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MC community acquired PNA? Nosocomial? CAP=S Pneu
PNA in EtOH? Nursing home? EtOH=Klebsiella
PNA in COPD? S Pneu, H Flu, Moraxella
top 3 causes of typical CAP S Pneu, H Flu, Klebsiella
causes of atypical PNA Mycoplasma, Chlamydia, Coxiella, Legionella + viruses (flu, adeno, parainflu, RSV)
how dx Legionella PNA need urinary Ag assay
what's empiric PNA tx for pts<60 without comorbidities macrolide (ie erythromycin) or doxycline
what's empiric PNA tx for pts>60 or w comorbities fluoroquinolone (levofloxacin) OR cefuroxime and azythromycin or doxycycline
for lung abscess what Abx use if 1) gram + cocci, 2) anaerobe, 3) gram - 1) ampicillin or amoxicillin/clavulonic acid or vanc for S Aureus, 2) cindamycine or metronidazole, 3) fluoroquinolone or ceftazidine has hi gram - coverage
where TB lesions found during difft stages of dz 1) lower lobe (Ghon's focus, or Ghon's/Ranke's complex if also Ca++ hilar LN), 2) 2ry TB: apical cavitating lesion
which meds are used to decrs common flu amantidine or rimantidine
what virus family is Flu A, B orthomyxovirus
t/f: viral flu has rapid onset t (usually)
if PPD + but no active TB dz how tx? INH 9 mos
how tx active TB 1) pt in isolation until sputum is -, 2) 2 mos: RIPE, 4 mo Rifampin and INH
for which pts is PPD + 10mm cut off homeless, prisoners, health care workers, nursing home, prevalent area
for which pts is PPD + 5mm cut off HIV, close contacts, CXR evidence of 1ry TB
MC causes bac meningitis in <3mo Grp B Strep > E Coli, Klebsiella > Listeria
MC causes bac meningitis in <50yo N Mening > S Pneu > H Flu
MC causes bac meningitis in >50yo S Pneu > N Mening > Listeria
MC causes bac meningitis in immunocomp Listeria > N Mening, Pseudo > S Pneu
empiric tx of bac meningitis of < 3 mo cefotaxime + ampicillin + vanc
empiric tx of bac meningitis of <50yo, >50yo Ceftriax or Cefotax + vanc (+ ampicillin for > 50yo bc Listeria)
meningitis signs + maculopap rash w petichae suggests which bug N Mening
meningitis signs + vesicular rash suggests which bug varicella or HSV
CSF findings for TB and fungal meningitis low glu (<50) and >100 cells that are LYMPHs
how Guillan Barre CSF look? MS? Guillan Barre=greatly incrsd protein but nml cell #-- MS=oligoclonal IgG nml cell#
difft bac and vira/aseptic meningitis by CSF bac=>1000 PMN, <50 glu, 100 protein, >200 pressure-- viral=100-1000 lymph, nml glu, nml/sl incrsd protein and pressure
MC cxn (1) of meningitis sensorineural hearing loss
tx aseptic meningitis none, just Rx pain and F
prophylaxis close contacts of N Mening meningitis rifampin or ceftriaxone
name named signs for meningitis Kernigs=can't extend legs when sitting-- Brudzinski=flex neck causes flex legs
2 MC causes of encephalitis HSV and Arbovirus
what clue if HSV-1 encephalitis temporal lobe location
before performing LP for meningitis or encephalitis check for incrsd ICP (ie papillodema), focal neural defects [would have to image before LP]
how tx cerebral edema in encephalitis hypervent, IV mannitol, steroids
what's the difftl for F and altered mental status 1) infxs: sepsis, UTI/urosepsis, PNA, meningitis/encephalitis--2) Rx: neuroeleptic malignant syndrome, delirium tremens--3) metabolic: thyroid storm
how dx HSV meningitis? CMV? both can be done PCR on CSF (also EBV, VZV)
tx for encephalitis: HSV? CMV? RMSF, Lyme? HSV=acyclovir 2-3 wks--CMV=ganciclovir +/- foscarnet-- RMSF, Lyme=doxycycline
how manage brain abscess if <2cm can manage medically, otherwise aspiration/surgical excision IV Abx 6-8 wks, PO 2-3--then serial CT to watch progress
how would brain abscess due to bac PNA hematogenous spread look MCA distribution, mltpl abscesses at gray-white jxn
brain abscess s/p trauma or surgery MC organism S Aureus
