Advanced PT Exam 1: COVID, Flu, HIV, and STIs PDF

**INFLUENZA and COVID:** - INFLUENZA: - Highly contagious, viral illness transmitted through inhalation of respiratory droplets. - Seasonal influenza epidemics result in 25-50 million cases, approximated 200,000 hospitalization and more than 30,000 deaths/yr...

**INFLUENZA and COVID:** - INFLUENZA: - Highly contagious, viral illness transmitted through inhalation of respiratory droplets. - Seasonal influenza epidemics result in 25-50 million cases, approximated 200,000 hospitalization and more than 30,000 deaths/yr in US. - Responsible for major pandemics - Etiology: - 3 types of influenza virus - Influenza A - Divided into subtypes based on 2 virus surface proteins - Hemagglutinin (h) and neuraminidase - H subtypes: H1 to H16 (H32 and HIN 1) are most common - N Subtypes: N1 to N9 - Biggest issue - May require hospitalization - Influenza B - Not divided into subtypes - Less pathogenic than Type A - Less pathogenic - No hospitalization. - Influenza C - Not divided into subtypes - Uncommon; mild form - Pathophysiology: - Hemagglutinin binds to respiratory epithelial cells - Neuraminidase cleaves the bond that holds replicating virions, allowing spreading of infections - Pathology: binding to sialic acid leading to entering the cell -\> replication -\> release from cell - Transmission: - May occur if a person touches on object contaminated with respiratory secretions and then touches their mucous membrane - Incubation period for influenza ranges between 1-7 days (average = 2 days) - Transmission occurs if the infected person is shedding virus from the respiratory tract - Adults are considered infectious withing 1 days before until 7 days after onset of illness - Children might be infections for longer than 10 days - Viral shedding may persist for weeks to months in severe immunocompromised people - Common Symptoms: days after onset of illness - Coryza: inflammation of mucous membrane - Sore throat - Myalgia: muscle pain - Headache - Cough - Anorexia - Malaise: tired - Types of Influenza Vaccine: - Main Vaccine Types Include: - IIV: inactivated influenza vaccine - RIV: recombinant influenza vaccine - LAIV: live attenuated influenza vaccine - Prefixes are used when necessary to refer to some specific IIVS: - for adjuvanted inactivated influenza vaccine (ex. AIIV3 AND AII4) - CC for cell culture-based inactivated influenza vaccine (ex CCIV3 and CCIIV4) - HO for high dose inactivated influenza vaccine (EX. HD-IIV3 AND HD-11V4) - SD for standard dose inactivated influenza vaccines (ex-SD-IIV3 AND SD-IIV4)( - Numerals following letter abbreviation, indicates valency (the \# of influenza virus hemagglutinin (HA) antigens represented in the vaccine) - 4 for quadrivalent vaccines: one A (HINI) one A (H3N2) and 2 B viruses (one from each lineage. - 3 for trivalent vaccines: one A (HINI) one A (H3N2) and one B viruses - Antigenic Drift vs Shift: - Influenza viruses are constantly. - They can change in 2 different ways either by drifting or shifting - Antigenic Drift: ENDEMIC - Small changes in influenza virus's gene that happen continually overtime as the virus replicates - Changes are created by point mutations in the surface antigens of a particular subtype - Seasonal epidemics are due to there "drifts" - Reason for changing the influenza vaccine yearly - Antigenic Shift: PANDEMIC: - Influenza virus acquires new hemagglutinin and/or neuraminate via genetic reassessment rather than point mutations - Pharmacologic Agents: - Cap-Dependent Endonuclease Inhibitor: - Baloxovir Morboxil (newer) - Dosage form: oral - SOA: influenza A - FDA-approved Indications: treatment/prophylaxis for A - Elimination: Hepatic (NO DOSE ADJUSTMENT) - ADR: - Diarrhea - Bronchitis - NA - HA - Nasopharyngitis - DUR: - MAOI increase the levels of rimantadine - Decrease the effect of influenza vaccine - Dose: - 40mg x1 if \80kg - Duration: 1 day - Neuraminidase Inhibitor: - Tamiflu - Dosage form = oral - SOA: influenza A/B - FDA-approved Indication: treatment/prophylaxis for A/B - Elimination: Renal - ADR: - N/V - Diarrhea - Conjunctivitis - Epistaxis - DUR: - Increase probenecid levels - Decrease effect of influenza vaccines - Dose: - PX -- 75mg QD - TX- 75 BID - Duration: 5 days - Zanamivir - Dosage Form: inhaled - SOA: influenza A/B - FDA approved Indication: treatment/prophylaxis - Elimination: renal - ADR: - HA - Throat/tonsil pain - Nasal symptoms - Cough - DUR: - Decreases the effect of the influenza vaccines - Treatment: - PX- 10mg inhalation x10 or x28 - TX: 10mg BID X5 - Peramivir - Dosage form: IV - SOA: Influenza A/B - FDA-approved Indications: Treatment - Elimination- renal - ADR: - INS - Hallucination - Delirium - Increase glucose - Neutropenia - DUR: - Decrease the effect of influenza vaccine - Dose: 600mg IV x1 - Duration- 1 day - Adamantanes: - Amantadine - Rimantadine - No longer recommended due to high resistance - Pathophysiology of COVID-19: - SARS-COV2 viral infection of host airway cells - TMPRSS2 activates viral S protein and cleaves ACE2 receptor to facilitate viral binding to host cell membrane - Virus enters host cell via endocytosis, releases its RNA and uses cell machinery to replicate itself and assemble more virions - One infected host cell can create hundreds of new virions, rapidly progressing infection - Early Stage COVID-19 - Bronchial epithelial cells type 1 and 2 alveolar pneumocytes and capillary endothelial cells are infected and on inflammatory response ensures: - Infected type 2 pneumocytes -\> SARS-COV2 virus release -\> t lymphocytes, monocytes and neutrophil recruitment -\> cytokine release enhances inflammatory response (TNF-a, IL-1, IL-6) - Late Stage of COVID-19: - Continued inflammatory response results in alveolar interstitial thickness increased vascular permeability and edema - Transmission: - Occurs primarily via respiratory droplets from face-to-face contact - To a lesser degree, via contaminated surfaces - Aerosol spread may occur, but the rule of aerosol spread in human remains under - An estimated 48%-62% transmission may occur via pre-symptomatic carries - LONG COVID: - Pathogens: - Persistent virus presence - Autoimmunity - Dysregulated microbiome - Tissues damage - Treatment: - Long term monitoring - Mental health care - Social support - Physical rehabilitation - Risk Factors: - SAR-COV2 variants - Severity of comorbidities - No vaccination - Female, older, or healthcare worker - Management: - Making guidelines - Improved health system - Strengthened international cooperation - Changing public attitude - \*\*\*KEY POINTS\*\*\*\* - Promote willingness of vaccinations - More attention to vulnerable populations - Increase health finance - Guarantee safety of vaccines - Disseminations proper information - Keeping supervision - CLINICAL PRESENTATION: - Fever - Dry cough - SOB - Fatigue - Myalgias - NV - Diarrhea - HA - Rhinorrhea - Anomia (loss of smell) - Ageusia (loss of taste) - COMMON LAB ABNORMALITIES AMONG HOSPITALIZED PATIENTS: - Lymphopenia- low lymphocytes - Elevated inflammatory markers - Sedimentation rate - C reactive proteins - Ferritin - Tumor necrosis factor a - IL-1 - IL-6 - Abnormal Coagulation Parameters: - Prolonged PT time - Thrombocytopenia- decrease platelet counts - D-dimer - Low fibrinogen - CLASSIFY SEVERITY: - Mild: NO NEED FOR HOSPITALIZATION - Fever - Malice - Cough - Upper respiratory symptoms - Less common- absence of dyspnea - Moderate: - Developed dyspnea (SOB) in addition to mild disease symptoms - Severe: - Hypoxemia (O2 SAT less than or equal to 94% on room air) - Need for oxygenation or ventillary support - 2-5L (severe but not critical) - \>6L (severe and critical) - \*\*\*\*RISK FACTORS\*\*\*\*\* - AGE \> 60 Y/O - BMI \>25 - DM, HTN, CV disease, chronic lung disease, cancer - immunocompromised - PREVENTION OF COVID-19: - mRNA Vaccines: - BNT162b2 (Pfizer/BioNTech) - mRNA1273 (Moderna) - Ad26.COV25 (J&J/ Janssen) - NVXCOV2373 (NOVAVAX) - Monoclonal Antibodies: Evusheld TM (Tixasevimab Co-packaged with Cilsavimab) - No longer authorize in any USA region due to high frequency of circulating SAR-COV2 variants that are not susceptible to Evuheld - Cannot be administered for pre=exposure prophylaxis for prevention of COVID-19 under emergency use authorization - LABS ASSOCIATED with SEVER COVID-19: - Abnormally (elevations in) - D-dimer \>1000 (normal limit \245 (normal limit 110-210) - Ferritin \>500 (normal limit \< 200 female; \ 4.5 - Diagnosis: - Usually performed with a wet mount or PAP Smear - Treatment: - Women: - Metronidazole 500mg BID x7 - Men: - Metronidazole 2g Orally in a single dose - Provide treatment for partner to mitigate the probability of re-infection. - Counsel patient on the significance of refraining from sex for 7 days after treatment - Rescreen patients 3 months after treatment, if there is a high probability of reinfection - BACTERIAL VAGINITIS: - Bug: G. Vaginalis, Mobiluncus species, Prevotella species, Mycoplasma species - Mos common genital tract infection amongst reproductive aged women - Diagnosis: - Vaginal gram stain - A 10% KOH solution mixed with the vaginal secretions yields a transient fishy odor - A wet prep of the specimen reveals "clue cells" - Vaginal pH \> 4.5 - Characteristic KOH "whiff" test - Treatment: - Metronidazole oral 500mg BID x7 - metronidazole gel 0.75% one 5g applicator intravaginally QD X5 - Clindamycin cream 2% one 5g applicator intravaginally HS X7 - GENITAL WARTS: - Clinical Presentation: - Appear as rough, thick, cauliflower-like lesions - Signs: - Black dots within warts - Disrupted surface - Symptoms: - Anogenital pruritus - Burning - Vaginal discharge - Bleeding - Rare: dyspareunia may occur with vulvovaginal condyloma - Diagnosis: - A definitive diagnosis of HPV is based on DNA, RNA, or capsid protein detection - Patients who are diagnosed with HPV should be tested for cervical cancer - Treatment: - Based on location of warts, Cryotherapy with liquid nitrogen is used consistently at all locations - HPV vaccine is available for 9-26 yr. old (vaccine in 27-45 yr old) - DRUG SIDE EFFECT PROFILES: - Metronidazole: - Candidiasis - Vaginitis - Metallic taste - Vaginal discharge - Ceftriaxone: - Injection site reaction - Doxycycline: - Influenza - Jarisch-Herxheimer Reaction - What is it? - Benign, self-limited complication of anti-treponemal antibiotic therapy that develops within hours after treatment of early syphilis - What are the clinical manifestations? - Fever, chills, myalgias, headache, tachycardia and hypotension - The reaction should not be interpreted as an allergic reaction to penicillin - It typically begins within the first 24 hours after antibiotic administration and normally subsides spontaneously, generally subsiding even while antibiotic is continued - Is JHR only associated with syphilis? - Notably JHR occur after administration of many antimicrobials and is nor is it exclusive to syphilis treatment, occurring in other spirochetes diseases, such as Lyme disease and relapsing fever - Penicillin G Benzathine: - N/V - Diarrhea - Tongue discoloration - Vomiting - Acyclovir: - Malaise - Skin irritation \#\#\# Advanced Patient Therapeutics Exam \#\#\#\# Topics: COVID-19, Influenza, HIV, and STIs \*\*Instructions:\*\* Answer all questions