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Physical examination show a febrile young man with temperature of 101 degrees F, not sick looking, no neck rigidity, no rash, bilateral soft cervical lymphadenopathy about 1 cm. diameter in the submandibular region, mildly tender. Throat was congested but no tonsil enlargement or pus or exudate on the tonsils. No arthritis. Tympanic membranes n ormal. Chest clear on auscultation. You would proceed to (Please indicate T or F for each for the following.) a) Take a throat swab for C&S b) Take a throat swab for influenza virus study c) Take blood for CBC d) Take blood for Mono spot test e) Start him on Penicillin V 500 mg. qid for 3 days f) Start him on Erythromycin 250 mg qid for 3 days g) Put him on symptomatic treatment with Paracetamol and Dequadin lozenges Acute upper respiratory tract infection (URTI) is an everyday problem in most GP practice. Common cold is the traditional term used by both clinician and laypersons for minor URT I. This term describe a syndrome caused by a number of infectious agents sharing in common fever, sore throat, nasal symptoms, cough, malaise and headache as their disease manifestations. Viruses s uch as rhinovirus, influenza virus, parainfluenza virus, respiratory syncytial virus an d adenovirus cause most common cold and related URTIs. A minority of URTIs is caused by Streptococcus py ogenes and Mycoplasma pneumoniae. Some respiratory viral infections have seasonal patterns. In Hong Kong, influenza A activity generally has its peaks in Spring (Jan to Mar) and Summer ( July -Sept). When influenza A is active, this virus will cause more than 50% of URTI illness. Infl uenza A infection is characterized by abrupt onset of high fever, headache, generalized muscle ache a nd unproductive cough. Confirmation of the diagnosis requires viral culture and serological stud ies which are not generally required in the GP setting except for surveillance purpose. During the flu season, a presumptive diagnosis can be made in persons presenting with typical symptoms. M ost viral URTI will resolve within a week. Unproductive cough or nasal symptoms may persist for longer, particularly in patients with allergic rhinitis and asthma. Treatment of URTI and influenza A is mainly symptomatic. Recently, a new class of agents (neuramidase inhibitor) has been sh own reduce the duration of influenza-related illness by 1 to 2 days. There is no evidence that antibiotic use can shorten the duration of URTI or prevent bacterial complications. It is likely that this patient has an acute viral URTI. Blood tests and viral cu lture are not indicated. Treatment is mainly supportive. Antibiotics should not be given for presumed URT I. Clinical findings

cannot reliably differentiate streptococcal from viral pharyngitis. Laboratory t esting involves cost and this is often quoted as the reason for blanket treatment. One must understand that indiscriminate use of antibiotics select for resistant bacteria, which might cause harm to the patient. The management of resistant bacteria is hugely expensive for the society. A penicill in for 10 days remain the treatment of choice for streptococcal pharyngitis (recommended by WHO, Ameri can Academy of Pediatrics and CDC). Patient compliance can be problematic with such prolonged t reatment. On balance, it is generally agreed that antimicrobial therapy should not be given t o a person with pharyngitis in the absence of diagnosed group A streptococcal infection (either by culture or rapid antigen detection test). 2) A mother brought along her 5 year old son and told you that he had diarrhoea for 10 times over the past 2 days period. The stool was watery with no mucus or blood. He cried an d seemed to be in pain because of colic. He was febrile with a temperature of 100.5 degrees F. He was not eating well and the mother said that he vomited up food after feeding. Examinati on showed no pharyngitis and normal tympanic membrane, no neck rigidity and soft abdomen with mild tenderness on deep palpation over paraumbilical region. Bowel sounds were active . No evidence of dehydration. Urinalysis by dipstick showed no leucocytes or red cell s. You would (Please indicate T a) Start him on Flagyl b) Start him on Tetracycline c) Give him Lomotil or Imodium or F for each for the following.)

d) Give him Buscopan, Kaopectate, rehydration solution, e) Give him Smecta (Dioctahedral smectite) f) Give him Lacteal Fort (Lactobacillus acidophilus) g) Check stool for C&S h) Check stool for Rotavirus i) Admit him for treatment of severe diarrhoea This child has acute gastroenteritis (GE). In children, it is important to exclu de acute appendicitis, urinary tract infection and acute otitis media that might sometimes present as a GE-like illness. Common causes of acute GE include food poisoning and infections by rotavirus, ca licivirus, small round structured virus, salmonella, vibrios and campylobacter. Rotavirus GE occu rs primarily in infants and young children (highest in 6 to 24 month-old age group). Irrespectiv e of the cause, management consists mainly of rehydration and replacement of electrolytes. Most patients with only mild to moderate dehydration can be treated on an outpatient basis with ORS (Ora l rehydration saline). Admission for frequent stools in the absence of dehydration is generally not nec essary. Anti-motility/diarrhoeal agents (Lomotil, Imodium, Smecta) should be avoided as they might aggravate some bacterial GE and prolong the duration of illness. Antispasmodic agent and k aopectate can be used cautiously in person with severe symptoms. Antibiotics are not required for treatment of most GE. Most bacterial GE such as non-typhoidal salmonella, vibrios, campylobacter w ill resolve on its own. There is no evidence antibiotics will shorten the duration of diarrhoea in these bacterial GE. Tetracyline is contraindicated in children because of potential toxicity on bone and teeth. Metronidazole is useful for pseudomembranous colitis but is unlikely without pre vious use of antibiotics. There is no convincing evidence that the probiotics (such as lactobacilli) are o f therapeutic value in GE. Use of these agents should be considered experimental at this stage. Stool cultu re need not be performed routinely as the result do not generally modify the management. It is indicated in those with bloody and severe diarrhoea. When shigellosis and typhoid fever are suspect ed on historical or epidemiological ground, laboratory testing is also indicated. When there is an o utbreak of GE, confirmation of the causative agent can be important. 3) An elderly lady 80 years old was brought to you in an wheelchair. She had a s troke resulting in dense hemiplegia and urinary retention and incontinence. The latter was treated with bladder