what bug causes descending flaccid paralysis starting w dry mouth, diplopia, trbl speaking--what progresses next? C Botulinum, then muscle paralysis (limbs)
what's phenazopyridine, aka? urinary analgesic for UTI, aka pyridium
how tx preg woman w UTI? Why (what at risk for)? NOT quinolone (fetal arthropathy), ampicillin, amoxicillin or cephalosporin for 7-10d--at risk for IUGR, premature labor, cxns in preg
how tx acute, uncomplicated UTI in non pregnant woman? if doesn't respond? Bactrim 3d, if doesn't respond tx for presumptive pyelonephritis (10-14d)
how tx acute, uncomplicated UTI in man? if doesn't respond? 7d Bactrim, if doesn't respond do urology w/u
if relapse UTI within 2 wks of treatment? If >2 UTI/yr continue 2 wks longer and obtain urine culture
what does a dipstick urine test? urine leukocyte esterase (pyuria), nitrite (grame neg bac)
what sympt would make think pyelonephritis not UTI if F, or if back pain/costovertebral pain/flank pain' (not just suprpub tenderness see in UTI)
MC causes UTI 80% E Coli, also Staph Sapro and Enteroccoc
in what ppl is pyelonephritis considered complicated men, elderly, underlying renal dysfxn, DM, immunocompromised
when is a UTI considered complicated any time spreads beyond bladder, if fxnl/structural abnmlty, metabolic or neuro dysfxn
how tx pyelonephritis outpt based on gram stain: GNR: Bactrim or fluoroquinolone 10-14d, Amoxicillin for gram + cocci (Enterococc, Staph Sapro)
MC causes pyelonephritis E Coli (MC), Proteus, Enterobac, Klebsiella, [PESK urease + exc Serratia] Pseudo
how tx pyelonephritis if relapse if relapse w same bug treat 6wks longer, if difft bug tx 2 wks
how tx pyelonephritis in patient broad IV Abx for 24 hrs (ie ampicillin + gentamicin or ciprofloxacillin), then oral Abx 14-21d
how tx pyelonephritis w urosepsis, how is it diagnosed? urosepsis need IV Abx 2-3wks-- anytime blood cx is positive
how tx prostatitis if mild acute: bactrim or fluoroquinolone + doxycycline for 4-6wks--severe may need hospital and IV--chronic: fluoroquinolone for extended time but may relapse
bugs for prostatitis PESK=Proteus, enterobac, serratia, klebsiella + E Coli and Pseudo
when do you need a urine culture? in all pyelonephritis cases (to see if urosepsis), if UTI need to get if pt >65, DM, recurrent UTI, presence of sympt >7d, use of diaphragm
what's the MC STD? MC bac STD? MC STD=genital warts (HPV)--MC Bac STD= Chlamydia
how dx Chlamydia STD? urine PCR, DNA probes/IF--gram stain: PMN but no organism (intracell)
tx of Chlamydia azythromycin (oral 1 dose) or doxycycline (oral 7d)--need to tx all sex partners
Chlamydia is more or less freq asympt in women more freq (80% v 50%men) so some say all sex active adolesc esp women should be screened
complications Chlamydia in women cervical cancer, PID, Fitz-Hugh (infects liver capsule), salpingitis, tubo-ovarian abscess, ectopic preg, infertility (bc scarring)
tx of gonorrhea ceftriaxone (IM 1 dose, bc also covers Syph), and give azythro (1 dose) or doxycyline (7d) to cover Chlamydia
dx of gonorrhea gram stain showing organisms within WBC, need to get cultures in all cases and see if dissem
features of 1ry HIV infxn, when it occurs, how long it lasts mono-like w F, sweats, malaise, HA, sore throat, maculopap rash, diarrhea, LAD 2-4 wks after exposure, lasts 3d-2wks
sympt HIV persistent generalized LAD, night sweats, wgt loss, diarrhea, vaginal yeast and trichomonal infxns, thrush, oral leukoplakia, derm: seborrheic derm, psoriasis exacerb, molloscum, warts
dx of HIV and when test becomes + ELISA (+ 1-12 wks after infxn), need confirm w W Blot
what are CD4 cut offs for infxns AIDS at risk for <200 PCP, <100 Toxo, <50 MAC
