By B. Wilson. William Paterson University. 2018.

She denies having nausea and vom- iting cheap 480 mg bactrim free shipping antibiotic prophylaxis for joint replacement, and she has been taking liberal amounts of fluid bactrim 480 mg line bacteria mitochondria. Initial urinalysis showed 10 to 25 red cells and more than 50 white cells per high-power field, and Gram stain of a spun urine sample demonstrated short, plump gram-negative rods. The emergency department physician has administered initial intra- venous fluids and antibiotics for presumed acute pyelonephritis caused by E. After an initial period of observation in the emergency department, which of the following is the most appropriate course of action? Admit the patient to the hospital and treat with intravenous ampicillin B. Admit the patient to the hospital and treat with intravenous piperacillin-tazobactam C. Discharge the patient after giving her a prescription for oral cipro- floxacin and scheduling a follow-up visit in clinic within 2 days D. Discharge the patient after giving her a prescription for oral trime- thoprim-sulfamethoxazole and scheduling a follow-up visit in clinic within 2 days E. Discharge the patient after giving her a prescription for oral trimethoprim-sulfamethoxazole and scheduling a follow-up visit in clinic in 3 weeks Key Concept/Objective: To understand the treatment of acute uncomplicated pyelonephritis caused by E. This patient has acute uncomplicated pyelonephritis that is likely caused by E. Given the fact that she is not severely ill, is able to take oral fluids well, and has adequate follow-up, outpatient management after stabilization in the emergency department is appropriate. Patients who appear toxic, who have significant nausea and vomiting, who have significant comorbidity (e. Follow-up in 48 to 72 hours is appropriate for outpatients to ensure improvement or resolution of symptoms and to review culture data. An impor- tant consideration in the selection of appropriate antibiotics for UTI is the emergence of antimicrobial resistance. Recent studies have demonstrated a significant increase in resistance to ampicillin, first-generation cephalosporins, and trimethoprim-sul- famethoxazole in strains of E. Thus, these agents are not recommended for use as monotherapy for acute pyelonephritis. In contrast, resistance to fluoroquinolones in strains causing UTI has been much less frequent, making these agents a reasonable choice. A 60-year-old man with a history of type 2 diabetes mellitus and rheumatoid arthritis is admitted for knee arthroplasty. Four days postoperatively, you are consulted because he has developed fever and cough productive of blood-tinged sputum. Chest radiography reveals a left lower lobe infiltrate. Which of the following is the most important pathogen to consider when choosing appropriate empirical antimicrobial therapy for this patient? Staphylococcus epidermidis Key Concept/Objective: To understand that Klebsiella and other enteric gram-negative rods are among the leading causes of nosocomial infections, including pneumonia This patient has developed hospital-acquired pneumonia. Although Klebsiella species only occasionally cause infection in otherwise healthy persons in the community, they are among the leading causative agents of nosocomial infections, including UTI, pneu- monia, biliary infections, and bacteremia. Nosocomial pneumonias are often polymi- crobial, with enteric gram-negative organisms (including Klebsiella, E. The other organisms most frequently implicat- ed in causing nosocomial pneumonia are Pseudomonas aeruginosa and Staphylococcus aureus. Broad-spectrum agents should be used for empirical antimicrobial therapy in this set- ting. The agents chosen should have potent in vitro activity against enteric gram-nega- tive rods; such agents include third-generation cephalosporins and combinations of β- lactam inhibitors and β-lactamase inhibitors. Nosocomial outbreaks of Klebsiella can be difficult to manage because these organisms may produce extended-spectrum β-lacta- mase and are often resistant to multiple drugs. A patient with a medical history of cirrhosis presents with fever, altered mental status, and bullous lesions on the legs and arms.

