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most common causes of pneumonia: children
- 1. viruses
- 2. mycoplasma
- 3. C.pneumo
- 4. S.pneumo
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most common causes of pneumonia: older adults
- S.pneumo
- H.flu
- anaerobes
- viruses
- mycoplasma
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classic pneumonia treatment
3G ceph, azithro
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atypical pneumonia organisms, tx
- mycoplasma, legionella, chlamydia
- macrolide, doxy, broad spec FQ (levo, moxi)
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most common causes of pneumonia: alcoholics
- S. pneumo
- Klebsiella
- S. aureus
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most common causes of pneumonia: CF
- Pseudomonas
- Burkholderia
- S. aureus
- mycobacteria
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most common causes of pneumonia: neonate
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When to hospitalize for pneumonia
- CURB-65 > 1 [confusion, inc urea, RR > 30, BP <90/ <60, age > 65]
- or any comorbidities, immunosuppression
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Pseudomonas: tx
- (piperacillin +/- tazo) + tobramycin
- or piperacillin + ceftazidime/cefepime
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TB: tx
- Active TB: Rifampin, INH, pyrazinamide, ethambutol x 2 mo, then Rifampin, INH x 4 mo
- Latent TB: INH x 9mo
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INH: side effects
- peripheral neuritis- give with pyridoxine to prevent
- hepatitis
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Centor criteria
- used to ID strep pharyngitis
- 3+ of - fever, tonsillar exudate, tender cervical LA, no cough
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Acute pharyngitis: complications
- non-suppurative: rheumatic fever (mitral stenosis > aortic stenosis), PSGN
- suppurative: mastoiditis, peritonsillar abscess, Lemierre's syndrome (thrombophlebitits of jugular vein)
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Corynebacterium: characteristics, complication, tx
- GP, highly pleomorphic "chinese characters"
- form pseudomembranes
- complication- dilated cardiomyopathy
- tx- erythromycin or PCN
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Sinusitis: acute vs chronic, tx
- Acute < 1mo, bacteria cause symp < 1 wk
- Chronic > 3mo, often dt obstruction or ongoing low grade anaerobe infx
- Tx- mostly symptomatic
- acute bacterial: Amox/Clavulanate (or macrolides, TMP-SMX, FQ)
- Chronic: adjuvant intranasal steroids, decongestants, antihistamine, longer course abx
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Coccidiodomycosis: population affected, tx
- consider in HIV+, Filipino, Af-Am, pregnant pt from SW US
- tx- consider IV amphotericin B for severe pulm infx or disseminated disease. otherwise PO azole for mild
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Meningitis: common causes in children + tx
- S.pneumo
- N. meningitidis
- Hib
- Enterovirus
- tx- Vanc + ceftriaxone/cefotaxime
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Meningitis: common causes in adults + tx
- N. meningitidis
- Enterovirus
- S. pneumo
- HSV
- tx- Vanc IV + ceftraixone/cefotaxime
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Meningitis: common causes in HIV
- Cryptococcus
- CMV, HSV, VZV
- TB
- toxo
- JC virus
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Meningitis: common causes in elderly + tx
- S.pneumo
- GNR
- Listeria
- N. meningitidis
- tx- Amp + Vanc + cefotaxime/ceftriaxone
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Encephalitis: clinical features, dx
- altered consciousness, HA, fever, seizures
- CSF- lymphocytic pleocytosis, inc protein, poss dec glucose
- obtain DSV gram stain, acid fast stain, India ink (cryptococcus), wet prep (amebae), Giemsa stain (trypanosomes), PCR
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Features of HSV encephalitis
- RBCs in CSF without history of trauma
- constrast-enhancing lesion in temporal lobe
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HIV: opportunistic infx
- CD4 < 50: disseminated MAC, histo, CMV retinitis, CNS lymphoma
- CD4 < 200: Pneumocystosis, toxo, cryptococcus, coccidioidomycosis, cryptosporidiosis
- higher CD4 count- TB, HSV, HZ, vaginal cadidiasis, hairy leukoplakia, Kaposi's sarcoma
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HIV: when to initiate antiretrovirals
- symptomatic regardless of CD4 of viral count
- asympt with CD4 < 350
- pregnant
- specific HIV-related conditions
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HIV: prophylaxis for opportunistic infx
- PCP- CD4 < 200, oral candidiasis, unknown fever x 2weeks
- MAC- CD4 < 50-100
- Toxo- CD4 < 100
- TB- PPD or high risk
- Candida, HSV- multiple recurr
- MMR vaccine: only live vaccine given to HIV pts (give if CD4 > 200)
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Oropharyngeal candiasis: features, dx, tx
- soft white plaques that can be rubbed off
- budding yeast + pseudohyphae
- local tx for thrush, PO azole for esophagitis
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Cryptococcal meningitis: features, dx, tx
- exposure to pigeon droppings
- LP- dec gluc, inc protein, leuk, opening pressure
- + CSF cryptococcal antigen test
- India ink stain- narrow based, unequal budding