AIDs prophylaxis and cut-offs <200 Bactrim (or dapsone and pentamidine), <100 erythro or clarithro
when start retro viral for AIDs any sympt HIV pts or asympt CD4<500
features of HAART therapy 2 nucleoside RT inhibitors + either a non-nucleoside RT inihibitor OR protease inhibitor
what pul infxns manifest during AIDs (4) bac CAP much more common esp CD4<200 (>1/yr is AIDs defining)--PCP (MC initial opport infix)--CMV and MAC (CD4<50)
what CNS manifest during AIDs(3) AIDs dementia in 1/3--Toxo (esp CD4<100)--Crypto meningitis
presentation of PCP, dx, tx hypoxia despite mild CXR, diffuse interstitial infiltrate-- dx: Silver/Giemsa-- tx: Bactrim 3 wk + steroids if hypoxis or incrsd A-a
imaging suggesting Toxo CNS >3 contrast mass lesions
dx and tx of Crypto meningitis in AIDs dx: CSF Crypto Ag or India Ink, tx Amph B 10-14d, then 8-10 wks oral fluconazole and lifelong maintenance w fluconazole
GI, oral, esophagus manifest in AIDs diarrhea (MC GI) can be many things incl Abx, Rx, CMV-- oral: thrush, ulcers (HSV, CMV), leukoplakia (EBV)-- esophagitis Candida, (also CMV, HSV)
Derm manifest in AIDs kaposi's sarcoma (vascular lesions), HSV, molloscum, shingles
what watch for w CMV in AIDs-- tx? retinitis that can cause blindness-- tx ganciclovir or foscarnet
MC bac opport infxn in AIDs--MAC
define HIV wasting syndrome loss 10% wgt with either chronic diarrhea or F and persistent wknss (not from other causes)
what should preg AIDs pt take AZT (ziduvidine)
what virus assoc w Bell's palsy HSV1
vesicle on end of finger think Herpetic whitlow-HSV inoculated into open sore--don't drain
what ocular problems can see w HSV keratitis, blepharitis, keratoconjunctivitis
describe 3ry syph CV syph, neurosyph (dementia, personality changes, tabes dorsales), gummas (subQ granulomas)
describe 1ry, 2ry syph 1ry: painless chancre (3-4wks after infxn, lasts 14wks)-- 2ry: 4-8wks after chancre healed maculopap rash (MC), +/- flu like, aseptic meningitis hepatitis
dx syphilis RPR/VDRL screening test, then FTA-Abs/MHA-TP
tx syph, if allergy 1 dose IM PCN (if allergy doxycycline, tetracycline oral 2wks)
what organism causes chancroid, what class of bug Haemophilus ducreyi (gram - rod)
what causes lymphogranuloma venereum Chlamydia trachomatis
tx C trachomatis doxycycline oral 21d
what genital ulcer is purulent w shaggy border Chancroid
what genital ulcer is beefy red nodules, coalescing to form granulomatous ulcers granuloma inguinale (klebsiella granulo)
which genital ulcer starts as papule, then vescle, then ulcer, usu only 1 lymphogran venereum
MC causes of cellulitis Strep Pyo and Staph Aureus
Cellulitis if wound, abscess: bug? Staph Aureus
Cellulitis if local trauma, skin break: bug? strep Pyo
Cellulitis if water, burns: bug? Pseudo
Cellulitis if fisherman: bug? Vibrio vulnificus
Cellulitis if acute sinusitus: bug? H Flu
define erysapelas S Pyo infxn of dermis and lymph causes well-demarcated bright red lesion
tx erysapelas IM or oral PCN or erythromycin
Nosocomial osteomyelitis: bug? Pseudo
osteomyelitis if prosthetic joint: bug? Staph epi
catheter septicemia and osteomyelitis:bug? S Aureus
how long and what route use for Abx for osteomyelitis 4-6wks IV
which PCN have good gram - coverage ampicillin and amoxicillin
what b lactamase inhibitor can be combined w amoxicillin clavulanic acid
what bugs is aztreonam good for Pseudo and Serratia (aerobic GNR)
which PCN is used for syph PCN G
which Abx is used for sickle cell prophylaxis PCN
PCN works synergistically w which Abx aminoglycosides
name Abx that are cell wall inhibitors PCN, cephalosporins, Vanc, imipenem/meropenem, aztreonam
name some bugs PCN is ineffective ag Rickettsia, Chlamydia (intracell), mycoplasma (no cell wall)
which PCN use for Staph coverage nafcillin or methcillin
