Awesome Review 2018 Internal Medicine ABIM Board Review

592 Pages·2018·148.7 MB·English

by  Awesome Review

Endocarditis
Meningitis
Urinary tract infections
Fungal Infections
STDs(Includes PID)
Tick Borne Diseases
Infectious Rashes
Osteomyelitis
Skin and Soft Tissue Infections
Animal Bites
Diarrhea
Travel Medicine
PPD
Bioterrorism
HIV
Antibiotics
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Endocarditis
Prosthetic valve
-7 Vanco + Rifampin +Gentamycin
2days later
r I
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MSSA MRSA Pen sen. Strep Pen res. Strep
Ceft./Naf + Cont. Vanco + Ceft./Naf Ceft. +
~ Rifampin + Rifampin + Gentamycin
Gentamycin Gentamycin
Native valve OR IVDU
-7 Vancomycin +Gentamycin
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MSSA MRSA Pen ~n. Strep Pen res. Strep
Ceft./Naf Cont. Vanco Ceft~/Naf + Ceft.+
dlc Vanco + dlc Gent. dlc Vanco + Gent
dlc Gent dlc Gent dlc Vanco
Indications for Surgery
• Severe CHF
• Persistent bacteremia -----+ repeat BCpos. in 48 hrs-7 cont. Abx
• Recurrent emboli , repea~C pos. in~ Surgery
• Valve abscess - ('';;'-'\-c\:c., 'O\oc\<.- ") 6.:.- IFG +0 ~ o're~
• Largefungal vegetation
Daptomycin can be used in rt. sided endocarditis with septic emboli.
r--r-; (Cubicln") \.{) (\d\ fer If''rICl..-
Q1. Pt.with symp. of Endocarditis. Blood cultures done and Vancomycin and Gentamicin are
started. 72 hrs. later, Blood culture results are positive for Pcnsens. Strep. Abx changed to
Penicillin & Gentamycin was discontinued. Repeat Blood cultures are done and 24 hrs. later
the blood cultures are again positive for Strep. w.t.d
A. Add Gentamycin & call Cardiothoracic consult
Continue antibiotics and repeat Blood cultures in 48 hrs.
C. Restart Vancomycin
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Q2. Pt.with history of injecting drugs, recently presents with fever, cough with
hemoptysis and pleuritic chest pain.
OlE: II/VI grade systolic murmur at the left sternal border, best heard on inspiration.
CXR:2-3 nodular densities.
~-t, ~;0-.-eJ.. e--~o.~h~
DX:-7
~~+o. Yy\\e,l
Empric TX:-7 Vc:;;r("\C -r 1'\
Q3. Pt. presents with fever. B.C(+) for Clostridium septicurn/Strep Bovis (gallolyticus). w.t.d
b »[o rrn\~Ur"\~r
-7 CO\(flC)~'I
04. IVDU issuspected of endocarditis and empiric Vanco +Gentamicin isstarted.
Cultures are positive for PCNsensitive enterococci. Vanco. isstopped and PCNis
started and afew hours later, Pt. with generalized pruritus, itching of eyes and
swelling of lips. w.t.d
-7 D/C PCNand restart Vancomycin.
QS.Pt. on Vancomycin develops itching and redness on the back of the neck.
4J ~i~\~-~~o.-\cd
Dx: Redman's syndrome
Q6. Pt. sip TURP(transurethral prostatectomy) 2weeks later with fever and growing
enterococci. The LEASTlikely treatment you would choose is
A. Ampicillin +Gentamicin
B. Vancomycin +Gentamicin J,
C. Piperacillin-tazobactam (Zosvn"] ~~-uf.
o.y
D. Linezolid {Zyvox®)~works for both VREfaecium and VREfaecalis. Also for MRSA,VISA~
Side Effects: Thrombocytopenia & Neutropenia, Serotonin syndrome,
Lactic Acidosis, Optic Neuritis l' OTIt
@
Ceftriaxone lp 6 wee.k.s1"
F. Quinupristin/dalfopristin (Svnercid")
G. Daptomycin
EnterococcallE mainly seen in elderly men, involves Aortic valve> mitral valve.
More CHFthan embolic events, lower mortality.
Aortic valve endocarditis most commonly associated with conduction defects.
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Q7. Youwould replace the valve in all the following with endocarditis EXCEPT:
A. Pt. with severe CHFnot responsive to medical treatment.
ECHOreveals severe Aortic regurgitation
B.Pt.with endocarditis isfebrile in the first week on appropriate
antibiotic treatment. Inthe second week develops aheart block.