catheterization. She was managed at home with Community Nurse visiting her at we ekly intervals. The nurse noticed cloudying of urine and sent for a urine culture spe cimen. The report confirmed the presence of E.coli sensitive to Ofloxacin, Gentamycin, Zinn at, Fortum but resistant to Ampicillin and Erythromycin and Keflex. On examination, you confirm ed the dense hemiplegia, no bed sores, good oral hygiene, clear lungs, and no abdominal mass or tenderness. She was afebrile, not sick looking, and the Foley catheter was in situ with slig htly cloudy urine in the bag. Basing on the physical examination and the urine culture report, you wo uld: (Please indicate T or F for each for the following.)

a) Start her on Ofloxacin 400 mg. bid for 5 days b) Give her one dose of Gentamycin 120 mg. imi stat c) Start her on Zinnat 500 mg. bid for 3 days d) Change her Foley catheter and put in a siliconized catheter e) Encourage fluid intake but do none of the above Bacteriuria is universal in patients on long-term urine catheter. Antibiotic tre atment of asymptomatic bacteriuria is not indicated. Treatment will not eradicate the bacteria as long as the underlying condition is there. The outcome in terms of renal function, symptomatic urinary tract infection (UTI) and survival are not improved by prophylactic antibiotic treatment. As such, there is no need to perform urine culture in the absence of symptoms of UTI such as fever, decrease general condition and loin pain. Cloudy urine is not pathognomic of infection. Cloudiness is somet imes a result of crystallization. In the chronically catheterized person, asymptomatic bacteriuri a cannot be prevented. The result is the same with frequent changing of catheter or the use of silicone catheter. In fact, the catheter can be left in-situ as long as it remains patent and functional. On the other hand, symptomatic UTI in the catheterized elderly is associated with significant morbi dity such as bacteremia and pyelonephritis. Management consists of a 7 to 10 day course of antibiotic to which the organism is sensitive in vitro. Opinion is divided but many would recommend a change of t he catheter before

the completion of antibiotic treatment. 4. A 60 years old diabetic patient came to you for fever, shortness of breath, coug h productive of purulent sputum. He has been treated in another clinic with Zinnat 500mg. bid fo r 5 days without response. Physical examination showed a sick looking man with a temperature of 1 02 degrees F. Throat was normal. Tympanic membrane was normal. No neck rigidity, no cervica l lymph nodes. Respiratory rate 20/minute. BP 120/80, pulse 105/minute, heart sounds nor mal. No rash. Abdomen normal. Chest auscultation showed crackles over right middle zone. Blood sugar was 12 mmol/L. An XR Chest taken 1 day ago showed RMZ pneumonia. You would: (Please indicate T or F for each for the following.) a) Treat him with Klacid 500 mg. bid b) Take blood culture, sputum culture, cold antibody titer, CBC ESR c) Admit him to hospital for treatment d) Start him on Rocephin 1 gm. imi stat and ask him to return daily for imi treatme nt of Rocephin e) Sent for CT Chest f) Ask your respiratory physician to do a bronchogram for him This patient has acute community-acquired pneumonia. (CAP) The decision to admit is based on an assessment of the age, co-morbidity, severity of illness and social support. Str eptococcus pneumonia is the most common cause (50-60%) of CAP and it carries significant mo rbidity and mortality in the elderly patient. Other important but less frequent causes are H aemophilus influenzae, Staphylococcus aureus (5-10% for both), and enterobacteriaceae (<5%). During inf luenza season, influenza A should be excluded by appropriate testing. Penicillin nonsusceptible S. pneumoniae (PNSSP) are highly prevalent (>50%) in Hong Kong. For infection outside the cent ral nervous system, the penicillins (e.g. amoxil, Augmentin, Unasyn) are still the treatment of choice although a higher dose may be required. The inhibitor combinations (Augmentin, Unasyn) has the added advantage of providing coverage for S. aureus, H. influenzae and many enterobact eriaceae. While

second generation cephalosporins (e.g. Zinnat) are useful for the latter three o rganisms, high level resistance is common among local strains of PNSSP. In this regard, the penicilli ns are to be preferred as empirical treatment of most with mild to moderate CAP. The third-ge neration cephalosporins (e.g. Rocephin) are active against most PNSSP. Widespread usage o f third generation cephalosporins might select greater resistance amon the pneumococci, they should be reserved for patients with severe CAP. Almost all local PNSSP strains (>90%) are resistant to the macrolides (erythromycin, Klacid, Rulid and Zithromax). Monotherapy with a macro lide for CAP is therefore not appropriate. In the diabetic patient, one should be vigilant about the possibility of tuberculosis, which might also present as acute pneumonia (10% in one local stud y 10 years ago). Bronchogram is seldom performed nowadays because of the risks and availability o f alternatives such as CT scan. In the acute management of most patients with CAP, both CT scan thor ax and bronchogram has little role. If lung abscess or carcinoma is suspected on the ba sis of findings from history or chest X-ray, CT scan thorax is indicated. Routine CT scan for patient s with CAP is not cost-effective.