what biggest SE for vanc red man syndrome--histamine release
name properties of ea cephalosporin generation 1st gen: like PCN + Proteus, Klebsiella, E Coli-- 2nd: more gram - and less gram +H Flu and Enterobac-- 3rd gen: more gram - and can cross blood-brain barrier-- 4th gen: most broad spec w Pseudo, Neisseria, MRSA
name Abx in ea cephalosporin class 1st gen: cefazolin, cephaloxin, cefadroxil the faz fad fell-- 2nd: cefaclor, cefoxitin, cefuroxime the fac fox furrowed-- 3rd gen: ceftriaxone, cefotax, ceftazidine-- 4th gen: cefipime
which Abx used CAP>60yo or w comorbidities cefuroxime
which cephalosporin used for gonorrhea ceftriaxone
vanc is often used with which Abx for enteroccoc aminoglycosides (gentamicin, streptomycin)
what Rx is imipenem or meropenem used w cilastatin
empiric coverage for gram - sepsis imipenem or meropenem w cilastatin
which bugs do tetracycline/doxycycline work on intracellul (Chlamydia, Rickettsia, Mycoplas), Vibrio Cholera, Lyme (Borrelia Burgd)
SE of tetracyclines GI, deposits Ca++ in tissues (can't use in preg or kids <8)-- also decrsd absorb if taken w milk or antacids
name some macrolides erythromycin, azithromycin, clarithromycin
name aminoglycosides gentamicin, streptomycin, neomycin
what bugs are aminoglycosides good for, name some Ags gram - aerobes (Klebsiella, E Coli)-- gentamicin, streptomycin, neomycin
what are macrolides good for? Name some intracellul (Mycoplasm, Legionella)-- erythromycin, azithromycin, clarithromycin
what PCN alternative can use in preg woman Erythro (since can't use tetracycline in preg)
which macrolides also work ag Staph and Strep erythro and clarithro
which macrolides also work ag H Flu Clarithro and Azithro
key use of clindamycin anaerobes
key use fluoroquinolones, name some gram - (ie UTI)-- levofloxacin, ciprofloxacin
which fluoroquinolone also has good gram + coverage, can be used CAP levofloxacin
which 2 classes of Abx can't be used in kids tetracyclines (Ca++ deposits into tissues), fluoroquinolones (damage cartilage)
what key use of metronidazole anaerobes [also E histolytica, Giardia, Trichomonas
which Abx can't consume w EtOH metronidazole (gives disulfiram like rxn]
in 2nd stage of Lyme dz, how present, cxns flu like w HA, stiff neck, F, chills musculo skel pain-- after several wks can get meningitis/encephalitis, cranial neuritis, peripheral radiculoneuropathy-- wks/mos can get carditis (heart block, pericarditis, carditis)
longterm effects Lyme dz arthritis (esp knee), chronic CNS, acrodermatitis chronica atrophicans (rare)
dx Lyme dz 1) erythema migrans w h/o tick exposure in endemic area-- 2) ELISA can detect within 1 mo and confirm w W Blot
tx of Lyme dz, cxns of Lyme dz oral doxycyline 21 d-- for cxns: 30-60d-- meningitis needs IV Abx 4wks
what abnml lab values might see w RMSF--increased LFTs and decrsd plts
describe present of RMSF F, chills, N/V, myalgias, photophobia, HA, papular rash starts peripheral, becomes maculopap and then petichae-- can get interstitial pneumonitis
tx RMSF doxycyline 7d [preg or CNS: chloramphenicol]
describe F pattern in difft types of malaria falciparum=F constant-- oval, vivax=F q24 hr-- malarial=q 72 hr
which malaria can have dormant hypozoites in liver? How tx that difftly? vivax and ovale, need to add 2 wks primaquine
which malaria is most life-threatening falciparum
tx malaria chloroquine, if resistance then quinine sulfate and tetracycline
prophylaxis malaria chloroquine if no resistance, otherwise mefloquine
key finding histopath that IDs rabies Negri bodies (eosinophilic inclusion bodies in nerve cell bodies)
which bug can give ulcer at site of tick bite, describe rest of presentation tularemia, also see F, HA, painful LAD
