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Pediatrics > HEENT > Flashcards

HEENT Flashcards

1
Q

Developmental concerns for eye for newborn

A

-Peripheral vision is intact in the newborn, but the macula (the area of sharpest vision) is absent at birth, but is developing by age 4 months and mature by 8 months. -By 3-4 months the infant can fixate on a single image with both eyes at the same time. -The eyeball reaches adult size by age 8.

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2
Q

normal objective data

A

– Neonate: test for light reflex – blinks – Allen test (picture card) for 2 1⁄2 - 3 yrs of age – Snellen E for 3-6 year olds – Snellen Alphabet Chart 7-8 + (20/20) – Screen two separate times before referral!

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3
Q

Color blindness

A

inherited X- linked trait affecting males, rarely females Test boy between 4-8: Ishihara’s Test

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4
Q

more objective data: extra ocular muscle test

A

Testing for strabismus is an important screening measureduring early childhood.
– Early diagnosis and treatment are essential to restore binocular vision. – Diagnosis after age 6 has a poor prognosis.
– Check corneal light reflex and cover test.

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5
Q

cranial nerves that helpwith muscle movements of the eye

A

3,4, & 6

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6
Q

pink eye definition and s/s

A

Definition
– Inflammation of the CONJUNCTIVA

Signs and symptoms

– Redness and swelling of the conjunctiva and discharge – usually bilateral

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7
Q

chemical conjunctivitis

A

newborns- from silver nitrate or chemotherapy prophylaxis

older children/ adolescents- could give themselves too much eye drops within a small time frame and burn sclera

  • usually self limiting
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8
Q

bacterial conjunctivitis

A

bilateral or unilateral, very contagious, lasts 8-10 days, sclera isn’t as pink like in viral
- possible organisms- staph, strep, H. influenza

(hint- check ears- if ear infection with conjunctivitis, treat with oral Augmentin)

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9
Q

viral conjunctivitis

A

very common, highly contagious, may or may not have discharge, associated with URI, enlarged preauricular lymoh nodes, lasts about 14 days with or w/o treatment (usually treat even if viral because only way to know for sure is a culture, so we just treat)

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10
Q

allergic conjunctivitis

A

bilateral, cardinal sx is ITCHING, inflamed cornea and conjunctiva, cobblestone papilla in conjunctiva, itching/ pain or feeling like something is stuck in the eye, associated with seasonal allergies.

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11
Q

bacterial vs viral vs allergic conjunctivitis

A
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12
Q

lacrimal duct obstruction

A

Dacryocystitis- inflammation of the lacrimal sac

-excessive tearing, purulent drainage. Its from failure of canalization of duct. Tx- simple message between nose and eye when hands are clean. would tx with erythrymycin ointment if infant got a secondary bacterial infection. Refer if it happens after 12 mos, could need surgery to open duct

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13
Q

periorbital cellulitis

A

acute infection and inflammation of the eyelid and surrounding tissues

Etiology- bacteremia, focal infection (trauma/ insect bit)

-more often in younger children

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14
Q

orbital cellulitis

A

acute inflammation of the orbital contents; periorbitalinduration, erythema

Etiology- extension from a sinus infection

  • more often in older childrern
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15
Q

periorbital/ orbital cellulitits diagnostic tests and treatment

A

diagnostic tests- visual exam, c/s of eye discharge, CBC (>15,000 suspect associated bacteremia) and blood culture

  • be very careful with this- could cause meningitis. Coordinate with MD if suspect meningitis, or if you think you need CT or MRI. May need to be treated inpatient
  • if not sever and kept outpatient- usually tx with aumentin
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16
Q

stye

A

aka Hordeolum** - acute localized inflammation of one or more sebaceous glands or eyelid or eyelashes

  • common in infants and children, C/S not necessary
  • could tx with warm compress or tea bag
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17
Q

what is this?

A

hypema -is a rupture or iris or ciliary body, could be caused by trama or bleeding disorderd.

-medical emergency! direct admit to ED

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18
Q

poor vision/ change in vision

A

do focused physical assessment- visual acuity.

could be hyperopia, myopia, astigmatism. Refer to opthalmologist

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19
Q

hyperopia

A

farsightedness

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20
Q

myopia

A

nearsightedness

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21
Q

strabismus-

exotropia

A

eye deviates outward

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22
Q

strabismus- esotropia

A

eye deviates inward

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23
Q

strabismus- hypertropia

A

eye deviates upward

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24
Q

strabismus-

pseudostrabismus

A

appear to be crossed d/t exaggeration of epithanthal folds

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25
Q

pediatric differences in the respiratory system

A

infants and yound children- size: shorter distance b/w structures, more flexible larynx, lumen in the resp tract is smaller and subsequently easily obstructed, eustachian tubes are shorter and more horizontal, making it easy for pathogens to transfer to middle ear, tonsillar tissue enlarged.

