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Ivy Ng Menti Code: 6787 6038 INFECTIONS 1 MEDED Y ear 3 Lecture Series Slides adapted from lecture delivered in 2023SESSION STRUCTURE Background Natural History Presentation Investigations Management = High Yield LECTURE CONTENT : 1. Chronic Viral Infection 2. Acute Infection 3. Emergencies • virus (HIV)odeficiency • Tonsillitis • Sepsisising Fasciitis • Herpes Simplex Virus (HSV) • Abscesses • Varicella zoster • Parvovirus • Epstein Barr Virus • MMReola CHRONIC INFECTIONS: • Herpes Simplex Virus (HSV)us (HIV) • Varicella zoster • Epstein Barr Virus HIV: Background Single-stranded, positive-sense, enveloped RNA retrovirus HIV-2 Transmission: West Africa, South Asia Sexual intercourse (75%) • M – M USA/UK • M – F GLOBALLY • F – M IVDU/ Needle stick injury/ Blood transfusion Vertical (Mother → Child) • Placenta HIV-1 • Breastmilk Common worldwide • Birth canal More likely to progress into AIDS HIV: Pathophysiology CD4 receptor: T-helper cells Dendritic cells CCR5 co-receptor: T cells Macrophages CXCR4 T cellsptor: Monocytes Dendritic cellsHIV: Natural History ACUTE Virus: Increase then decline (still detectable) Symptoms: Flu-like (fever, myalgia, sore throat)/ Myalgia & Lethargy CHRONIC / LATENT Virus: STABLE then STEADY INCREASE Symptoms: • Asymptomatic OR • Oral/vaginal candidiasis • Skin rashes – Herpes Zoster, Pruritic popular eruptions • TB • Oral hairy leukoplakia (EBV) AIDS Virus: May INCREASE significantly T cell countdrops below 200-500 cells/mm Symptoms: severe immune compromise • fever, weight loss, diarrhoea, lymphadenopathy • ‘AIDS-defining’ illnesses • Neuropsychiatric disease Menti Code: 6787 6038 SBA 1 A 35-year-old man with untreated HIV presents with gradual, painless loss of vision in his right eye over the past week. He also reports seeing floaters. His most recent CD4 count was 40 cells/mm³. On fundoscopy, thereare areas of retinal whitening with haemorrhages, described as having a "pizza pie" appearance. Which of the following is the most likely diagnosis? A. HIV retinopathy B. Cytomegalovirus (CMV) retinitis C. Toxoplasma chorioretinitis D. Herpes simplex virus retinitis E. Progressive multifocal leukoencephalopathy (PML) SBA 1 A 35-year-old man with untreated HIV presents with gradual, painless loss of vision in his right eye over the past week. He also reports seeing floaters. His most recent CD4 count was 40 cells/mm³. On fundoscopy, thereare areas of retinal whitening with haemorrhages, described as having a "pizza pie" appearance. Which of the following is the most likely diagnosis? A. HIV retinopathy C. Toxoplasma chorioretinitisnitis D. Herpes simplex virus retinitis E. Progressive multifocal leukoencephalopathy (PML)HIV: AIDS-defining illness Infections Neoplasm Cervical Cancer - Mycobacterium tuberculosis - Pneumonia (recurrent 2+ episodes in 12 Non-Hodgkin lymphoma months) Kaposi’s sarcoma Viral: - Cytomegalovirus - Caused by HHV-8 - Herpes Simplex - Purple patches/ nodules - membrane that line GI tract - Pneumocystis jiroveci (PCP) (from mouth to anus) - Oesophageal candidiasis - Cryptococcosis - Histoplasmosis HIV: Diagnosis Antibody = response to HIV Antigen = presence of HIV protein RNA/DNA = presence of HIV genome Serum p24 Antigen Test Other investigations: Serum viral load (HIV RNA) Serum HIV ELISA (IgG, IgM) CD4 count – immune status and assist in RNA > 100,000 copies/mL Window period - 15-45 days until +ve staging Hep B/ Hep C Serology – baseline and every 12 monthsHIV: HAART Class Examples Nucleoside and nucleotide reverse Tenofovir transcriptase inhibitors (NRTIs) abacavir, zidovudine stavudine, Lamivudine emtricitabine Non-nucleoside reverse transcriptase Efavirenz inhibitors (NNRTIs) nevirapine etravirine Integrase inhibitors Raltegravir Protease inhibitors Fosamprenavir Atazanavir Darunavir lopinavir saquinavir (ritonavir) CCR5 inhibitors Maraviroc Fusion inhibitors Enfuvirtide START EVERYONE ON HAART, REGARDLESS OF CD4 COUNT & VIRAL LOAD HERPES VIRUSES Family of double-stranded linear DNA viruses Herpes simplex virus (HSV 1, 