which arbovirus can give isolated LAD,how dx, tx? bartonella henslea (cat scratch dz), dxserology, clinica, no tx nec
which spriochete can contaminate water-- how present, how tx leptospirosis-- anicteric=rash, LAD, incrsd LFTs-- icteric=renal or liver failure, vasculitis and vascular collapse-- tx tetracycline or doxycycline
describe presentation of leptospirosis anicteric=rash, LAD, incrsd LFTs-- icteric=renal or liver failure, vasculitis and vascular collapse
what cutaneous lesions can Candida create erythematous eroded patches esp in DM, obese, under skin folds
t/f candida esophagitis can be painless TRUE
how dx candida KOH showing yeast
how treat vaginal candida miconazole or clotrimazole cream
how treat thrush nystatin mouthwash (3-5x/d) or clotrimazole troches (5x/d)
differentiate bw Blasto, Histo, and Cocci in terms of clinical present Blasto=constitut sympt, LAD, PNA-- Histo=flu like, erythema nodosum, hepatosplenomegaly-- Cocci=asympt or non-specific respir (if dissem will have focal CNS)
differentiate bw Blasto, Histo, and Cocci in terms of tx generally oral itraonazole (or fluconazole) 6mos, if severe or immune comp IV Amph B
clinical present of Sporothrix Schenki (localized and dissem) localized=hard subQ nodules that ulcerate-- dissem=PNA and meningitis
tx of Sporothrix Schencki KI 1-2 mo or itraconazole 3-6mos, if dissem amph B
tx cryptococc amph B w flucytosine 2 wks, + oral flucanazole-- if AIDs then continue fluconazole until CD4>100 for 1 yr
describe E Histolytica present, tx (amebiasis)=bloody diarrhea, tenesmus, abd pain, +/- liver abscess-- tx iodoquinol or paramomyon + metronidazole if liver abscess
what is bug for round worm, what cxns, how tx ascaris-- can cause pan duct of CBD obstruct-- tx albendazole, mebendazole, or pyrantel pamoate
what is bug for hook worm, how present, how tx ancylostoma duodenale, cough, anemia, malabsorb, eos-- tx=mebendazole or pyrantel pamoate
what is bug for pin worm, how present, how tx Enterobiasis, perianal pruritus, tx=mebendazole or pyrantel pamoate
what worm from undercooked meat, how tx tape worm (taenia solium)-- tx praziquentel
what bug can cause B12 defic, how tx tape worm (Diphyllobothrium Latum)-- tx praziquentel + B12
which bug can block portal vein, how tx Schistosomiasis-- tx praziquentel
present of Cryptoporidiosis, tx watery diarrhea, supportive
which bugs MC for intrabd infxn Enterococc, Bacteroides, E Coli
bugs for endocarditis: subacute, acute IV drug, prosthetic valve subacute: Step viridans-- , acute IV drug: Staph Aureus, prosthetic valve: Staph Epi-- if S Bovis shows up watch for GI malignancy
MC bugs acute sinusitus viral, S Pneu, H Flu Moraxella
MC bugs chronic sinusitus Staph Aureus, anaerobes
what bug causes TSS Staph Aureus MC (also Strep Pyo)-but it’s the toxin that causes the dz
clinical present of TSS rapid onset hi F, HA, myalgias, diffuse macular eryth rash, strawberry tongue and hypotension-- rash desquamates during convalescent phase
what lab values might see in TSS incrsd ALT/AST, incrsd BUN or Cr and pyuria, decrsd plt, incrsd creat kinase
define neutropenic fever and common causes if PMN and bands <1500 then F may be only sign for a really bad infxn-- MC septicemia, cellulitis, and PNA
tx of neutropenic F isolation, broad spec Abx, if doesn't resolve add anti-fungal
CF and CGD are at risk for which bugs Staph and Pseudo
asplenic are at risk for which bugs encapsulated: S Pneu, Neisseria, H Flu
cxns of mono decrsd plts, hemo anemia, splenic rupture
what Ab is detected in Monospot test? What would PBS show? heterophil Abs, PBS shows large atypical lymph
what can trigger Herpes Zoster break in skin at that site, immunocompromise
tx Herpes Zoster antiviral + TCA (desipramine) for neuropathic pain + steroids
