV?
acyclovir or valacyclovir (easier to dose
| test for other STDs (HIV, syphilis)
157
What test do you use to evaluate TB in a pt who has received the BcG vaccine?
gamma-interferon releasing assay
158
What can you see in chest xrays with asbestos exposure?
calcified pleural plaques - tells you they have had significant asbestos exposure
159
How do you tx OSA?
1. weight loss
2. CPAP is the gold standard
3. surgery is anatomical cause
160
Who is high risk with hepatitis E infection?
pregnant women
161
Tricks for remembering antiretroviral meds
Nucleosides (needs 2) end in "ine" except abacavir and tenofovir
+ 1 of either
Protease inhibitors all end in "navir"
NNRTIs all have "avir" buried inside the word
Integrase inbitors end in "ravir"
162
What must you do if a pt comes back for one STD?
Test for others - esp syphilis (VDRL test) and HIV
163
When do you need to cover for pseudonmonas?
1. malignant otitis externa in diabetics
2. septicemia
3. burn victims
4. cystic fibrosis
5. severely neutropenic pts (<500)
6. ventilator-associated pneumonia
164
What lung findings do you see with sarcoidosis?
bilateral hilar adenopathy +/- paranchymal/interstitial disease
165
When should we consider MRSA pneumonia?
IV drug users
recent or concurrent flu
severe penumonia needing intubation/ICU admission
necrotizing (cavitary) pneumonia
166
How is asymptomatic (latent) syphilis categorized?
less than 1 year - early
| over a year - late latent
167
How do you dx OSA?
atleast 5 events per hour on sleep study + symptoms/sign of OSA
168
How do you tx acute emphysema exaccerbation?
1. O2 - maintain sats 90-92%
2. inhaled bronchodilators (ipratropium or tiotropium) and/or b-agonist (careful can incr HR and cause cor pulmonale)
3. antibiotics (azitrhomycin, CTX, fluoroquinolones)
4. Sputum cx and graim stain
5. corticosteroids (IV -> PO) (like asthma in acute setting)
169
What is the dx and tx of a positive PPD and negative chest xray?
latent TB, tx with 9 months of INH + vit B6 (pyridozine)
170
How do you treat bleeding esophageal varices in a cirrhotic pt?
at increased risk for spontaneous bacterial peritonitis, so give a prophylaxis with Ceftriaxone for 1 week
171
What is a side effect of acyclovir?
acute tubular necrosis (Hydrate!!!!)
172
What factors are associated with a poor prognosis in cryptococcal meningitis?
Eleveated opening pressure
Low WBC coung in CSF
Low glucose level in CSF
Positive India InkHihg cryptococcal antigen titers
173
What medicine may cause chronic cough?
ACE-inhibitors (lisinopril, enalapril, captopril)
174
How do you treat outpatient community acquired penumonia?
azithromycin - probably mycoplasma
| levofloxacin or moxifloxacin
175
How do you treat campylobacter?
supportive - hydration!, should resolve in 3-7 days
| Avoid loperimide
176
What is the side effect of daptomycin?
myocitis - monitor CPKs while on it
177
How do you treat severe asthma?
LABA/systemic corticosteroids/luekotriene inhibitors
178
What is the treatment for bacterial meningitis?
```
Empiric antibiotics (CTX, vancomycin, +/- ampicillin)
Dexamethasone (improves outcomes esp for step pneumo)
```
179
What are good narrow antibiotics?
ampicillin
TMP/SMX
first gen cephalosporin
180
What does tigecycline cover?
everything except psuedomonas and proteus - very broad
181
How do you treat mild intermittent asthma?
short-acting inhaled beta-2 agonist as needed
182
What increases survival in emphysema?
stop smoking
home o2 if they meet the criteria
vaccines (pneumococcal + booster and flu)
lung transplant
183
How do you dx necrotizing fascitiis?
CLINICAL though gold standard is Tissue biospy in the OR
184
How do you treat lyme with a rash, bell's palsy, or joint involvement?
doxycyline (tx lyme and erlichiosis - commonly co-infection) or amoxicillin (doesn't tx erlichiosis) for pregnant/young children
185
How do you vaccinate against hep A?
