1. Algorithm for who gets a CXR: 
- + findings on exam: breath sound changes, crackles, egophany
- High fever as long as you don't think it's flu (What makes you think its the flu - flu season, unvaccinated)
- Immunocompromised
- Any SOB.
- Heart failure & COPD - exam is really unreliable in people with COPD because they have bullae and its hard to hear the pathology
- Abnormal vital signs.
2. Who do you treat even if the CXR is negative
- Pneumonia is a clinical diagnosis - if someone's clinical picture looks like pneumonia, still treat it even if the CXR is negative
- Get the CXR anyways so you can establish a baseline (in case they dont get better you can see the changes over time), and to look for complications (parapneumonic effusion - needs to be tapped to check for superinfection)
3. Tx: when to treat beyond azithro+ceftriaxone
- Upper lobe, reticulonodular, chronic, cavitary: TB
- Cavitary, post-viral: Staph (+ vanc)
- Aspiration risk: anaerobes (+ clinda)
- Diffuse, known HIV risk factors: PCP (+bactrim/steroids)
- HCAP risk factors (recent hosp, nursing homes): pseudomonas
4. Acute bacterial pneumonia in HIV+ looks just like acute bacterial pneumonia in everyone else.  
- Abrupt in onset, fever, focal (NOT diffuse) infiltrate = data says its overwhelmingly normal CA bacterial pneumonia, so you treat as you would treat anyone else.
- Don't add coverage for PCP or staph. Don't bronch him.
5. 90% of the lung infections in AIDS are one of the following: 
- Bacterial pneumonia: acute (<1 week), any CD4 count, lobar consolidation, injection drugs. Dx c sputum cx/gram stain, blood cx. Treat empirically
- PCP: subacute (weeks to months), CD4 <200, b/l diffuse perihilar, symeeetric homogenos. Clues: elevated LDH, more hypoxia than expected from CXR. Dx with BAL, silver stain, DFA for PCP
- TB: subacute, weeks to months, any CD4. When CD 4 <200 it can present in any way possible on CXR. Pleural effusion often present. Dx with sputum smear and cx.
6. Headache in an HIV+ patient (with a clean CT scan and exam) 
- MRI much more sensitive than CT in AIDS patients.
- Meningitis: cryptococcal most common meningitis in AIDS patients-- presents with neg exam, neg CT, neg MRI, subacute/indolent course -- this agent is not very virulent, doesn't affect normal people, and people can have it for weeks and look fine, no meningeal signs. Dx with serum cryptococcal antigen or fungal cx. LP will be normal 1/3 of the time-- so if you're gonna tap someone, you have to specifically request testing for cryptococcus). Can also do serum cryptococcal antigen- 95% sensitive. No substitute for CSF but if you can't get an LP you can use it.
- Encephalitis
7. Headache, HIV+, focal neuro signs/seizures => mass lesion: 
- Toxo: serum toxo IgG: not 100% sensitive, and only proves past exposure not current infection. Biopsy isn't very sensitive (often necrotic). The way to deal with this is to treat it. All of the following criteria must be fulfilled to just do empiric toxo treatment and not work up futher: 1) not on bactrim prophy as it works well to prevent toxo 2) + toxo IgG 3) Multiple ring enhancing lesions 4)no meningeal signs. The danger is not in overtreating but missing something else which needs different treamtn.
- Primary CNS lymphoma (assoc w EBV 100% of the time in AIDS patients, other people with primary CNS lymphomas not always assoc with EBV, happens in people with CD4s of 0)
- PML (progressive mulitfocal leukoencephalopathy - can see in MRI): caused by JC virus. Treat with HAART, no specific treatment for it ?
8. Before you get an LP
- CT
- Coags!! Coags!!! Coags!!!! Prevent epidural hematoma.
9. Insulin pump
- cons- need frequent needle changes (q2-3 days), need training on carb counting and input, possib of DKA if pump malfunctions, cost (>6,000$), tethered to device
- pros- less glucose variability, better lifestyle, don't have to carry around a kit
10. New insulins
- inhaled
- oral
- plant based
- artificial pancreas