Atrans-esophageal ECHOisdone and shows valvular abscess.
Afebrile currently on antibiotics.
@Pt. with endocarditis febrile on i.vantibiotics. Repeat blood cultures 48~s.
later positive. Mild aortic regurg. with EF60%. BUN/Creat 25/2.0 0-- .l..Y''''" ~p\e,."'y
Q8. Pt. being treatea for endocarditis defervesces and WBC decrease.
EKGshows a 10heart block. Isthis acause for concern?
(i)Yes
B. No.
W.t.d next?
A. Observe
@
Transesophageal ECHO
Endocarditis
First know High risk conditions, then know High risk procedures
Endocarditis antibiotic prophylaxis required ONLYfor high risk procedures in high risk
conditions.
High risk conditions
• All prosthetic valves
• Previous history of endocarditis
• Congenital heart disease; Unrepaired cyanotic CHD,including shunts
• Repaired Congenital heart disease within 6 mths. of repair
• Posttransplant Heart with valvular disorders
• Repaired congenital heart disease with prosthesis or a patch in place or residual defect.
High risk procedures (likely to cause bleeding and induce bacteremia)
• Dental: Extraction, periodontal procedures, root canal, dental implants
Not High risk anymore: --hl\;~ ~t ~t
• GIor GU procedures (only if there isa risk of mucosal damage)
lOW risk conditions
• ASDsecundum type - !V\VP
• 6 months after repair of ASD,VSD,PDA
• previous CABG/HOCM
• Pacemaker
• MVP with murmur ORredundant leaflets, MS,AS,HOCM, Bicuspid valve
• Functional murmurs
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low riskprocedures (unlikely to cause bleeding and induce bacteremia)
• Dental: Filling cavities
• Respiratory: Endotrach. intubation, flexible bronchoscopy with or without biopsy
• GI:All GI& GU procedures are now considered low risk.
• GU: Vaginal hysterectomy, C-section, D&C,therapeutic abortion, IUD insertion or
removal.
• Others: Cardiac catheterization, Circumcision.
Antibiotic prophylaxis for Endocarditis
Procedure Antibiotic of choice NOPO PCNallergy post procedure
Azithromycin Nothing
Dental Amoxicillin 2g Ampicillin i.v
(Zithromax®)
po 1hr prior
Or
Clindamycin
Q9. Pt. with PDAgoing for cystoscopy. Need prophylaxis for endocarditis?
---------'
Ql0. Pt. with bacteremia with Staph aureus, Vanco i.vstarted. w.t.d
, if negative.
week5
B.Cnegative < 72 hrs on Abx w.t.d ~ Cont. i.vAbx for )....
Y wed.;
B.Cpositive> 72 hrs on Abx w.t.d ~ Cont i.vAbx for
B.Cpositive in immune compromised ~ Cont. ivAbx for l( (.AJeek <;;.
B.Cpositive in Pt.with prosthetic valve ORCardiac device ORArthroplasty ~ Cont. i.vAbx for
IfTEEpositive
~ Tx:with antibiotics for G - '2s' ("JW,5
Ql1. Pt.with suspected diverticulitis presents with fever and chills and abdominal
pain. 3 days later Temp is10lF. Tunnel catheter exit site appears clean.
WBC is 17,000. What meds. will you start?
A. Clindamycin & Metronidazole (Flagvl")
@vancomycin & Meropenem
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15' )l:Jfr-B/t.'jf
Q12. The above Pt. weighs 240 Ibs. What dose of Vanco. would you start?
A. 1gi.v q12h
®
1.5 gl.vq12h
lQ13.35 yr. old with IVDAadmitted with fever and chills and has amurmur, found to
have vegetation on the ~e, blood ex has~
What isthe most appropriate treatment ----
Y'-.
@ Daptomycin - fo\\ow C
B. Cefepime (Maxipime")
C. Nafcillin
D. Ceftriaxone
EmpiricTxof Meningitis
Head Staph. aur. Vanco.+
to cc:ve.r
trauma! Strep. pneumo. Cefepime -----l~~
Neuro Sx Gram neg. bacilli (Maxlplme") P<O~oC'O\$
50 Y +- Listeria Ampicillin +
Strep. pneumo. Ceftriaxone +
Neisseria. mening. Vanco.
15Y Strep. pneumo. Ceftriaxone
Neisseria. mening.