2) Varicella Zoster virus Epstein bar virus Human cytomegalovirus Human herpesvirus 6 (roseola) Human herpesvirus 8 (Kaposi’s sarcoma) HSV: Background + Natural HSV-1 & 2 Initial infection Retrograde movement Transmission • Sexual transmission • Mucosal / skin breaks • Vertical transmission (M → B) RF: Immunosuppression • Medications • HIV/AIDS Latency Reactivation Low lviral genession of Replicmovementanterograde Menti Code: 6787 6038 SBA 2 Mike is a 32-year-old man who presents to his healthcare provider with painful blisters on his genital area. He reports that he has had multiple sexual partners over the past few months and has not consistently used protection. He also reports experiencing a burning sensation during urination. Upon examination, the healthcare provider observes that the blisters are clustered and appear to be fluid-filled. The provider suspects that Mike has been infected with herpes simplex virus (HSV) and decides to order further testing to confirm the diagnosis. What is the most appropriate management strategy for Mike's confirmed HSV infection? A. Prescribe antibiotics B. Prescribe acyclovir C. Recommend pain relievers D. Provide no treatment and wait for the symptoms to resolve on their own E. Start Aspirin Answer Mike is a 32-year-old man who presents to his healthcare provider with painful blisters on his genital area. He reports that he has had multiple sexual partners over the past few months and has not consistently used protection. He also reports experiencing a burning sensation during urination. Upon examination, the healthcare provider observes that the blisters are clustered and appear to be fluid-filled. The provider suspects that Mike has been infected with herpes simplex virus (HSV) and decides to order further testing to confirm the diagnosis. What is the most appropriate management strategy for Mike's confirmed HSV infection? A. Prescribe antibiotics B. Prescribe acyclovir C. Recommend pain relievers D. Provide no treatment and wait for the symptoms to resolve on their own E. Start Aspirin HSV: Presentation & Tx Vesicular lesion → ulceration → crusted Herpes labialis Genital herpes lesion Disseminated Caused by HSV1 Less severe More severe Ix – HSV culture/ PCR if lesions are present Antivirals – acyclovir, valaciclovir, famciclovir IV Oral Hospitalisation Topical (labialis) *Pregnant – prophylaxis, CS Menti Code: 6787 6038 SBA 3 A 5-year-old child presents to the clinic with a 2-day history of feve, malaise, and an itchy rash. The rash began on theface and trunk and has now spread to the arms and legs. On examination, there are multiple small, fluid-filled vesicles of various stages (some crusted, some intact), scattered across the child’s body. Thechild’s vaccination history is unknown. What is themost likely diagnosis? A. Impetigo B. Measles C. Varicella Zoster Infection D. Hand, Foot, and Mouth Disease E. Herpes Simplex Virus Infection SBA 3 A 5-year-old child presents to the clinic with a 2-day history of fev, malaise, and an itchy rash. The rash began on theface and trunk and has now spread to the arms and legs. On examination, there are multiple small, fluid-filled vesicles of various stages (some crusted, some intact), scattered across the child’s body. Thechild’s vaccination history is unknown. What is themost likely diagnosis? A. Impetigo B. Measles C. Varicella Zoster D. Hand, Foot, and Mouth Disease E. Herpes Simplex Virus Infection VZV: Background & Natural Historyary Infection: Chickenpox Children – NOT immunised - Immunocompromised Transmission: Aerosolised droplets OR direct contact with lesion Reactivation: Shingles Timeline: • Incubation 14 days Adults (>50) – immunocompromised – stress • Infectious 1-2 days BEFORE rash until all lesions crusted Timeline: Prodrome 2-4 days before rash Life cycle: Life cycle: reactivation of dormant VZV in ganglia → travels down axon → local skin inflammation VZV: Presentation & Tx CLINICAL DIAGNOSIS 1. Lesions develop first centrally as macules(face, scalp, torso), then on extremities. encephalitis 2. They then become fluid-filled