by selecting the most appropriate option. Each question is based on a patient case. Choose the single best answer for each. \-\-- \#\#\# Section 1: Influenza and COVID-19 1\. \*\*Patient Case:\*\* A 67-year-old male with a history of COPD presents with fever, malaise, myalgia, and a nonproductive cough. Influenza is suspected. What is the most appropriate antiviral treatment for this patient? \- A. Amantadine \- B. Baloxavir marboxil \- C. Oseltamivir \- D. Rimantadine 2\. \*\*Patient Case:\*\* A 25-year-old female receives the live attenuated influenza vaccine (LAIV). Which of the following conditions would contraindicate its use? \- A. Pregnancy \- B. Mild asthma \- C. Age below 50 years \- D. Seasonal allergies 3\. \*\*Patient Case:\*\* A 35-year-old immunocompromised patient is hospitalized with confirmed influenza A. Which medication should be avoided due to potential resistance? \- A. Oseltamivir \- B. Zanamivir \- C. Peramivir \- D. Amantadine 4\. \*\*Patient Case:\*\* A 45-year-old female presents with flu-like symptoms. She has a BMI of 35 and was recently diagnosed with type 2 diabetes. Which of the following factors increases her risk for severe COVID-19 complications? \- A. BMI \> 25 \- B. Recent diagnosis of diabetes \- C. Female gender \- D. Age \< 50 5\. \*\*Patient Case:\*\* A 52-year-old male with a history of hypertension is diagnosed with mild COVID-19. Which of the following is a primary treatment goal for this stage of the disease? \- A. Administer intravenous remdesivir \- B. Manage symptoms and monitor for progression \- C. Initiate oxygen therapy \- D. Prescribe Paxlovid without renal adjustment 6\. \*\*Patient Case:\*\* A 30-year-old female is considering the mRNA COVID-19 vaccine. She asks about potential long-term side effects. What is the appropriate counseling? \- A. Long-term effects are well-studied and common. \- B. Vaccines contain live virus and may cause infection. \- C. Clinical studies show no evidence of severe long-term side effects. \- D. Vaccines are contraindicated in women of childbearing age. 7\. \*\*Patient Case:\*\* A 70-year-old patient with chronic kidney disease presents with COVID-19 symptoms for 6 days. Which outpatient treatment is recommended? \- A. Paxlovid \- B. Supportive care only \- C. Remdesivir for 3 days \- D. Ritonavir 8\. \*\*Patient Case:\*\* A 29-year-old male healthcare worker has significant exposure to COVID-19. What prophylactic treatment is no longer recommended in the U.S.? \- A. Evusheld \- B. Paxlovid \- C. Remdesivir \- D. Molnupiravir \-\-- \#\#\# Section 2: HIV 9\. \*\*Patient Case:\*\* A 34-year-old male diagnosed with HIV is starting antiretroviral therapy (ART). His HLA-B\*5701 test is positive. Which medication should be avoided? \- A. Lamivudine \- B. Abacavir \- C. Tenofovir alafenamide \- D. Dolutegravir 10\. \*\*Patient Case:\*\* A 28-year-old female presents with fever, pharyngitis, and lymphadenopathy. She reports recent unprotected sexual contact. Which lab test would confirm an HIV diagnosis? \- A. CD4 count \- B. HIV RNA level \- C. HIV-1/2 antigen-antibody test \- D. Complete blood count 11\. \*\*Patient Case:\*\* A 45-year-old male with HIV has an undetectable viral load on ART. What monitoring frequency is recommended for CD4 count? \- A. Every 3 months \- B. Every 6 months \- C. Every 12 months \- D. CD4 count monitoring is optional 12\. \*\*Patient Case:\*\* A patient is being considered for pre-exposure prophylaxis (PrEP). Which of the following is an appropriate regimen? \- A. Lamivudine and zidovudine \- B. TDF-emtricitabine \- C. Maraviroc \- D. Darunavir and ritonavir 13\. \*\*Patient Case:\*\* A 52-year-old male is diagnosed with HIV and reports severe bone pain. Which NRTI is associated with reduced bone