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Infectious Disease 1. Case 1 fever, cough, chest pain a. Pleuritic chest pain: PE, pneumonia, pericarditis b.

. Petechia, murmur, fever, injection drug user (poisons tricuspid valve) or prosthetic valves c. Dx for endocarditis blood cx but start abx (vanco and gentamicin), cxr (multiple nodular lesions visible bilaterally emboli from tricuspid valve shooting into lungs) i. Further dx: echo vegetation on tricuspid valve d. Endocarditis: positive blood cx, echo, roth spots, janeway lesions, osler nodes, splinter hemorrhages, fever e. Tx: IV nafacillin or oxacillin for 4-6wks, gentamicin for 1 wk initially i. Sx if acute decompensation occurs, myocardial abscess, repeated emboli, very large vegetations or fungal endocarditis, valve rupture CHF ii. If Strep bovis found, colonoscopy f. Prophylaxis: prosthetic valve, cyanotic unrepaired heart lesions, previous h/o endocarditis and dental procedure with blood Case 2 pain and swelling of the left leg a. Fever, red, warm, swelling cellulitis (strep causing cellulitis can cause nephritis, but not rheumatic fever heart) b. Tx: oxacillin/nafcillin or 1sts gen cephalosporin. If MRSA, use vanco, linezolid, daptomycin, tigercyclin (only drug that covers MRSA and GNR) Case 3 fever, chills (bacteremia), RUQ pain a. CBC, BMP, LFTs (alk phos and GGTP go up with obstructive jaundice) - cholangitis b. US shows dilated duct c. Tx: admit, IVF and IV abx. ERCP (detects stones, strictors, tumors or obstruction diagnostic and therapeutic) when stable d. Not cholecystitis RUQ, pain, anorexia, vomiting rarely jaundiced i. US shows gallstones; HIDA scan to assess biliary function ii. Tx with IV abx and laparoscopic removal Case 4 fever, HA, and neck stiffness for 2 days a. Meningitis vs encephalitis (confusion) b. CT before LP if focal neuro symptoms, papilledema, seizures, confusion c. DDX meningitis d. Empiric tx: ceftriaxone, vanco, steroid, add ampicillin (HIV, neonates, elderly, steroid use listeria) e. Rash, asplenic, teen neisseria meningitis isolate, rifampin or cipro to close contacts

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If lymphocytes 10-100 with CD4 < 100 HIV, think Cryptococcus. Test with India ink and cryptococcal antigen (best test). Initial tx with amphotericin then livelong fluconazole g. Lung lesions, immigrant, TB meningitis 4 drugs + steroids h. Tx for bacterial meningitis: empiric IV ceftriaxone and vanco. If sensitive, change to PCN or ampicillin. IV dexamethasone. Repeat LP in 3-4 days. Exam otitis, mastoiditis or sinusitis i. MC complication of untreated meningitis CN 8 deficit hearing loss Case 5 my belly is swollen and it hurts a. Ascites, fever, pain/tender, edema alcoholic cirrhosis b. CBC, PT, albumin, AST/ALT, abd XR, CXR c. SBP: paracentesis Tap > 250 PMN. Tx cefotaxime (renal excretion) d. SAAG > 1.1 means portal HTN Case 6 abd pain a. 65M, ulcer disease, tachycardic, hypotensive and confused. Abd rigid with guarding Peritonitis b. Give IV NS bolus c. CBC, abd XR upright (air fluid levels under diaphragm), ABG acidosis, serum bicarb low, meta acidosis, serum K - hyperkalemic, BUN/Cr d. CHF decreased CO, increased wedge pressure and SVR e. Tx: IVF until SBP > 90 dopamine, phenylephrine is needed. Abx for GNR and S. pneumo. Surgical exploration Case 7 decreased hearing and pain in my ear a. Displaced pinna. Fluctuant mass. Red, bulging TM OM becoming mastoiditis b. Dx: biopsy tympanocentesis (best), XR, CT c. Tx: abx dependent on biopsy results Case 8 cant remember things a. Young man, periods of disorientation, rapid progressive dementia, myoclonic jerks CJD i. NPH memory, incontinence, ataxia b. Dx: CT/MRI, B12, biopsy (spongiform disease), VDRL/FTA, TFT, EEG, LP CSF (14-3-3 protein) c. Tx: No therapy Case 9 Im here to see what meds I need a. She has AIDS with CD4 47, viral load 180k. PPD > 5mm INH for 9 months, TMP/SMX if < 200 PCP, < 50 MAC prophylaxis azithromycin, HAART if < 350 2NRTI, 1 PI or I efivarenz b. Med SEs i. Pancreatitis, peripheral neuropathy stavudine, didanosine ii. Stones indinavir iii. Efivirenz is teratogenic c. Needlestick prophylaxis 2NRTI and 1 PI for 4wks