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The crite- ria for delirium caused by a general medical condition include the following: distur- bance of consciousness (i order bactrim 480 mg on-line antibiotic cefuroxime. Independent risk factors for delirium in elderly medical patients during hospitalization include the use of psychoactive med- ications generic 960mg bactrim overnight delivery antibiotic resistance scientific journal, severe illness, cognitive impairment (dementia), vision impairment, and a high ratio of BUN to creatinine, implying dehydration. Precipitating factors for deliri- um in hospitalized elderly persons include the use of physical restraints, more than three medications added to the patient’s drug regimen, bladder catheterization, and any iatrogenic event (e. In medically ill patients, delirium is most commonly associated with acute infections, such as pneumonia and urosepsis; hypoxemia; hypotension; and the use of psychoactive medications. Psychoactive med- ications include many antiarrhythmic agents, tricyclic antidepressants, neuroleptics, gastrointestinal medications, and antihistamines. When used in large doses or in com- bination at therapeutic doses, these agents may induce delirium. The patient with delir- ium presents with an acute change in mental status and clinical features of disturbed consciousness, impaired cognition, and a fluctuating course. Perceptual disturbances, such as misperceptions, illusions or frank delusions, and hallucinations, are often accompanied by increased psychomotor activity. Most patients with delirium vacillate between hypoalertness and hyperalertness. A 76-year-old white woman presents to your clinic with a complaint of incontinence. She says that she has had this problem for “years” and has never undergone evaluation for it. Which of the following statements regarding urinary incontinence in the geriatric population is true? The most common predisposing factors are overactive bladder resulting from changes in the bladder smooth muscle; prostatic 8 INTERDISCIPLINARY MEDICINE 19 hypertrophy; bladder wall relaxation or prolapse; medication side effects; and cognitive impairment B. The preferred management strategy includes thorough diagnostic workup before implementation of therapy, because empirical man- agement is largely unsuccessful C. In female patients with stress incontinence, first-line therapy includes medications D. To be considered abnormal, the postvoiding residual volume (PVR) of urine must be greater than 500 ml Key Concept/Objective: To understand the causes, diagnostic workup, and management of uri- nary incontinence in the geriatric population Urinary incontinence—the involuntary loss of urine of sufficient severity to be a social or health problem—is a common, costly, and potentially disabling condition that is never a consequence of normal aging. An over- active bladder associated with changes in the smooth muscle of the bladder, prostatic hyperplasia in men, bladder wall relaxation or prolapse in women, medication side effects, and cognitive impairment are the most common factors predisposing older patients to urinary incontinence. Acute incontinence typically has a sudden onset and is associated with an acute illness (e. There are four basic types of established inconti- nence: stress, urge, overflow, and functional incontinence. In patients with established incontinence, blood tests should measure renal function, electrolytes, blood glucose, and serum calcium; these measurements help to exclude polyuric conditions that may cause incontinence. The most useful bedside test of lower urinary tract function is meas- urement of the PVR urine. Accurate measurement of the PVR is most often accom- plished by straight catheterization of the urinary bladder after the patient attempts complete voiding. Pelvic ultrasonography and portable bladder scanning are safe and accurate alternative methods of estimating PVR. A PVR of less than 50 ml of urine is considered normal. A PVR of greater than 150 ml is abnormal even in elderly patients and indicates the need for further urologic evaluation or repeat measurement of PVR. Strategies for the management of urinary incontinence include behavioral modifica- tion techniques, medications, patient and caregiver education, surgical procedures, catheter placement, and incontinence supplies. The acute onset of incontinence should be evaluated and treated promptly. Urinary tract infection, acute urinary retention, stool impaction, and adverse effects of medications (e. After the initial diagnostic evaluation, most patients should be treated on the basis of the most likely type of incontinence. This empirical approach will lead to successful management of a large percentage of incontinent patients. Medications play a modest role in the treatment of stress incontinence.