mineral density? \- A. Tenofovir disoproxil fumarate (TDF) \- B. Emtricitabine \- C. Abacavir \- D. Zidovudine 14\. \*\*Patient Case:\*\* A 36-year-old female presents with a rash and fever 1 week after starting abacavir. What is the most likely cause? \- A. Drug-induced liver injury \- B. Hypersensitivity reaction \- C. Opportunistic infection \- D. Immune reconstitution syndrome 15\. \*\*Patient Case:\*\* A healthcare worker experiences a needle-stick injury from an HIV-positive patient. Which post-exposure prophylaxis (PEP) regimen is recommended? \- A. Maraviroc + dolutegravir \- B. Raltegravir + TDF-emtricitabine \- C. Atazanavir + lamivudine \- D. Dolutegravir + abacavir 16\. \*\*Patient Case:\*\* A patient with HIV is initiating therapy with darunavir. What is the role of ritonavir in this regimen? \- A. To enhance absorption \- B. To act as a protease inhibitor \- C. To inhibit CYP3A4 metabolism \- D. To reduce resistance to NRTIs \-\-- \#\#\# Section 3: Sexually Transmitted Infections (STIs) 17\. \*\*Patient Case:\*\* A 25-year-old male presents with dysuria and purulent urethral discharge. Gram-negative diplococci are identified. What is the recommended treatment? \- A. Doxycycline \- B. Ceftriaxone \- C. Azithromycin \- D. Metronidazole 18\. \*\*Patient Case:\*\* A 32-year-old female with genital ulceration is diagnosed with primary syphilis. What is the appropriate treatment? \- A. Benzathine penicillin G IM single dose \- B. Ceftriaxone \- C. Acyclovir \- D. Doxycycline 19\. \*\*Patient Case:\*\* A 40-year-old male reports painful vesicular lesions on the genitalia. HSV-2 is confirmed. What is the first-line therapy? \- A. Metronidazole \- B. Acyclovir \- C. Doxycycline \- D. Valacyclovir 20\. \*\*Patient Case:\*\* A 28-year-old female presents with a \"strawberry cervix\" and excessive yellow-green discharge. Wet mount confirms trichomoniasis. What is the appropriate treatment? \- A. Metronidazole \- B. Doxycycline \- C. Azithromycin \- D. Ceftriaxone 21\. \*\*Patient Case:\*\* A 35-year-old female presents with malodorous vaginal discharge and a positive \"whiff\" test. Microscopy reveals clue cells. What is the recommended treatment? \- A. Metronidazole oral 500 mg BID x7 days \- B. Clindamycin cream 2% intravaginally x7 days \- C. Fluconazole oral 150 mg single dose \- D. Azithromycin 1 g orally single dose 22\. \*\*Patient Case:\*\* A 26-year-old male presents with a painless genital ulcer and reports recent unprotected intercourse. Which test is the gold standard for diagnosing syphilis? \- A. Nontreponemal test (RPR) \- B. Treponemal test (FTA-ABS) \- C. Dark-field microscopy \- D. PCR for Treponema pallidum 23\. \*\*Patient Case:\*\* A 31-year-old male presents with dysuria and urethral irritation. NAAT confirms chlamydia. What is the first-line treatment? \- A. Azithromycin 1 g orally single dose \- B. Doxycycline 100 mg BID x7 days \- C. Ceftriaxone 500 mg IM single dose \- D. Metronidazole 2 g orally single dose 24\. \*\*Patient Case:\*\* A 45-year-old female reports vaginal itching and discharge. Examination reveals \"strawberry cervix\". Rescreening is planned in 3 months due to high reinfection risk. What condition is this management for? \- A. Trichomoniasis \- B. Bacterial vaginosis \- C. Genital herpes \- D. Gonorrhea 25\. \*\*Patient Case:\*\* A 30-year-old male with a history of multiple sexual partners is diagnosed with HPV. What is the recommended prevention strategy? \- A. HPV vaccine \- B. Cryotherapy for warts \- C. Podophyllotoxin cream \- D. Imiquimod cream \-\-- \#\#\# Answer Key (for instructors only): 1\. C 2\. A 3\. D 4\. A 5\. B 6\. C 7\. C 8\. A 9\. B 10\. C 11\. D 12\. B 13\. A 14\. B 15\. B 16\. C 17\. B 18\. A 19\. B 20\. A 21\. A 22\. C 23\. B 24\. A 25\. A