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Dx: RPR/VDRL, toxoplasmosis antibody, hepatic panel, CBC, BMP, pap smear, CXR i. Viral load changes most quickly after therapy Case 10 cant eat, urine is dark, and stomach ache for 7 days a. 39M upper abdominal discomfort, light stools, weight loss, jaundice b. DDX: acute viral hepatitis (incr ALT and bilirubin), drug induced hepatitis (incr AST) c. Dx: hepatitis panel d. Tx: chronic HBV interferon, lamivudir; HCV interferon and ribuvirin Case 11 pain in my leg for the last several weeks a. 54M h/o DM and PVD, ulcer in L leg below the knee b. Ulcer just on skin or spread to bone? c. Ulcer is red, warm and tender with purulent drainage d. Dx: XR of leg, bone scan (95% sens, 30% spec) dont need if XR is positive. XR look for periosteum elevation i. If XR is neg, MRI (more specific) and biopsy to id pathogen ii. ESR follow for response to therapy e. Tx: if staph IV ox/clox/diclox/naf. If MRSA, vanco, linozelid, daptomycin or tigecillin 6-12wks i. Enterobactericiae, pseudomonas, ecoli and other GNRs fluoroquinolones (PO) b/c it concentrates in the bone Case 12 fever, cough, body aches and sputum a. Chills sign of bacteremia MCC pneumococcus b. Admit if incr RR and P, hypotension, confusion c. DDX: pneumococcal pneumonia MCC, legionella pneumonia GI and CNS symptoms, mycoplasma young people d. Dx: CXR, sputum gram stain, sputum culture, CBC, pulseOx i. Gram positive, lancet shaped diplococci in pairs and chains ii. Decubitus XR for pleural effusion e. Tx: azithromycin and ceftriaxone i. Inpt: drain effusion ii. Outpt: macrolides or fluoroquinolones if lung disease Case 13 fever and increasing HA for 1 wk a. 38M w/ AIDS, HA b. Tenofovir, emtricitabine, efavirenz QD drugs c. Dx: LP, serum CSF cryptococcal antigen, CT head (ring-enhancing lesion) d. Tx: IV amphoterin followed by oral fluconazole for life unless CD4 rises Case 14 itchy, red feet for several wks a. 15M, b/l erythematous, dry, itchy b. Scabes burrows under skin, not visible

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Fungus visible on skin, near hair Dx: KOH melts away skin cells not fungus; culture is most specific but not necessary e. Tx: permethrin. i. Fungal infections: topical antifungals for 2-4wks (clotrimazole). Local foot care keep clean and dry ii. Nail infections 6wks of terbinafine Case 15 burning sensation in my penis when I urinate a. 28M, penile sputum b. Dx: urethral swab for gram stain and culture, HIV and VDRL c. TX: empiric therapy ceftriaxone (GC) and azithromycin (Chl) i. Treat partner Case 16 Ive got some blisters on my penis a. 37M, painful penile vesicles b. Dx: Tzank stain, viral culture (most accurate but not necessary) c. Tx: acyclovir, valacyclovir, famcyclovir IV i. Foscarnet alternative, renal side effects Case 17 I have a pain in my ear a. 27M swimmer b. Malignant otitis externa in DM pt d/t pseudomonas cranial osteomyelitis i. Otitis externa cellulitis of ear commonly seen in swimmers c. Right TM and canal normal d. Dx: culture e. Tx: topical polymyxin + neomycin i. Prevention: 2% acetic acid drops or 1/3 alcohol + 2/3 vinegar drops to keep ear canal acidotic ii. Hydrocortisone drops if severe Case 18 diarrhea for past 2 days a. Is there blood? Yes = then cant be staph or b. cereus they also present with vomiting b. Campylobacter is MCC c. E. coli O157:H7 dont give abx or platelets; associated with HUS d. Vibro parahemolyticus = shellfish e. Vibrio vulnificus = liver/skin f. Gives symptoms 10min later, N/V/D = scombroid histamine fish poisoning g. Dx: stool exam for blood and leukocytes, stool culture (most accurate) h. Tx: hypotension, abd pain, fever, tachycardia give ciprofloxacin i. Salmonella: bacteremia, biliary system involvement, osteomyelitis, meningitis, and arteritis ampicillin may predispose to biliary colonization and chronic carrier state j. Shigella: HUS or Reiter syndrome

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