what bugs are assoc w Gullan Barre Camp Jej MC, also CMV, EBV, and Mycoplasma
describe Dengue fever presentation mosquito flavivirus, muscle/joint pain, macular rash, cervical LAD, injected conjuctiva w incrsd LFT, WBC and decrsd plts in hemorrhagic kind
how hairy oral leukoplakia present? Tx? (EBV) white projections on one side of tongue, tx=acyclovir
tx dissem Toxo trimethoprim and sulfadiazine (Bactrim)
how does Crypto meningitis present that's different often doesn't have stiff neck, photophobia or vomitting, just F, malaise and HA
name 3 anti-cough meds codeine, bextramethorphan, benzonatate
when need to get CXR for bronchitis if suspect PNA, ie F, tachypnea, crackles, dullness to percussion
MC causes acute bac sinusitis S Pneu, H Flu, anaerobes
MC causes of chronic bac sinusits and which difft from acute same as for acute (S Pneu, H Flu, anaerobes) + Staph Aureus and GNR
when get imaging in acute sinusitis if no imrpovement after 1-2 wks of Abx and decongestants
what Abx used for acute sinusitis (4) 1) amoxicillin +/- clavulanate, 2) Bactrim, 3) levofloxacin or morafloxacin, 4) cefuroxime
what anti-His are used for acute sinusitis w allergic component (3) 1) loratadine (Claritin), 2) fexofenadine (Allegra), 3)chlorpropamine (ChlorTrimeton)
what decongestants are commonly used, for how long pseudoephedrine, oxymetazoline (<3-5d)
MC causes laryngitis viral, also Moraxella and H Flu
Abx for strep throat PCN for 10d (or erythromycin)
when do endoscopy for GERD if wgt loss, dysphagia, anemia, persist despite tx, suspect ulcer or stricture (also monitor Barretts)
how monitor for Barretts in GERD if sympt GERD 5yrs, should do endoscopy and bx q3 yrs
tx GERD (by phases) 1) behavior mod and antacids after meals and at bedtime, 2) add H2 blocker, 3) switch to PPI, 4) add promotility (metoclopramide or bethanechol), 5) combo
promotility
Rx used in GERD metoclopramide or bethanechol
sx for GERD (2) Niessen's fundoplication if esophageal motility is good, if motility isn't good do a partial fundoplication
when do you need to check stool sample for WBC in cases of diarrhea if bloody stool, systemic symptoms (ie F), dehydration, abd pain, N/V
if no F and no blood and have diarrhea, what could be causes viral (Rota or Norwalk), Enterotoxic E Coli (traveler's diarrhea), or food poison S Aureus, C perf)
if diarrhea, when need to order stool culture WBC in stool, invasive bac suspected, hospitalized, moderate/severe illness or F
MC acute bac diarrhea C Jejuni
name Abx used for Shigella, C Jejuni, Giardia Shigella=Bactrim, C Jejuni=erythromycin, Giardia=metronidazole
generally what Abx used for mod-severe diarrhea 5d ciprofloxacin
what cxn to look for w hermorrhagic E Coli 0157:H7 HUS and TTP
how difft 2 MC food poisoning bugs C Perfringens has crampy abd pain, not vomit or F-- S Aureus has N/V and assoc w mayonnaise
foul smelling diarrhea w bloating is assoc w ? Tx? Giardia (tx metronidazole)
when should loperamide be used in diarrhea if mild-mod w no F and no blood
differentiate shigella and salmonella in terms of sympt shigella often has tenesmus and less often N/V-- salmonella can be w/o blood whereas Shigella almost always has blood
tx for constipation psyllium, dietary fiber, colase, cisapride
what Rx can be used specifically for IBS? How does it work? Tegaserod maleate (Zelnorm), serotonin agonist
what Rx can be used for N/V prochlorperazine (Compazine) or promethazine (Phenergan)
key differentials for N/V usu viral gastroenteritis or food poisoning-- also preg, metabolic (incl DKA), pancreatitis/appendicitis, Neuro/incrsd ICP, acute MI, Rx
some key Rx can cause N/V chemo, esp cisplatin, Abx (ie erythromycin), digitalis toxicity
Created by: ehstephns on 2010-10-16



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