- tx- IV ampho B + flucytosine x 2 weeks. lifelong maintenance tx until CD4 > 200 for >6 mo
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Histoplasmosis: dx, tx
- CXR, urine and serum polysaccaride antigen test, silver stain (yeast)
- tx- itraconazole 1 yr for chronic cavitary lesions, ampho B followed by itraconazole for severe pulm or disseminated dz
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Pneumocystis jiroveci: dx, tx
- silver stain
- high dose TMP-SMX x 21d
- alternate- clinda, primaquine, pentamidine
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CMV: transmission, manifestations
- via sex, breast milk, resp droplets, blood transfusion
- CMV retinitis
- AIDS cholangiopathy
- CMV pneumonitis- pts with heme malig
- CNS- polyradiculopathy, transverse myelitis, encephalitis (periventricular calicification)
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Mycobacterium avium Complex: features, dx, tx
- fever, weak, wt loss in pts not on HAART or prophylaxis
- dx- blood cx, inc alk phos and LDH, bone marrow shows foamy macrophage with AFB
- tx- clarithromycin + ethambutol +/- rifabutin. HAART
- prevent- weekly azithromycin if CD4 < 50
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Toxoplasmosis: features, dx, tx
- raw or undercooking meat, cat litter, France
- dx- serology, PCR, CT scan if CNS involvement (multiple ring-enhancing lesions with predilection for basal ganglia)
- tx- PO pyrimethamine, sulfadiazine + leukovorin, spiramycin (for preg)
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Chlamydia: presentation, dx, tx, complications
- often asympt, urethritis, mucopurulent cervicitis, PID
- lymphogranuloma venereum - affect LN then "anogenital syndrome"
- clinical dx, culture is gold standard. GS may show PMNs but no bac
- tx- doxy or azithro
- Reiter's syndrome, Fitz-Hugh-Curtis syndrome
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Gonorrhea: presentation, dx, tx
- GN intracell diplococus
- green/yellow discharge, adnexal pain, in male purulent urethral discharge
- monoarticular septic arthritis, tenosynovitis
- GS and culture is gold standard
- tx- ceftriaxone or cefepine x 1 dose
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Syphilis: presentation
- primary: painless chancre
- secondary: flu-like symp, macpap rash on soles and palms, condylomata lata
- early latent < 1 yr
- late latent > 1yr --> may progress to tertiary
- tertiary: gummas, neurosyphilis (tabes dorsalis, Argyll Robertson pupil), cardiovasc (thoracic aortic aneurysm)
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Syphilis: dx, tx
- dx- darkfield (1', 2'), VDRL/RPR (false positives, become neg when infx clears), FTA-ABS (remain positive for life)
- tx- benzathine pcn x 1d (tetracycline or doxy). possible Jarisch-Herxheimer rxn
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UTI: tx
- uncomplicated- TMP-SMX or FQ x 3d, nitrofurantoin x 7d
- complicated- above x 7-14d
- pregnant- nitrofurantoin or cephalosporin x 3-7d
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SIRS: definition
2 or more of temp (< 36 or > 38), tachypnea, tachycardia, leukocytosis/leukopenia
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Sepsis: causes in neonates
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Sepsis: causes in children
- H.flu,
- pneumococcus
- meningococcus
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Sepsis: causes in asplenic pt
- pneumococcus
- H.flu
- meningococcus
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Malaria: tx
- uncomplicated- chloroquine +/- primaquine for hypnozoites (P.vivax, P.ovale)
- severe- IV quinidine or proguanil/atovaquone
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Infectious mono: compliations
- CNS infection
- splenic rupture
- bac superinfx- strep pharyngitis
- fuminant heaptic necrosis
- autoimmune hemolytic anemia
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EBV associated cx
- nasopharyngeal cx
- African Burkitt lymphoma
- posttransplant lymphoprolif d/o
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Lyme disease: presentation, tx
- Borrelia burgdorferi carried by Ixodes tick
- 1' (early local)- erythema migrans
- 2' (early dissem)- migratory polyarthropathy, neurologic phenom, meningitis, conduction abnl
- 3' (late)- arthritis, subacute enceph
- tx- doxycycline for early dz, ceftriaxone for advanced
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Rocky Mountain Spotted Fever: presentation, tx
- Rickettsia rikettsii carried by dermacentor dog tick
- macular rash on wrists/ankles spread centrally as petechia/purpura
- look very ill, DIC
- tx- doxycycline (chloramphenicol 2')
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Endocarditis: etiologies + associations
- S.aureus- IVDU
- Viridans strep- left-sided subacute IE, native valve
- Coag neg staph- prosthetic valve
- Strep bovis- GI malig
- Candida/aspergillis- immunocompromise, long-dwelling IV
- HACEK- culture neg
- Libman-Sacks- SLE
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Endocarditis: tx
vancomycin (or pcn) + gentamicin/tobramycin
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Osteomyelitis: causative orgs, tx
- S.aureus, Salmonella
- oxacillin, cefazolin, vanc
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Cellulitis: causative orgs, tx
- Strep, Staph
- dicloxacillin, cephalexin
- if MRSA, TMP-SMX or clinda
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Septic arthritis: causative orgs, tx
