Topic
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Questions
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Evidence
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Snapshot
  • A 54-year-old man presents to her primary care physician for a worsening productive cough. His cough began approximately 2 months ago, and over the past week, he has been producing more yellow sputum. Medical history is significant for chronic obstructive pulmonary disease. He drinks occasionally and smokes 1-pack per day for the past 35 years. The patient is started on broad-spectrum antibiotics and receives 23-valent pneumococcal polysaccharide vaccine (PPSV23) due to his current cigarette use and chronic lung disease.
Introduction
  • Definition
    • an effective preventative health measure of disease
  • Terminology
    • live-attenuated vaccine
      • microorganism pathogenicity is lost but can still induce a cellular and humoral response
    • killed or inactivated vaccine
      • pathogen is inactivated but the epitope structure is maintained, inducing a humoral response
    • subunit vaccine
      • contains only that antigen that stimulates the immune system best
    • toxoid vaccine
      • bacterial toxoid with an intact receptor binding site
Vaccinations in Children (0-6 Years of Age)
 
Vaccinations in Children
Vaccine
Age
Comments
Hepatitis B
  • First dose within the first 24 hours of life
  • Second dose at 1-2 months of age
  • Third dose at 6-18 months of age
  • Subunit vaccine
  • In HBsAg-positive mothers, the infant should receive the hepatitis B vaccine and hepatitis B immune globulin 
Rotavirus
  • First dose at 2 months
  • Second dose at 4 months
  • Third dose at 6 months
  • Live-attenuated vaccine
  • Can increase risk for intussusception  

Diphtheria, tetanus, and/or pertussis

  • First dose at 2 months
  • Second dose at 4 months
  • Third dose at 6 months
  • Fourth dose at 15-18 months
  • Fifth dose at 4-6 years of age
  • Booster doses are given starting at 11 years of age
  • Inactivated vaccine
H. influenzae type b conjugate
  • First dose at 2 months
  • Second dose at 4 months
  • Third dose at 12-15 months
  • Inactivated vaccine
Pneumococcal conjugate (PCV 13)
  • First dose at 2 months
  • Second dose at 4 months
  • Third dose at 6 months
  • Fourth dose at 12-15 months
  • Inactivated vaccine

Poliovirus

  • First dose at 2 months
  • Second dose at 4 months
  • Third dose at 6-18 months
  • Fourth dose at 4-6 years 
  • Inactivated vaccine
Influenza
  • Annually ≥ 6 months of age
  • Intramuscular vaccine is an inactivated vaccine 
  • Intranasal vaccine is a live-attenuated vaccine
Measles, mumps, and rubella
  • First dose at 12-15 months
  • Second dose at 4-6 years of age
  • Live-attenuated vaccine
Varicella
  • First dose at 12-15 months
  • Second dose at 4-6 years of age
  • Live-attenuated vaccine
Hepatitis A
  • First dose at 12-24 months
  • Second dose given at least 6 months after the first dose
  • Inactivated vaccine
 
Vaccinations in Adolescents (7-18 Years of Age)
 
Vaccinations In Adolescents
Vaccine
Age
Comments
Tetanus, diphtheria, acellular pertussis (Tdap)
  • 11-12 years of age
  • Inactivated vaccine
Human papillomavirus
  • Two doses at 9-14 years of age
    • in patients between the ages of 9-14, the 2 dose are administered 6-12 months after the first dose
  • Three doses at ≥ 15 years of age
    • given at 0, 1-2, and 6 months
  • Subunit vaccine
  • Three doses of this vaccine are also recommended in immunocompromised adolescent patients
Meningococcal
  • First dose at 11-12 years of age 
  • Second dose at 16 years of age
  • Inactivated vaccine
Influenza
  • First dose given at 7-10 years of age and then annually
  • Intramuscular vaccine is an inactivated vaccine 
  • Intranasal vaccine is a live-attenuated vaccine
 
Vaccinations in Adults (> 18 Years of Age)
 
Vaccinations in Adults
Vaccine
Age
Comments
Influenza
  • One dose annually
  • Inactivated vaccine
  • In HBsAg-positive mothers, the infant should receive the hepatitis B vaccine and hepatitis B immune globulin 
Tetanus, diphtheria, acellular pertussis (Tdap) or tetanus and diphtheria (Td)
  • One dose Tdap and then a Td booster every 10 years 
  • In pregnant women, 1 dose of Tdap should be given during each pregnancy between 27-36 weeks gestation