vesicles. Varicella pneumonitis 3. Early lesions scab over while new peripheral lesions *Congenital varicella develop. syndrome 4. Crusting within 5 days and crusts fall off after 1-2 weeks Less severe More severe Antivirals – acyclovir, valaciclovir, famciclovir Self-limiting IV antivirals Oral antivirals IVIG Topical Calamine lotion *Pregnancy = separation, Paracetamol prophylaxis VZV: Presentation & Tx Ramsay Hunt syndrome Post-herpetic neuralgia Herpes zoster ophthalmicus Dermatomal distribution Erythemaotus maculopapular rash → Painful vesicles Less severe More severe Antivirals – acyclovir, valaciclovir, famciclovir Self-limiting Oral antivirals IV antivirals Calamine lotion (within 72hr onset if immunocompromised or IV IG non-truncal involvement or moderate/severe Paracetamol pain/rash.) *Pregnancy = separation, prophylaxis Menti Code: 6787 6038 SBA 4 A 59-year-old woman comes to the emergency department because of vertigo for the past 2 days. She also complains of ear pain, tinnitus, and altered taste perception. Physical examination shows vesicles in the auditory canal and auricle in addition to right-sided facial paralysis. Which of the following is the most likely diagnosis? A. Bell’s palsy B. Dyssnergia cerebellaris myoclonia C. Trigeminal neuralgia D. Ramsay Hunt syndrome E. BPPV Answer A 59-year-old woman comes to the emergency department because of vertigo for the past 2 days. She also complains of ear pain, tinnitus, and altered taste perception. Physical examination shows vesicles in the auditory canal and auricle in addition to right-sided facial paralysis. Which of the following is the most likely diagnosis? Ramsay Hunt Syndrome A. Bell’s palsy Reactivation of varicella-zoster virus (VZV) in the geniculate B. Dyssnergia cerebellaris myoclonia ganglion of the facial nerve (cranial nerve VII) C. Trigeminal neuralgia - Hearing and vestibular symptoms D. Ramsay Hunt syndrome - Facial Paralysis E. BPPV - Lesions in ears EPSTEIN BARR VIRUS: HHV-4 Primary infection +/- Sxis / glandular fever aka ‘kissing disease’ Transmission:ial cells → B cells • Saliva • Sexual contact Latent T cell response controls infection B cells = reservoir ReactivaViral sheddingg B cells EPSTEIN BARR VIRUS: PresentaPrimary infection Complications Triad: Fever, sore throat / Splenic rupture – pharyngitis, avoid contact sports! lymphadenopathy Lymphoma – Hodgkin’s, Unnoticed OR Burkitt’s Mild URTI / flu- like Sx Hepatosplenomegaly EPSTEIN BARR VIRUS: Diagnosis & Tx FBC + BLOOD FILM MONOSPOT LFTs +ve heterophile Raised transaminases antibodies (IgM) 50% cases react with sheep/horses +/- Direct viral detection: RBCs → agglutination EBV DNA, EBV-specific Abs Treatment: Lymphocytosis (50%) Analgesia, anti-pyretics – NOT ASPIRIN Corticosteroids if upper airway obstruction Atypical = large, irregular nuclei + IVIG if thrombocytopaenia clumped chromatin Menti Code: 6787 6038 SBA 5 A 28-year-old woman presents to her GP with vaginal itching, discomfort, and thick white discharge. She reports that the dischargeis non-offensive and resembles cottage cheese. Shehas no significant past medical history but recently completed a course of broad-spectrum antibiotics for a urinary tract infection. She is sexually activeand uses combined oral contraceptive pills. On examination, there is vulval erythema and thick white vaginal discharge. What is themost likely diagnosis? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhoea E. Chlamydia Answer A 28-year-old woman presents to her GP with vaginal itching, discomfort, and thick whitedischarge. She reports that the dischargeis non-offensive and resembles cottage cheese. She has no significant past medical history but recently completed a course of broad-spectrum antibiotics for a urinary tract infection. She is sexually activeand uses combined oral contraceptive pills. On examination, there is vulval erythema and thick white vaginal discharge. What is themost likely diagnosis? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhoea E. ChlamydiaACUTE INFEC•Candidiasis •Tonsillitis •Abscesses •Parvovirus •Roseola •MMR CANDIDIASIS: Background Candidiasis / thrush = overgrowth of Candida species (C. albicans) Risk Factors: Young Dentures ASteroidscs mellitus Malnutrition Xdry mouth – HIV/AIDS Pregnancy Chemotherapy COCP CANDIDIASIS: Presentation Pseudomembranous = creamy-whitish plaques Scraped off → erythematous base Atrophic (Denture) = red flat lesions, no plaques Hyperplastic = non-scrapable plaques Thick white discharge ‘cottage cheese’ Dyspareuniaing + burning Asymptomatic OR Cotton feeling Dysuria Pain/tenderness Decreased taste Angular cheilitisCANDIDIASIS: Diagnosis & Tx Microscopy KOH Test Treatment Oral Topical antifungal – miconazole, nystatin, clotrimazole Systemic antifungal – fluconazole ** NOT in pregnancy ** Vulvovaginal Uncomplicated: • 150mg oral fluconazole • OTC Pessaries • OTC vaginal creams/ointment Species dependent – (C. Albicans) Complicated: Candida = Hyphae • 150mg Fluconazole in 2-3 doses Branched pseudohyphae • Intravaginal boric acid OR flucytosine cream TONSILLITIS: Background VIRAL or BACTERIAL Rhinovirus Adenovirus Group A streptococcus Respiratory syncytial virus Risk factors: 5-15yrs – Crowded environments – Winter/early spring – Incomplete Abx course TONSILITIS: Presentation VIRAL BACTERIAL Fever PAIN – 1 pt each (for Strep Pharyngitis) Low grade Fever last 24h fever Purulent tonsils Attend rapidly, onset <3 days Inflamed tonsils (severe) No cough or coryza CENTOR – 1pt each High grade fever Can’t Cough Exudate (tonsillar) Nodes (anterior cervical lymphadenopathy) Sore throat OR (age <15, +1 OR age >45, -1 ) Cough Rhinorrhoea Odynophagia, DysphagiaTONSILITIS: Diagnosis & Tx ADULTS Phenoxymethylpenicillin OR Clarithromycin (penicillin allergic) OR Erythromycin (penicillin allergic + pregnant) CHILDREN = same Abx, different doses CONFIRMING DX If high risk of Rh fever, very old/young, immunosuppressed OR very severe Sx Rapid antigen Group A Strep Test (RAST) + culture if negative ABSCESS: Collection of pus surrounded by inflamed tissue Due to pyogenic (pus forming) bacteria Strep pyogenes Strep epidermidis P. aeruginosa Any site: Superficial – skin, soft tissue Internal – liver, lung, brain Risk Factors: Trauma Foreign body (piercing) IVDU Derm conditionsABSCESS: Presentation Peritonsillar Warmth Erythema Swelling Soft tissue Tenderness/pain Fluctuant mass PilonoidalABSCESS: Diagnosis & Tx USS CT MRI Anechoic/hypoechoic Central decreased attenuation T1 – central hypointense area homogenous fluid collection Ring enhancement T2 – hyperintense Treatment: USS-guided aspiration → specimen culture Incision, drainage Menti Code: 6787 6038 SBA 6 A 28-year-old woman presents to the clinic with a 5-day history of a red, lacy rash on her cheeks, which later spread to her arms and legs. She also reports mild fever , fatigue, and joint pain. She denies any respiratory symptoms or recent exposure to anyone with a cold. She is otherwise healthy and not pregnant. The clinical presentation is consistent with erythema infectiosum. What is themost appropriatetreatment for this patient? A. Antibiotics B. Antiviral therapy C. Non-steroidal anti-inflammatory drugs (NSAIDs) D. Intravenous immunoglobulin (IVIG) E. Antihistamines SBA 6 A 28-year-old woman presents to the clinic with a 5-day history of a red, lacy rash on her cheeks, which later spread to her arms and legs. She also reports mild fever , fatigue, and joint pain. She denies any respiratory symptoms or recent exposure to anyone with a cold. She is otherwise healthy and not pregnant. The clinical presentation is consistent with erythema infectiosum. What is themost appropriatetreatment for this patient? A. Antibiotics B. Antiviral therapy C. Non-steroidal anti-inflammatory drugs (NSAIDs) Parvovirus is a self limiting disease! D. Intravenous immunoglobulin (IVIG) E. Antihistamines Parvovirus: SUMMARY SLIDE Background: Investigations: Caused by Parvovirus B19 B19 Serology: IgG/ IgM Incubation period – 10days before – 1 day after rash develRT-PCR Transmitted via respiratory secretions or vertical transmission History: Management: ✶ Asymptomatic or coryzal ✶ Self-limiting – will clear in 3 illness for 2-3 days weeks ✶ Erythema infectiosum ✶ Does NOT need to stay off school - Red ‘Slapped cheek’ rash on face - Maculopapular (lace) like rash in trunksortive and limbs ✶ Fluids, analgesia, rest - Common in children ✶ Polyarthropathy syndrome Complications: - Pain and swelling in joints - Common in adults ✶ Aplastic anaemia in immunocompromised or with blood disorders ✶ Leukaemia/ cancers ✶ HIV infection ✶ Sickle cell disease/ thalassemia Roseola infantum: SUMMARY SLIDE Background: Investigations: Caused by Human HerpesVirus (HHV -6) CLINICAL DIAGNOSIS Common in children between 6mo – 3 years of age HHV6/7 Serology: IgG/ IgM History: Management: ✶ High Fever (3-4 days) ✶ Self-limiting ✶ Generalised macular ✶ Does NOT need to stay off school rash (small pink spots) Rash develop after fever wanes ✶ Supportive - Blanching rash ✶ Fluids, analgesia, rest - Non-itchy - Starts on neck/ body -> spread to arms Complications: Runny dose, irritability, tiredness, lymphadenopathy ✶ Febrile seizures/ convulsions (10-15%) ✶ Safety net on high fever Incubation period – 9-10days after exposure Transmitted via respiratory droplets or direct contact with saliva Menti Code: 6787 6038 SBA 7 A 7-year-old unvaccinated boy is brought to the GP with a 3-day history of fever , cough, and conjunctivitis. Today, he developed a red, blotchy rash that started behind his ears and has now spread to his faceand trunk. On examination, you notice small white spots on the buccal mucosa opposite his molars. What is themost likely diagnosis? A. Measles B. Mumps C. Rubella D. Scarlet fever E. Roseola infantum SBA 7 A 7-year-old unvaccinated boy is brought to the GP with a 3-day history of fever , cough, and conjunctivitis. Today, he developed a red, blotchy rash that started behind his ears and has now spread to his face and trunk. On examination, you notice small white spots on thebuccal mucosa opposite his molars. What is themost likely diagnosis? A. Measles B. Mumps C. Rubella D. Scarlet fever E. Roseola infantum NOTIFIABLE DISEASE Measles, Mumps, Rubella: SUMMARY SLIDE Transmitted via respiratory droplets Caused by paramyxovirus Mumps Measles Incubation period: 16-18 days Incubation period: 7-18 days Infectious5 daysbefore and5 days after the parotid swelling Infectious4days before and 4daysafterrash History: History: - Asymptomatic (in 30% of cases) - Prodrome: High fever, irritability, conjunctivitis - Headache, fever, myalgia - Maculopapular rash (face/neck → hands/ feet) - Parotid swelling (persist for ~10 days) - Koplik spots (small white spots surround by red ring in mouth) - No lymphadenopathy Investigations: CLINICAL DIAGNOSIS Investigations: Confirmed by saliva sample to detect IgM mumps antibody (PCR) Measles serology (IgG and IgM) from Oral Fluid Test PCR blood/ saliva Management: SELF-LIMITING (resolve over 1-2 weeks) SELF-LIMITING (resolve over 1-2 weeks) ISOLATE for 5 DAYS from time of parotid swelling Management: - Rest, adequate hydration, analgesia for symptomatic relief ISOLATE for 4 DAYS from rash development - Warm/ cold packs to parotid gland - Rest, adequate hydration, analgesia for symptomatic relief - Immunise close contacts Complications: Mumps orchitis, viral meningitis, deafness Complications: Otitis media, encephalitis, pneumonia NOTIFIABLE DISEASE Measles, Mumps, Rubella: SUMMARY SLIDE Transmitted via respiratory droplets Rubella Caused by Togavirus Incubation period: 6-21 days Infectious1 weekbefore and5 days after onsetofrash History: - Prodrome: mild fever/ asymptomatic - Pink Maculopapular rash (face → whole body) – fades in 3-5 days - 20% Forchheimer spots (red spots on soft palate) - Lymphadenopathy Investigations: CLINICAL DIAGNOSIS Confirmed by rubella serology (IgG and IgM) from oral fluid test nd RT-PCR (2 line) Management: SELF-LIMITING (resolve over 1-2 weeks) ISOLATE for 4 DAYS from rash onset Co - Rest, adequate hydration, analgesia for symptomatic relief icat ions thrombocytopenia → haemorrhage : EMERGENCIES : •Necrotising Fasciitis •Sepsis Menti Code: 6787 6038 SBA 8 A 56-year-old