H.influenza
2m Strep. agalactiae Ceftriaxone +
E.coli Ampicillin
Listeria
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CSFfindings in Meningitis
Cell count Type Glucose Protein Other
15-45
Normal <5 Lymph. 40-80
Bacterial 10-100 K PMNs w l' 1'OP
muscle weakness,
WNV 10-1 K Lymph. w l'
rash, wDTRs
TB 10-1 K Lymph. w 1'1'
fV\ C. - ~o.. f-o-
Aseptic 10-2 K Lymph. N Ent~rovfr'uses, OKT3
.J l'iN
(!MN-;, G.f1h:tt v:. \-cf:.+- d~~
N~~tDS,Bactrim
i",\~ •.\•\Y., ~ \j-;)-
Early 10-1 K Lymphs. w CSFto Ser.
l' ~
Bacterial > PMNs Glu <0.4
~
Encephalitis 1-2 K Lymph. N ~ ~O';)Sl'iN
300 -
.J-) W&.
HSV 1-2 K Lymph. N RBCs(+)
l'iN ~l'!.(..
lOOO
Encephalitis
S~/ '.r.C."'C~C~ . > \:lvrI'IS - ffiiR."). ~.\.>ce ~~. l'O.c--cO.) ~~ IGNllAC-O"&';)eh-{/
Q14. A 70 yr.old Pt. with DM presents with mental status changes. Spinal tap ~"L. '1 .:: f~
shows many WBCs, mainl PMNs. Gram stain negative. Cultures are pending. w.t.d ~G.I",
~ Ce.f-+r; ~e..
T- \JCX"\CD
to cover Resistant Strep. Pneumo
Q15. A 55 yr.old, post renal transplant Pt. on steroids presents with fever and neck
stiffness. Spinal tap reveals ~ "~' in the CSF;PMNs 65%
and Lymphs. 35%. Most likely diagnosis is
A. Strep Pneumo.
B. Nocardia
(S)isteria monocytogenes
BestTx:
<;e-r<A-r"",,,.:
A. Ceftriaxone +Vanco.
B. Vanco. +Ampicillin
$"oy"'"'
@)Ampicillin +Gentamicin --.L-
1000 t--c ~
CSF ~
+---t-ct,V('f\a
-
?-O 1
f-(SU ~h.
~
~
~
~
~
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Q16. 24 yr. old male presents with neck pain and headache. Neck signs positive. Spinal tap
reveals WBC 105, 100% lymphs, No RBCs,Glucose 50. Most likely cause?
®A. Herpes encephalitis
Entero/Echo virus meningitis
.s'""-Pporhve ~e..
Tx:~
• Also remember NSAIDs,Bactrim, OKT3Abs ascauses of aseptic meningitis.
where initially there will be neutrophilic pleocytosis in CSF.
Q17. A 70 yr. old man with history of capo and pneumonia twice in the past year
presents with cough, fever, chills and mental status changes.
WBC 17 K,70% PMNs
CXR Left lower lobe consolidation
CTscan head No bleed
Spinal tap WBCs> 2000, mainly PMNs.
Glucose -J;, Protein 1',Gram stain shows~. ~+re.p.~.
Blood and CSFcultures pending. Youwould start
Ceftriaxone +Vancomycin +QMS .L Yl"'d""t-\ity
B. Ampicillin +Ceftriaxone
C. Imipenem
D. Ceftriaxone
Rifampin for pcn resistance t
Q18. A Pt. presents with meningitis. Lumbar puncture shows WBC 75 with ~Protein
elevated, opening pressure 290, ~ Gram stain neg. Youwill treat this Pt.for
=
LO"'eu.c-~-.e \A"\\~~)'
7
A. Cryptococcal meningitis th" '" b,.d G;..};.1i
@Bacterial meningitis L.p 'f'ClC~ ()~ ~~~ 0:"'\ ~p).. &rn-ecc
..r '\. V
= frvu~ '~IL ,~.
Q19. 16yr.old with mental status change, high fever. BP80/60. Exam reveals a~
~n. Labreveals Leukocytosis. L.(> ':;@~y
Hx.of a Motor vehicle accident 2 yrs. ago with splenectomy. Most likely organism is
A. trep. pneumonia
B. Listeria monocytogenes
C. Staph.
D. Strep. pyogenes.
Q20. Pt.with meningitis by history and physical. What to do next? 1-" ,;rr,o,.\ \ 'r100Gf ',l-'-
r=>;
A. CTbrain
®
l.vAntibiotics»
C. Lumbar puncture
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021. A Pt. presents with headache of 2days duration. Hefelt dizzy and now ~
Exam reveals meningeal signs (+). This ishis 7th episode in the past 6years.