Varicella

  • Two doses 4-8 weeks apart if the patient is without immunity to varicella
-
Zoster
  • Two doses given 2-6 months apart at ≥ 50 years of age
-
Pneumococcal (PPSV23)
  • Given at least 1 year after PCV13 administration in adults ≥ 65 years of age
  • PPSV23 is indicated in
    • patients 19-64 years of age with the following
      • chronic heart disease (excluding hypertension
      • chronic liver disease
      • chronic lung disease
      • diabetes mellitus
      • cigarette smoking
    • patients ≥ 19 with
      • immunodeficiency disorders
      • HIV
      • anatomical or functional asplenia
      • chronic renal failure or nephrotic syndrome
      • cerebral spinal fluid leak
      • cochlear implant
  • PPSV23 is given after PCV13
  • PPSV23 is not conjugated and does not stimulate a helper T-cell response 
 
Special Circumstances
  • Splenectomy
    • patients should receive vaccines to protect against encapsulated organisms
      • S. pneumoniae (pneumococcus)
      • H. influenzae
      • N. meningitidis (meningococcus)
    • vaccine regimen
      • PCV13 followed by PPSV23 ≥8 weeks later
      • H. influenzae type b vaccine
      • meningococcus vaccine
    • antibiotic prophylaxis
      • most children with anatomy or functional asplenia/hyposplenism
        • antibiotic prophylaxis (with penicillin V or amoxicillin) until the age of 5 for at least 1-year post splenectomy
  • HIV
    • inactivated vaccines are generally safe in this patient population
    • live-attenuated vaccines can be given in this patient population when their CD4+ T-cell count is ≥ 200 cells/μL 
  • Patients with an egg allergy
    • can receive the measles, mumps, and rubella vaccine
    • cannot receive the yellow fever vaccine 
  • Pregnancy
    • live vaccines are generally avoided in pregnancy
    • vaccines to be avoided
      • human papillomavirus
      • measles, mumps, and rubella
      • varicella
      • zoster
 

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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.ID.1) A 1-year-old boy presents to his pediatrician for episodes of crying and being hunched over. He has also had decreased oral intake during this time. He is generally healthy and has no medical issues. His temperature is 97.0°F (36.1°C), blood pressure is 94/54 mmHg, pulse is 100/min, respirations are 22/min, and oxygen saturation is 99% on room air. The child appears well and is playing; however, while in the office he has another spell of crying and being hunched over. An ultrasound is performed as seen in Figure A. Which of the following vaccines is associated with this patient's most likely diagnosis? Review Topic | Tested Concept

QID: 102733
FIGURES:
1

Hepatitis B

0%

(0/0)

2

Measles

0%

(0/0)

3

Poliovirus

0%

(0/0)

4

Rotavirus

0%

(0/0)

5

Tdap

0%

(0/0)

M2 D

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(M2.ID.24) A 34-year-old woman is assaulted and suffers a number of stab wounds to her abdomen. Bystanders call paramedics and she is subsequently taken to the nearest hospital. On arrival to the emergency department, her vitals are T: 36 deg C, HR: 110 bpm, BP: 100/60, RR: 12, SaO2: 99%. A FAST and abdominal CT are promptly obtained which are demonstrated in Figures A and B, respectively. Her chart demonstrates no other medical problems and vaccinations/boosters up to date. The patient is diagnosed with a Grade V splenic laceration and is immediately brought to the OR for emergent splenectomy. The splenectomy is successfully performed with removal of the damaged spleen (Figure C). Following the operation, the patient should receive which of the following vaccines: (I) H. influenzae (II) Tetanus (III) N. meningitidis (IV) S. pneumoniae (V) Hepatitis B Review Topic | Tested Concept

QID: 105661
FIGURES:
1

I, II

0%

(0/24)

2

I, III, IV

71%

(17/24)

3

I, V

0%

(0/24)

4

II only

0%

(0/24)

5

III, IV

25%

(6/24)

M2 A

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(M2.ID.93) A 68-year-old woman with chronic idiopathic thrombocytopenic purpura (ITP) presents to her hematologist for routine follow-up. She has been on chronic corticosteroids for her ITP, in addition to several treatments with intravenous immunoglobulin (IVIG) and rituximab. Her labs today reveal a white blood cell count of 8, hematocrit of 35, and platelet count of 14. Given her refractory ITP with persistent thrombocytopenia, her hematologist recommends that she undergo splenectomy. What is the timeline for vaccination against encapsulated organisms and initiation of penicillin prophylaxis for this patient? Review Topic | Tested Concept

QID: 104733
1

Vaccinate: 2 weeks prior to surgery; Penicillin: 2 weeks prior to surgery for an indefinite course

9%

(2/22)

2

Vaccinate: 2 weeks prior to surgery; Penicillin: at time of surgery for an indefinite course

32%

(7/22)

3

Vaccinate: 2 weeks prior to surgery; Penicillin: at time of surgery for 5 years

32%

(7/22)

4

Vaccinate: at the time of surgery; Penicillin: 2 weeks prior to surgery for an indefinite course

14%

(3/22)

5

Vaccinate: at the time of surgery; Penicillin: at time of surgery for 5 years

9%

(2/22)

M2 A

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Evidences (11)
Topic COMMENTS (14)
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