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Amoxicillin Key Concept/Objective: To know the specific indications and options for malaria prophylaxis for the international traveler Appropriate malaria chemoprophylaxis is the most important preventive measure for trav- elers to malarial areas discount bactrim 960 mg antibiotic with sulfa. In addition to advice about the avoidance of mosquitos and the use of repellants discount 960 mg bactrim amex infection from bee sting, most visitors to areas endemic for malaria should receive chemoprophylax- 8 BOARD REVIEW is, regardless of the duration of exposure. In most parts of the world where malaria is found, including Africa, chloroquine resistance is common, so chloroquine would not be recommended as prophylaxis for this patient. Pyrimethamine-sulfadoxine is no longer rec- ommended for prophylaxis because of the associated risk of serious mucocutaneous reac- tions. Amoxicillin does not have known efficacy against Plasmodium. Mefloquine is the preferred agent for malaria chemoprophylaxis in areas of the world where chloroquine- resistant malaria is present. A 56-year-old man seeks your advice regarding malaria prophylaxis before a planned 10-day business trip to New Delhi, India. His medical problems include atrial fibrillation and medication-controlled bipolar disorder. He has no known allergies; his regular medications include diltiazem and lithium. What should you recommend to this patient regarding malaria prophylaxis? No prophylaxis is required because his trip will be less than 14 days long ❏ B. Doxycycline Key Concept/Objective: To understand the options for prophylaxis of chloroquine-resistant malaria Chloroquine-resistant malaria is widespread and occurs in India. Pyrimethamine-sulfadoxine is generally not used for prophylaxis because of the risk of severe mucocutaneous reactions. Mefloquine and doxycycline are the most commonly used chemoprophylactic agents for travelers to chloroquine-resistant malarial areas. Although mefloquine is generally well-tolerated in prophylactic doses, underlying cardiac conduction abnormalities and neuropsychiatric disorders or seizures are generally considered contraindications for mefloquine use. Thus, daily doxycycline taken from the start of the travel period until 4 weeks after departure from malarial areas would be the best choice for malaria chemoprophylaxis for this patient. Her only medical prob- lems include diet-controlled diabetes mellitus and occasional candidal vaginitis. She will be visiting Bombay and several rural villages for a total of 8 days as an inspector of sewage-treatment facilities. Given her tight schedule, it is imperative that she not lose any time as a result of diarrhea. You counsel her about safe food practices, prescribe mefloquine for malaria prophylaxis, and immunize her appropriately. Travelers should follow safe food practices and may take either chemo- prophylaxis or begin treatment after onset. For the patient in this question (whose visit will be relatively short and who cannot afford to have her schedule interrupted by an episode of diarrhea), chemoprophylaxis is a reasonable approach. A quinolone, trimetho- prim-sulfamethoxazole, bismuth subsalicylate, and doxycycline are all options. Resistance to trimethoprim-sulfamethoxazole is widespread, so this drug would be less than optimal. Vaginal candidiasis is a common complication of doxycycline (particularly in a patient CLINICAL ESSENTIALS 9 with diabetes and a history of candidal vaginitis), and therefore doxycycline would not be suitable for this patient. Of the choices, ciprofloxacin would be the best option. A 35-year-old woman in excellent health is planning a trip to remote areas of Asia. She has not traveled abroad before, and she wants some information on travel-related illnesses and risks. She has had her childhood immunizations, and her tetanus immunization was updated last year. She has an aversion to immunizations and medications but will accept them if needed. What is the most common preventable acquired infection associated with travel for this person? Yellow fever Key Concept/Objective: To understand the risks of infection associated with travel to various parts of the world Travel-related risks of infection are dependent on which part of the world an individual will be traveling to, the length of stay, and any underlying predisposing medical factors.