CSFreveals granular cells (monocytes). What isthe most likely di~agn-osis?
..-----------------~
,'-\-\$
~ f't\o\\O('e:\\.s
r'0e(\~
J.. )
(Benign and recurrent lymphocytic meningitis caused r'6V
Tx:~ Supportive, Antivirals have not shown to benefit
022. Pt. presents with fever, headache, vomiting, and episode of seizure.
Hehad been confused in the past week and complains of smelling 'burning rubber',
'fishy odor', and auditory hallucinations.
MRI brain-s hy erintensity increased signal) from the temporal lobes.
HG~ sharp an slow waves from temporal lobes
Spinal tap~ WBCs 200 mainly lymph's, glucose 45 and protein 75mg/dl, RBCs65 (+)
OX:~ Herpes Encephalitis
Confirm by:~ PCRassayof CSF
023. A 70 yr.old Pt. isbrought with headaches, fever for the past 5days. Slightly
confused, complains of ocular pain and diplopia. Hishiking partner had similar
symptoms which resolved. Mild neck signs (+) ORfocal weakness of one side of the
body with ~ Spinal tap reveals: WBC 55, 100% Lymphs, Protein 90mg/dl, Glucose
50mg/dl. w.t.d next
A. WNV PCR
©B. HSVPCR d week', C\\I")'CD!. \', \.l~.,.~t"'_-..-.u'>A +
WNV IgM antibodies
Most important prognostic factor?
A. Creatinine - +,->r..SJ:' t-r'IOt-e..- ~•••••p••or+orf
(i;)Age >75 yrs.
C. OM
024. Pt. presents with fever and headaches of 2days duration.
Exam reveals neck stiffness.
WB~ is8,800 with 68% PMNs,~
Spinal tap reveals WBC 85 with 54% PMNs, 33% lymphocytes. RBCsO.
Glucose is26 and serum Glucose is86, Protein is68mg/dl.
What isthe most likely diagnosis?
A. Viral meningitis
@Early bacterial meningitis
C. HSVEncephalitis
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Q25. A 20 yr. old woman isbrought from college with atonic clonic ~
Friends sayslast week she was complaining of headaches and acting weird with
~
anxiety and paranoid behavior. Shehas no psychiatric or drug abuse history.
Exam reveals orthostatic hypotension, ~movements and she has
difficulty choosing right words.
CSF:40 WBCs,96% lymphs, 3 RBCs,Glucose 62mg, Total protein 30mg/dl
CThead normal.
Pt.was treated for HSVencephalitis without improvement and HSVPCRnegative.
Most likely diagnosis?
A. West nile virus encephalitis
@
NMDA receptor encephalitis
Q26. 20 yr. old man with head ache and fever, soon after becomes menta~ >e _
He had gone s~ pond and a river ORhad used~t afew 0 ~ s"""'s~
Claysago. Spinal tap revealed Glu 20, WBC 120, Protein 110. He has not responded to -th ~ -k:,
?-
Ceftriaxone, Vancomycin and acyclovir for more than 24 hrs. w.t.d? 4-~,'<.Jr~\n - ~.• o....~
dcx-'+- ~.,. ~Ii
-7C'?~ ue+ mount for trophozoites, which were positive. W.t.d?
from CDC
Q27. Pt. isbrought with headache, confusion, and diffuse petechial maculopapular
rash. CTscan isnegative and spinal tap reveals WBCs > 2000, mainly PMNs and low
glucose. Gram stain shows gram negative diplococci.
Pt. isdiagnosed with meningococcal meningitis, treated with Ceftriaxone and 3 days
later he goes into hypotensive shock.
w.t.d
Ifthe Pt.works in day care. w.t.d
-7 Prophylax day care/nursery school contacts.
-7 Prophylax house hold contacts. r 1--0iu.b~te~
• Prophylax with ~600mg po bid for 2days. Ifcontraindicated then ~one dose.
• If on OCP,change contraception method while using Rifampin .
If pregnant -7 ~250 mg 1Mx 1dose
• -e,
~>
Droplet precaution. or ~
~
Q28. Pt. isbeing treated for meningococcal meningitis since yesterday morning.
How long will you continue isolation?
@d/c isolation now j.,V\ ~ cr» A-n-hbo,,",cs
B. d/c isolation tomorrow
C. d/c isolation when antibiotics are stopped
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