man with a history of type2 diabetes presents to A&E with severe pain and swelling in his right leg following a minor cut he sustained two days ago. On examination, theleg is erythematous with areas of skin necrosis and crepitus. He is hypotensive, tachycardic, and febrile. Despite the appearance, the area is exquisitely tender beyond what would be expected. Blood tests show raised CRP , leukocytosis, and metabolic acidosis. What is the most appropriate next step in management? A. Start IV flucloxacillin and monitor B. Arrange urgent surgical debridement C. Take wound swabs and await culture results D. Prescribe oral co-amoxiclav and review in 24 hours E. Perform Doppler ultrasound of the leg SBA 8 A 56-year-old man with a history of type2 diabetes presents to A&E with severe pain and swelling in his right leg following a minor cut hesustained two days ago. On examination, the leg is erythematous with areas of skin necrosis and crepitus. Heis hypotensive, tachycardic, and febrile. Despite the appearance, the area is exquisitely tender beyond what would be expected. Blood tests show raised CRP , leukocytosis, and metabolic acidosis. What is the most appropriate next step in management? A. Start IV flucloxacillin and monitor B. Arrange urgent surgical debridement C. Take wound swabs and await culture results D. Prescribe oral co-amoxiclav and review in 24 hours E. Perform Doppler ultrasound of the leg Necrotising Fasciitis: Life-threatening subcutaneous soft-tissue infection, and may extend to deep fascia (NOT into muscles) extensive necrosis and gangrene of theskin Risk Factors: Chronic illness: Diabetes, alcohol dependence Causative organism Cutaneous trauma/ surgery • GROUP A STREPTOCOCCUS IVDU • Staph aureus/ Haemophilus Immunocompromised • Anaerobic (E.coli/ Bacteroides) • Clostridium perfringens (Type III) Necrotising Fasciitis: Presentation Severe Pain Oedema Vesicles/ bullae (patient may have normal skin) Grey discolouration of skin Systemic signs of infection : Nausea and vomiting Tachycardia, hypotension, palpitations, tachypnoea Necrotising Fasciitis: Ix and Surgical exploration – Finger Test - 2 cm incision into deep fascia - +ve finger test – minimal resistance to finger dissection - Presence of necrotic tissue - Murky or greyish ‘dishwater’ fluid. Blood and tissue culture Gram stain Require RAPID SURGICAL DEBRIDEMENT + Empirical IV antibiotics Antibiotics: piperacillin/tazobactam or ceftriaxone or ciprofloxacin MRSA Cover – vancomycin/ linezolid Menti Code: 6787 6038 SBA 9 A 68-year-old woman is brought to the emergency department from a care home with confusion and fever. Her past medical history includes type2 diabetes and chronic kidney disease. On examination, her temperature is 39.1°C, heart rate 112 bpm, blood pressure 88/52 mmHg, respiratory rate 26 breaths/min, and oxygen saturation is 94% on room air. Shehas reduced skin turgor and dry mucous membranes. Urinalysis is positivefor nitrites and leukocytes. What is the most appropriate immediate management step? A. Prescribe oral antibiotics and discharge with safety netting B. Administer IV fluids and broad-spectrum IV antibiotics C. Request a CT abdomen and pelvis D. Start high-flow oxygen via a non-rebreather mask E. Refer to ITU for vasopressor support SBA 9 A 68-year-old woman is brought to the emergency department from a care home with confusion and fever. Her past medical history includes type2 diabetes and chronic kidney disease. On examination, her temperature is 39.1°C, heart rate 112 bpm, blood pressure 88/52 mmHg, respiratory rate 26 breaths/min, and oxygen saturation is 94% on room air. She has reduced skin turgor and dry mucous membranes. Urinalysis is positivefor nitrites and leukocytes. What is the most appropriate immediate management step? A. Prescribe oral antibiotics and discharge with safety netting B. Administer IV fluids and broad-spectrum IV antibiotics C. Request a CT abdomen and pelvis D. Start high-flow oxygen via a non-rebreather mask E. Refer to ITU for vasopressor support SEPSIS: Life-threatening organ dysfunction caused by a