2 shots given 6 months apart = immunity x10 yrs, if leaving within 2 weeks give vaccine and immune serum globulin
186
What are PFT findings in asthma?
obstructive
decr FEV1 and FVC
*do bronchodilator to tell different between asthma and COPD
*if normal, do a provocative challenge with methacholine, cold air, or exercise
187
What are the side effects of rifampin and isoniazid?
liver failure - check LFTS
188
Who and when should people get the pneumococcal vaccine (PPSV23)?
everyone at 65 yo, otherwise anyone with sickle-cell or splenectomy, cardiopulmonary dz, alcoholism, cirrhosis, alaska natives and certain antive american populations, immunocompromised (cancer, chronic renal failure, HIV-positive, immunosuppresive meds)
189
How do you treat pts with a hx of spontaneous bacterial peritonitis?
prophylactic antibitics: norfloxacin, ciprofloxacin, or trimetho-sulfa
190
How do you treat HIV in pregnancy?
Always treat with combo failure no matter the CD4 count to prevent transmission, start immediately (don't wait until later in pregnancy)
191
How do you treat HIV with antiretroviral therapy?
If CD4 <500 - start anti-retrovirals
2 nucleosides
NNRTI or protease inhibitor or an integrase inhibitor
192
What is the differential for elevated liver enzymes over 1000?
1. viral hepatitis
2. drug toxicity (acetaminophen)
3. ichemic liver dz (shock liver)
193
What is the best test to detect acute HIV?
HIV viral load, antibody tests will be negative
194
Lung cancer screening recs
Smokers with >30pack years from 55-80 with annual low dose CT (if current smoker or quit <15 yrs)
195
How do you monitor response in HIV patients?
viral load - goal is to make viral load undetectable
196
What is the triad of symptoms of disseminated gonoccal infection?
1. migratory polyarthritis
2. tenosynovitis
3. skin lesions in 75% (hemorragic pustules, esp palms and soles)
197
How do you work up a solitary pulmonary nodule?
CT chest with contrast
- if > 3cm - worry about cancer
- if mediastinal adenopathy - cancer
- if spiculated borders - cancer
- if central calcifications, "popcorn, onion skin, bull's eye" - benign
198
What is the length of treatment for pyelonephritis?
7-10 days
199
How do you treat any serious skin or soft tissue infection caused by group A strep?
penicillin plus clindamycin
200
How do you treat bleeding in a pt with vonWillebrand's disease?
desmopressin
201
What must be checked prior to giving a pt dapsone?
G6PD deficiency - bc they are at risk for hemolytic anemia with dapsone
202
What do you see on a CT angio with a pulmonary emobolism?
filling defect
203
What sites can TB affect?
```
Lungs (80%)
Pleura
CNS
Lymphatic system
Genitourinary system
Bones and joints
Peritoneum
```
204
What is good empiric coverage for infective endocarditis?
vancomycin and gentamicin
205
How to treat cellulitis?
empirically - IV oxacllin or nafcillin 1g q4 hrs or cefazolin, elevation of leg/warm soaks
could do oral dicloxacillin or cephalexin if very mild
*if penicillin allergy - cefalexin
*if severe pcn allergy - clindamycin, macrolides, new fluoroquinolones
206
How do you culture Neiseria?
on Thayer-Martin agar (contains abx to kill other things besides neiseria)
207
How do you treat invasive aspergillus?
Voriconazole
208
Can you get a culture for osteomyelitis?
NO MUST BE A BONE BIOPSY!!!
209
What measure on PFTs is a hallmark of emphysema?
```
decr DLCO (diffusion is impaired due to destruction of alveolar membranes)
FEV1 tells you how bad the emphysema is
```
210
Why do you give vitamin B6 with isoniazid in treating TB?
to reduce peripheral neuropathy
211
What is the best test to detect osteomyelitis?
MRI (but always do an xray first)
212
How do you treat symptomatic sarcoidosis?
oral corticosteroids
213
What programs have helped to increase compliance for meds in disease like TB?
DOT - direct observed therapy (care providers give medicine everyday in home/community)
214
What are the latest blood transfusion guidelines based on hemoglobin for GI bleeds?
give RBCs when Hgb <7 for normal pts
| give RBCs when Hgb <8-9 for cardiac dz pts
215
How do you treat community acquired pneumonia?
(treat penumococcus, heamophilus, moxerella, atypicals (legionella)
1. Ceftriaxone (3rd gen) or amp/sulbactam
+
azithromycin or doxy or
2. moxifloxcin or levofloxacin
216
What antibiotic is used for endocarditis prophylaxis?
amoxicillin 30-60 mins prior to procedure
| - clindamycin, cephalexin, or macrolide is allergic to penicillin
217
Who has a PPD cutoff of 5 mm?
HIV, immunocompromised, organ transplant, pts with prior TB dz
218
What is a normal blood gas?
pH 7.35-7.45
PCO2: 35-45
PO2: >90
HCO3: 18-24
219
Mortality in necrotizing fasciitis without surgical debridement?