- S.aureus- vanc
- GNR- ceftazidime or ceftriaxone
- N.gonorrhea- ceftriaxone, cipro, spectinomycin
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empiric antibiotics for Strep A/B
- PCN, cefazolin (1G)
- erythromycin
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empiric antibiotics for S.pneumo
- macrolide, doxy
- 3G ceph + macrolide or doxy
- FQ c atypical coverage
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empiric antibiotics for enterococcus
- PCN or amp+gent
- Vanc + gent
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aminoglycoside types + uses
- gentamicin, tobra, strptomycin
- aerobic GNR, TB
- endocarditis c stronger GPC abx (amp+gent)
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empiric antibiotics for gonococcus
- ceftriaxone or cefixime (3G)
- spectinomycin
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empiric antibiotics for meningococcus
- ceftriaxone or cefotaxime (3G)
- chloramphenicol or Pen G
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empiric antibiotics for Haemophilus
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empiric antibiotics for mycoplasma
- erythromycin, azithromycin
- doxycycline
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macrolide: types and uses
- azithromycin, erythromycin
- GPC + mycoplasma, legionella, mycobacterium (think broader PCN)
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Antipseudomonal PCNs
ticarcillin, pipercillin (think zosyn)
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Antistaph PCNs
dicloxacillin, methicllin, oxacillin, nafcillin
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Pneumonia after exposure to exotic bird
Chlamydia psittaci
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Seizures with ring-enhancing brain lesions on CT
- Taenia solium- albendazole or praziquantel
- Toxoplasmosis
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SCC in middle east or africa
Schistosoma haematobium
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Worm infection in children: cause, dx, tx
- Enterobius
- dx- + tape test, perianal itching
- tx- mebendazole or albendazole
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Measles: presentation, complication
- fever, cough, runny nose, conjunctivitis
- 3 days later, Koplik's spots
- then macpap rash on head/neck c cephalocaudal progression
- giant-cell pneumonia, subacute sclerosing panencephalitis (years later)
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Rubella: presentation, pregnancy
- vaccine contraindicated in pregnant
- milder than measles
- 2-3d prodrome then rash on face, neck with cephalocaudal progression
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Roseola infantum: cause, presentation
- HHV6
- children > 3yo
- high fever with no known cause x 4 d, then diffuse rash on chest/abd
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Erythema infectiosum (fifth disease): cause, presentation
- parvovirum B19
- "slapped cheek" rash on face, followed by rash on arms, legs, trunk
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Scarlet fever: cause, presentation, tx
- GAS
- pharyngitis then sandpaper-like rash on trunk, circumoral pallor, strawberry tongue
- PCN V PO
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Kawasaki dz: presentation, complication
- < 5 yo
- fever > 5d, strawberry tongue, conj injection, skin desquamation, rash beginning 1d before fever, cervical LA, arthralgia
- complic- coronary a aneurysm, arrhythmia, MI
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Kawasaki dz: tx
IVIg, ASA
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Croup: cause, presentation, tx
- Parainfluenza virus
- 1-2 yo in fall/winter
- viral URI --> "barking" cough, stridor
- "steeple sign" on radiograph
- tx- supportive, racemic epinephrine
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Epiglottitis: cause, presentation, tx
- Hib >> S.aureus, S.pyogenes, S.pneumo
- 2-5 yo
- little/no prodrome c rapid progression to high fever, toxic appearance, drooling, resp distress c no cough
- "thumb sign" on lateral radiograph
- tx- estblish airway, oxacillin/cefazolin/clinda/vanc + cefotaxime/ceftriaxone
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Bronchiolitis: cause, presentation, tx
- RSV
- 0-18mo, fall/winter
- viral URI then respiratory distress
- tx- supportive, consider ribavirin if severe
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Congenital syphilis: presentation, tx
- early- skin rash + lesions, HSM, "snuffles," jaundice, anemia, metaphyseal dystrophy, periostitis
- late signs (> 2yo)- Hutchinson's triad (peg shapped teeth, interstitial keratitis, deafness. saddle nose, saber shins, CNS involvement
- tx- PCN G IV
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Congential Toxoplasmosis: presentation
- consumption of raw meat, contact cat feces
- hydrocephalus, intracranial calcifications, chorioretinitis, ring-enhancing lesions on CT
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Congenital Rubella: presentation
- "blueberry muffin" rash
- PDA
- cataract
- MR
- hearing loss
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Congenital CMV
- the most common congenital infx
- petechial rash (blueberry muffin like)
- periventricular calcification
- IUGR, microcephaly
- HSM
- chorioretinitis
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