dysregulated host response to an infection. Risk Factors: Age > 65 Immunocompromised Indwelling lines/ catheters Recent surgery IV drug use/ Alcohol dependence Signs associated with specific source of infection: NEWS2 Score >5 Respiratory tract (cough/pleuritic chest pain) • High/ Low temp, with rigors Urinary tract (flank pain/dysuria) Abdominal/upper gastrointestinaI tract (abdominal pain) • Acutely altered mental status Skin/soft tissue (abscess/wound/catheter site) • Low Oxygen sats Surgical site or line/drain site. • HypotensionSEPSIS 6: GIVE 3 : • Oxygen (Sats >94%) • IV Antibiotics • IV Fluids TAKE 3 : • Bloods (culture, glucose, FBC, U&Es, CRP , clotting) • Urine Output • LactateTHANK YOU FOR PLEASE FILL IN THE FEEDBACK FORM! Menti Code: 6787 6038 SBA 10 Mr. Johnson is a 75-year-old man who presents to his healthcare provider with a painful rash on his left side. He reports that the rash began as a few small, red bumps, which have since developed into blisters. He also reports experiencing a burning or tingling sensation in the affected area. Upon examination, the healthcare provider observes that the rash is located on Mr. Johnson's left chest. The rash is made up of small, fluid-filled blisters that are clustered together. What is the likely infective agent causing Mr. Johnson’s current symptoms? A. Varicella zoster virus B. Influenza virus C. Staphylococcus aureus bacteria D. Streptococcus pyogenes bacteria E. Herpes Simplex Virus 1 Answer Mr. Johnson is a 75-year-old man who presents to his healthcare provider with a painful rash on his left side. He reports that the rash began as a few small, red bumps, which have since developed into blisters. He also reports experiencing a burning or tingling sensation in the affected area. Upon examination, the healthcare provider observes that the rash is located on Mr. Johnson's left chest. The rash is made up of small, fluid-filled blisters that are clustered together. What is the likely infective agent causing Mr. Johnson’s current symptoms? A. Varicella zoster virus B. Influenza virus C. Staphylococcus aureus bacteria D. Streptococcus pyogenes bacteria E. Herpes Simplex Virus 1 SBA 11 Maria is a 25-year-old woman who presents to her healthcare provider with complaints of fatigue, sore throat, and swollen lymph nodes. She reports that she has been feeling unwell for the past few weeks and has had difficulty getting out of bed. She denies any recent travel or exposure to sick contacts. Upon physical examination, her healthcare provider notes enlarged lymph nodes in her neck and armpits. Her tonsils are also inflamed and covered in white patches. Based on her symptoms and physical exam findings, the healthcare provider suspects an infection with the Epstein-Barr virus (EBV). What is the most appropriate management strategy for Maria's suspected EBV infection? A. Prescribe antibiotics B. Prescribe antiviral medication C. Recommend rest and supportive care D. Advise Maria to avoid contact sports E. Schedule a tonsillectomy Answer Maria is a 25-year-old woman who presents to her healthcare provider with complaints of fatigue, sore throat, and swollen lymph nodes. She reports that she has been feeling unwell for the past few weeks and has had difficulty getting out of bed. She denies any recent travel or exposure to sick contacts. Upon physical examination, her healthcare provider notes enlarged lymph nodes in her neck and armpits. Her tonsils are also inflamed and covered in white patches. Based on her symptoms and physical exam findings, the healthcare provider suspects an infection with the Epstein-Barr virus (EBV). What is the most appropriate management strategy for Maria's suspected EBV infection? A. Prescribe antibiotics B. Prescribe antiviral medication C. Recommend rest and supportive care D. Advise Maria to avoid contact sports E. Schedule a tonsillectomy SBA 12 Mark is a 35-year-old man who presents to his healthcare provider with persistent flu-like symptoms, such as fever, fatigue, and muscle aches. He also reports experiencing night sweats and unintended weight loss