100%
220
How do you treat HIV + mom during delivery of baby?
give baby zidovudine during delivery and for 6 wks after
221
What is the differential for acute diarrhea lasting more than 48 hours with blood in stool?
Bacterial! Salmonella, Shigella, Campylobacter, Yersinia, and E. Coli
222
How do you treat chronic cough d/t post nasal drip?
decongestant and/or antihistamine
223
What are the 3 common causes of chronic cough in a young, nonsmoker?
Exercise induced asthma
GERD
postnasal drip
224
What else needs to be worked up with new PE?
malignancy
225
What much be considered when a pt has recurrent Neisseria gonorrhea infections?
Terminal compliment deficiency (C5-C9)
226
Once someone has latent TB, will their PPD become negative once treated?
NO! Once positive - will always be positive (unless old and lose T cell memory)
227
What types of lyme dz are tx with IV ceftriaxone?
Lyme myocarditis, meningitis or encephalitis
228
Who should receive the shingles vaccine?
at age 60 everyone!
229
How do you evaluate and treat an HIV pt who had an exposure to TB?
treat them even if chest xray and PPD negative
230
How do you treat chronic emphysema?
1. stop smoking
2. home oxygen x24 hours (esp at night!) (if meets criteria)
3. vaccines (pneumococcal and flu)
4. tx symptoms with inhaled bronchodilators (ipratropium and tiotropium)/inhaled corticosteroids if severe
231
What does a CXR show in emphysema?
flat diaphragm, narrow cardiac silhouette, no infiltrates
232
What do PFTs show in interstitial lung disease?
Low FEV1, low FVC, normal FEV1FVC (restricitve)
| decr TLC, decr DLCO
233
Traveler's most common vaccine preventable disease
hep A
234
Most common causes of bacterial meningitis in babies?
GBS
E Coli
Strep pneumo
235
What is the differential for discharge from the penis?
Gonococcal urethritis
Non-gonococcal urethritis (chlamydia, herpes, mycoplasma, ureaplasma)
Trichomoniasis
Reiter syndrome
236
How do you treat mild persistent asthma?
add an inhaled glucocorticoid (controller) + short acting B-2 agonist
237
What type of lung dz is seen with PE findings of increased antero-posterior diameter and hyperresonance to percussion?
obstructive
238
How do you treat latent TB?
Isoniazid + vitamin B6 (pyridoxine) for 9 months
| check LFTs q3 months
239
What drugs should be avoided in asthmatics?
NSAIDs, Aspirin, Beta-antagonists, coloring agents like tartrazine
240
What is the risk of untreated OSA?
increased all-cause and cardiovascular mortality
241
What med can women with factor 5 leiden NEVER take?
hormonal birth control
242
What test is good for ruling out pulmonary embolism?
D-dimer in low risk pts
243
If you can't anticoagulate a pt with a PE, how do you treat them?
Place a vena cava filter for temporary fix, become pro-thrombotic after a couple weeks
Control bleed, take filter out and start anticoagulation
244
Malaria prophylaxis
mefloquine (doxycycline is an alternative)
245
How do you treat rocky mountain spotted fever meningitis?
doxycycline
246
What test do you order to check for hemochromotosis?
transferrin saturation (iron level over the TIBC)
247
How do you empirically treat pyelonephritis?
```
Ceftriaxone
Levofloxacin/ciprofloxacin
ampicillin/sulbactam
gentamicin w/ or w/o ampicillin
aztreonam *good for severe PCN allergy
```
248
How do treat HIV with CD4 < 50?
prophylaxis for Mycobacterium avium: azithromycin weekly (Macrolide for MAC)
249
How do we screen for osteoporosis?
Screen women age 65 and greater with a DEXA exam, can start at 60 if low body weight or incr risk of fx
250
How do you treat community acquired MRSA?
vancomycin (IV)
*can also use daptomycin, ceftaroline (5th gen cephalosporin)
For milder cases - can use clindamycin, doxycycline, or trimethoprim/sulfamethoxazole
251
What travelers should get the Yellow fever vaccine?
travel to sub-sarahan africa and some S. america countries
252
How do you dx active TB?
If PPD pos, chest xray pos, get acid fast TB test - if pos tx for active TB
253
What travelers should receive Hep B vaccines?
Anyone staying >6 months, close contact with local people, having medical procedures, sexual relations.
254
What needs to be screened for in COPD pts?