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Lesion sites include the midbrain bactrim 960mg with mastercard antibiotic treatment for bronchitis, subarachnoid space bactrim 480 mg on line antibiotic you cant drink alcohol, cavernous sinus, supe- Topographical rior orbital fissure, or orbit. The affected eye is sometimes extorted (although this may not be apparent to Signs the observer) and exhibits poor depression during adduction. Isolated lesion of the trochlear nerve is rare, although it is the most common Pathogenesis cause of vertical diplopia. More often trochlear nerve dysfunction is observed in association with lesions of CN III and CN VI. Metabolic: Diabetes Vascular: Hypertension Subarachnoid hemorrhage 44 Uncertain: microvascular infarction Vascular arteriosclerosis, diabetes (painless diplopia) Infection: Mastoiditis Meningitis Inflammatory: Ophthalmoplegia or diplopia associated with giant cell arteritis Compression: Cavernous sinus, orbital fissure lesions Inflammatory aneurysms ( posterior cerebral artery, anterior superior cerebellar artery) Trauma: Head trauma causing compression at the tentorial edge Lumbar puncture or spinal anesthesia Surgery The trochlear nerve is the most commonly injured cranial nerve in head trauma. Neoplastic: Carcinomatous meningitis Cerebellar hemangioblastoma Ependymoma Meningioma Metastasis Neurilemmoma Pineal tumors Trochlear nerve sheath tumors Others: Superior oblique myokymia Pediatric: congenital, traumatic and idiopathic are the most frequent causes. Diagnosis Diagnosis can be facilitated by the Bielschowsky test: 1. Diplopia is exacerbated when the affected eye is turned nasally 3. Diplopia is improved by tilting the head away from the affected eye Also, when viewing a horizontal line, the patient sees two lines. The lower line is tilted and comes closest to the upper line on the side towards to the affected eye. Subtle diagnosis: “Cross over” or Maddox rod techniques Differential diagnosis Skew deviation, a disparity in the vertical positioning of the eyes of supra- nuclear origin, can mimic trochlear palsy. Myasthenia gravis, disorders of the extraocular muscles, thyroid disease, and oculomotor palsy that affects the superior rectus can also cause similar effects. Surgery could be indicated to remove compression or repair trauma. The recovery rate over 6 months was observed to be higher in cases of diabetic Prognosis etiology than other non-selected cases. Berlit P (1991) Isolated and combined pareses of cranial nerves III, IV, and VI. J Neurol Sci 103: 10–15 Jacobson DM, Marshfield DI, Moster ML, et al (2000) Isolated trochlear nerve palsy in patients with multiple sclerosis. Neurology 55: 321–322 Keane JR (1993) Fourth nerve palsy: historical review and study of 215 inpatients. Neurol- ogy 43: 2439–2443 Rush JA, Younge BR (1981) Paralysis of cranial nerves III, IV, and VI. Arch Ophthalmol 99: 76–79 46 Trigeminal nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + Somatosensory evoked potentials Reflexes: masseteric, corneal reflex, EMG Fig. General sensory: Face, scalp, conjunctiva, bulb of eye, mucous membranes of paranasal sinus, nasal and oral cavity, tongue, teeth, part of external aspect of tympanic mem- brane, meninges of anterior, and middle cranial fossa. Anatomy The trigeminal nuclei consist of a motor nucleus, a large sensory nucleus, a mesencephalic nucleus, the pontine trigeminal nucleus, and the nucleus of the spinal tract. The nerve emerges from the midlateral surface of the pons as a large sensory root and a smaller motor root. It ascends over the temporal bone to reach its sensory ganglion, the trigeminal or semilunar ganglion. The bran- chial motor branch lies beneath the ganglion and exits via the foramen rotun- dum. The sensory ganglion is located in the trigeminal (Meckle’s) cave in the floor of the middle cranial fossa. The three major divisions of the trigeminal nerve, ophthalmic nerve (V1), maxillary nerve (V2), and mandibular nerve (V3), exit the skull through the superior orbital fissure, the foramen rotundum and the foramen ovale, respectively. V1 (and in rare instances, V2) passes through the cavernous sinus (see Fig. Some features of trigem- inal neuropathy: A Motor lesion of the right trigeminal nerve.

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