over the past few months. He admits to engaging in unprotected sexual activity with multiple partners, some of whom were known to be HIV positive. Upon examination, the healthcare provider notes that Mark has swollen lymph nodes in his neck, armpits, and groin. Given his symptoms and high-risk sexual behavior, the provider suspects that Mark may have contracted HIV and decides to order further testing to confirm the diagnosis. What is the most appropriate test to diagnose Mark's potential HIV infection? A. Urine drug screen B. X-ray C. Stool culture D. Antigen antibody test E. Monospot Test Answer Mark is a 35-year-old man who presents to his healthcare provider with persistent flu-like symptoms, such as fever, fatigue, and muscle aches. He also reports experiencing night sweats and unintended weight loss over the past few months. He admits to engaging in unprotected sexual activity with multiple partners, some of whom were known to be HIV positive. Upon examination, the healthcare provider notes that Mark has swollen lymph nodes in his neck, armpits, and groin. Given his symptoms and high-risk sexual behavior, the provider suspects that Mark may have contracted HIV and decides to order further testing to confirm the diagnosis. What is the most appropriate test to diagnose Mark's potential HIV infection? A. Urine drug screen B. X-ray C. Stool culture D. Antigen antibody test E. Monospot Test SBA 13 A 70-year-old man comes into the clinic due pain when he wears his dentures, which has developed over the last week. Physical examination shows erythema on his gums and white plaque on the buccal mucosa. Which is most likely to be seen on microscopic analysis of the plaque A. chain-forming cocci B. pseudopod-forming nonflagellate organisms C. septate hyphae D. acid-fast rod bacilli E. yeast-like cells and pseudohyphae RECAP A 70-year-old man comes into the clinic due pain when he wears his dentures, which has developed over the last week. Physical examination shows erythema on his gums and white plaque on the buccal mucosa. Which is most likely to be seen on microscopic analysis of the plaque A. chain-forming cocci B. pseudopod-forming nonflagellate organisms C. septate hyphae D. acid-fast rod bacilli E. yeast-like cells and pseudohyphae SBA 14 A 26-year-old woman presents to the clinic with a sore throat and difficulty swallowing for the past 3 days. She also reports a fever of 101°F (38.3°C), fatigue, and swollen glands in her neck. On examination, her tonsils are red and swollen, and there are white spots visible on them. She has no significant medical history and is not currently taking any medications. Further questioning reveals that the patient has had recurrent sore throats over the past few months, but this episode is more severe than previous ones. She denies any recent travel or exposure to sick contacts. Physical examination reveals mild erythema of the pharynx with bilateral tonsillar exudates and tender anterior cervical lymphadenopathy: Which of the following is the next best step in the management of this patient? A. Begin phenoxymethylpenicillin B. CT Head C. Supportive care D. Sinus aspiration E. Begin clarithromycin RECAP A 26-year-old woman presents to the clinic with a sore throat and difficulty swallowing for the past 3 days. She also reports a fever of 101°F (38.3°C), fatigue, and swollen glands in her neck. On examination, her tonsils are red and swollen, and there are white spots visible on them. She has no significant medical history and is not currently taking any medications. Further questioning reveals that the patient has had recurrent sore throats over the past few months, but this episode is more severe than previous ones. She denies any recent travel or exposure to sick contacts. Physical examination reveals mild erythema of the pharynx with bilateral tonsillar exudates and tender anterior cervical lymphadenopathy: Which of the following is the next best step in the management of this patient? A. Begin phenoxymethylpenicillin B. CT Head C. Supportive care D. Sinus aspiration E. Begin clarithromycin