Lung cancer - low dose CT yearly
255
How do we treat heparin induced throbocytopenia
Factor 10 inbihitor (fondoparinaux) or direc thrombin inhibitor (argatroban)
stop heparin
256
Which cancers do we recommend regular screening for?
colon, breast, cervix, lung
257
What is the most common cause of cirrhosis and HCC in the US?
chronic hepatitis C
258
What should you think of associated with loud S2, S3, or S4?
loud S2 - pulm htn
S3 - dilated heart
S4 - stiff heart (diastolic dysfx)
259
How is hep A transmitted?
food or water contamination
260
What organisms can cause culture-negative endocarditis?
HACEK organisms (Haemophilus, actinobacillus, cardiobacterium, eikenella, kingella)
261
When do you have to replace the valve in infective endocarditis?
```
Severe regurgitation with hemodynamic compromise
myocardial abscess
repeated emboli
very large vegetations >10 mm
fungal endocarditis
prosthetic valve endocarditis
```
262
Most common cause of bacterial mengiitis?
strep pneumoniae
263
How do you follow a solitary pum nodule?
Low risk pt (short smoking/non-smoker, >15 yrs out from smoking)
- repeate imaging in 3-6 months to confirm no growth
- if there is an old xray that shows the nodule (>1 yr out), then no f/u
High risk (>45 yo, w/ sig tobacco hx)
- bronchoscopy with biopsy, ct-guided biopsy, open lung biopsy
264
How do you bridge heparin to warfarin?
start LMWH and warfarin
keep heparin on for >5-7 days until INR is >/= 2 for 48 hours
stay on anticoagulation for 6 mos - life
265
How do you dx PID?
1. cervial motion tenderness
2. adnexal tenderness
3. uterine tenderness
266
What are causes of interstitial lung disease?
Occupational: asbestosis, silicosis, berylliosis, coal worker's pneumoconiosis
Non-occupational: idiopathic pulmonary fibrosis, interstiial pneumonia, hypersensitivity pneumonitis
267
What is ther management for necrotizing fasciitis?
immediate surgical debridement
| NO TIME FOR IMAGING
268
How do cover prophylactic infections in post-neurosurgical or post-head trauma pts?
vancomycin + cefepime or meropenem or ceftazidime to cover MRSA and pseudomonas
269
What is the CAGE tool to screen for alcoholism?
```
tried to CUT down
Annoyed by critisicm about drinking
guilty about it
Eye opener
*2 of 4 is positive
```
270
What risk factors make MRSA cellulitis more likely?
household contacts with MRSA, children, MSM, IV drug users, athletes in contact sports, Native Americans/Pacific Islanders
271
How do you treat meningitic with TB?
At least 9-12 months and with steroids
272
Who gets invasive aspergillus?
Neutropenic fever
273
How do you treat a patient with a pulmonary emoblism?
start anticoagulation
* Enoxaparin (low-molecular weight heparin) and warfarin on day 1-2
* for renal failure or morbid obese pts - unfractionated heparin
274
What is the work up for acute diarrhea?
check for blood in stool
| only send cultures if lasts longer than 48 hours
275
How long does it take for antibiotics to lead to clinical improvement with pneumonia?
72 hours (ok to have fever up to 72 hours - not tx failure until after 72 hrs)
276
What organisms are not covered by cephalosporins?
```
LAME
Listeria
Atypicals
MRSA (except ceftaroline)
Enterococcus
```
277
What is the treatment for candidemia? (pts on TPN)
Fluconazole
278
What must be considered with a pt with recurrent sinusitis and recurrent community acquired pneumonia?
C3 deficiency
IgG, IgA, and IgM for Common Variable Immunodeficiency
*get recurrent infections with encapsulated organisms
279
How do you treat hospital assocaited staph line infection sepsis?
4 weeks of IV Abx
280
What labs do you order when thinking about osteomyelitis?
x-rays, ESR, CBC
281
How do you treat acute viral hepatitis?
supportive care
282
What is Immune reconstitution inflammatory syndreom?
inflammatory disorders that develop in pts with AIDS upon starting antiretroviral therapy
-paradoxical worsening as CD4 counter recovers when there is an infection present (TB, cryptococcal meningitis)
283
How long do you treat complicated cystisi?
7 days (ex: man with cystitis)
284
When do you treat infectious diarrhea with antibiotics and which antibiotic?
Severe cases - hospitalized, can't stay hydrated not getting better
Ciprofloxacin
(could also do trimethoprim/sulf)
285
What is the differential for progressive shortness of breath?
Interstitial lung dz
Bronchogenic carcinoma (squamous cell and small cell carcinoma)
COPD/emphysema
Congestive Heart Failure
286
How do you empirically treat spontaneous bacterial peritonitis?
cefotaxime or ceftrixaone + IV albumin on day 1 and 3 (if Cr is greater than 1.5 to reduce risk of hepatorenal syndrome)
287
How do you dx lyme dz?
```
Lyme titers (though not very specific so only do it if you have a high pre-test probability beceaeuse there are a lot of false positives with lyme titers
*done by ELISA or Western blot
```
288
How do you work up shortness of breath?
ox sat, cxr, PFTs (outpt, when not in acute episode), maybe ABG (for severity of dz)
289
Who needs to be covered with ampicillin in menigitis?
For listeria
| *infants, pts > 50, any chronic dz, immunocompromised, on agents like infliximab/etanercept (TNF alpha inhibitors)
290
Who needs endocarditis prophylaxis?
1. prosthetic valve
2. previous infective endocarditis
3. congenital heart surgery not repaired or with prosthetics material
4. cardiac transplant with cardiac valvulopathy
291
When do patients who need endocarditis prophylaxis need it?
dental procedures, procedures to respiratory track involving incision or biopsy, debridement of skin/soft tissue wounds
292
Who and when should people get the HPV vaccine?
everone at age 11-12, if didn't complete it, could do up to age 26
293
What can happen if lyme dz if not treated?
dissemined dz or late stage with arthritic findings 60% (knee very commonly involved)
294
How do you treat exercise induced asthma?
short acting beta-2 agonist (better for adults) to be taken before exercise or cromolyn is an alternative good for kids bc SABAs can affect height long term
295
Colon cancer screening recs for normal population
start at 50
* colo every 10 yrs
* feccal occult every yr
* sigmoid with barium enema every 5 yrs
296
Can daptomycin be used in pneumonia?
NO! surfactant inactivates it
297
What cephalosporin covers MRSA?
Ceftaroline (5th gen. cephalosporin) - good gram neg (except pseudomonas) and MRSA
298
How do you treat meningitis with brain abscess?
surgical drainage plus metronidazole (bacteroides fragilis) and CTX +/- vancomycin
299
How do you work up discharge from the penis?
best test: nucleic acid amplification urine test
300
What are the drugs in the RIPE tx for active TB?
Isoniazide (+vit B6)
Rifampin
Pyrazinamide
Ethambutol
301
Side effects of protease inhibitors?
increased LDLs, put on a statin (only provastatin, ruvastatin, or low-dose atorvastatin)
302
What is the differential for acute diarrhea?
```
Salmonella
Campylobacter
Shigella
norwalk virus
Yersinia
Enteroinvasive E. Coli
```
303
What tests should be sent for a new dx of HIV?
CD4, HIV viral load, resistance testing of viral genome
| RPR, toxoplasmosis, CBC and lytes, pap smear, chest x-ray, hep A, B, C, PPD
304
How do you treat gonorrhea?
```
Start empirically (before results come back)
Ceftriaxone IM for gonorrhea
+ one dose azithromycin or 1 wk doxycyline to cover chlamydia
```
305
How do you treat Mycobacterium Avium Complex?
macrolide with ethambutol with/without rifabutin
306
When should you follow up acute issues in CCS?
follow up once to make sure the issue resolved, then can click "return as needed"
307
What is the natural hc of HSV?
Recurrence can happen anytime, frequent recurrences can be suppressed with regular doses of acyclovir
308
What is the most common complication from bacterial meningitis?
hearing loss
309
Do you hold antibiotics if your meningitis pt needs a head CT prior to LP?
NO, get blood cx and start Abx
310
What are the empiric treatment for bacterial meningitis?
Ceftriaxone (strep penumo and neisseria meningitis)
Vancomycin (for penicillin resistant pneumococcus in the CSF, better concentrating than CTX in CSF))
* add Ampicillin for listeria in infants, pts >50, DM, and chronically ill pts
311
How do you treat HACEK endocarditis?
ceftriaxone, ampicillin-sulbactam, or ciprofloxacin x4 wks
312
How do you follow pts with chornic Hep B?
screen with liver U/S every 6 months to check for hepatocellular carcinoma
313
When do you treat chronic hepatitis B?
NO. only pts who are actively replicating - HBeAg positive or high viral load and high transaminases
314
What is the first step in treating a GI bleed?
Fluid resuscitation, CBC, PT/PTT, type and cross BEFORE endoscopy
315
How do you treat hypoglycemia?
IV dextrose (50 ml %50 dextrose)
316
Who should not receive the varicella vaccine?
bc live attenuated
| *immunocompromised, HIV pos with <200 CD4, pregnant women
317
What is the different in the primary complain of emphysema vs chronic bronchitis?
emphysema - dyspnea
| chronic bornchitis - productive cough
318
How do you treat lyme disease meningitis?
ceftriaxone