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26
Q

the most common infection for which ABX are prescribed for kids in the US

A

acute otitis media

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27
Q

when does incidence of AOM peak?

A

between 6- 9 months of age. By 1 year 75% of all kids will have had at least 1 episode of AOM. Increased time with middle ear dx is associated with poor linguistic and school performance

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28
Q

diagnosing acute otitis media

A

definitive diagnosis MUST have all 3:

  • rapid onset
  • presence of middle ear effusion
  • s/s of middle ear inflammation
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29
Q

symptoms of acute otitis media

A

ear- related symptoms- earache, rubbing of ear, feeling of blocked ear

-fever, earache, excessive crying

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30
Q

middle ear effusion indicated by

A
  • bulging tympanic membrane
  • limited or absent mobility of the tympanic membrane
  • air- fluid behind tympanic membrane
  • otorrhea
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31
Q

middle ear inflammation- s/s

A

distinct erythema of the tympanic membrane OR distinct otalgia (discomfort clearly referable to the ear that interferes with normal activity or sleep)

32
Q

chronic otitis media with effusion

A
  • more common than AOM
  • may accompany viral or respiratory infections
  • preclude AOM or may be a sequele of AOM

(acute otitis media- requires the presence of MEE)

***the big difference: AOM is accompanied by an infection and OME is not***

33
Q

middle- ear effusion

A

presence of fluid in the middle ear without other symptoms of AOM. Usually no pain or fever but may feel fullness or need to “pop”

-TM often cloudy, could use tympanogram

34
Q

OME (chronic otitis media with effusion)

A
  • identify kids at risk (developmental delays, speech/ language delays)
  • those not at risk- watch and wait
  • no effective tx and no recommendations
  • re- examine in 3-6 months intervals
35
Q

initial treatment for AOM

A
36
Q

observation period

A

this option is changing. There was a landmark trial called the “wait and see approach” (WASP)

-she doesn’t support this approach

37
Q

“wait and see” prescription

A

wait 48hrs to see if has improved

38
Q

most common pathogens in neonates (for ear infection)

A

group B strep

E.coli

S.aureus

chlamydia

39
Q

most common pathogens in children >30 days old (ear infections)

A

S. pneumoniea 25- 50%

H. influenzae 15-30%

M. cattarhalis 3-20%

(viruses found in respiratory secretions and/or MEE in 40- 75% of cases)

40
Q

ABX treatment for ear infections

A

Amoxicillin 80- 90 mg/kg/ day divided BID (80% of pts with AOM will respond to this- including S. pmeumoniae)

(this is a HIGH dose, never use this for regular dosing of AOM)

Rationale for amocicillin- effective egainst most strains of Strep pneumoniae, safe for most pts, low cost, tastes good, narrow microbiological spectrum

41
Q

when to use Augmentin instead of Amoxil

A

amoxicillin- clavulanate (augmentin) drug of choice for patients who meet these criteria:

  • severe illness with severe otalgia or fever >39C
  • pts for whom coverage for H influenzea and M catarrahalis is desired- ie. conjunctivitis in addition to ear infection
42
Q

Augmentin dose

A

must use Augmentin ES 600 formulation*** for high dose tx. (>80mg/kg/day amoxil component)

  • too much clavulanate will cause diarrhea and upset stomach. The augmentin ES is formulated to have a lower ratio of clavulanate per amoxil ration
  • should be aware of all the different formulations of Augmentin liquid
43
Q

amoxicillin allergy options-

Non- type 1 hypersensitivity

A

Non- type 1 hypersensitivity:

  • cefdinir (omnicef) 14mg/kg/day in 1 or 2 doses
  • cefpodoxime(vantin) 10mg/kg/day QDay
  • cefuroxime (ceftin) 30mg/kg/day in 2 divided doses
44
Q

amoxil allergy options-

Type 1 hypersensitivity

A

Azithromycin (zithromax) 10mg/kg/day for day 1 followed by 5mg/kg/day for 4 days (all Qday)

(limited efficacy against s. pneumoniae and h. influenzea)

or

Clindamycin 30-40mg/ kg/ day in 3 divided doses. (may be used for suspected PCN- resistant S pneumoniae)

45
Q

length of therapy

A
  • for patients less than 6 years or with severe disease: 10 days
  • for patients 6 years of age with mild to modrate disease: 5-7 days
46
Q

predicting amoxil resistance: risk factors for resistance

A

child care

recent (<30 days) recipient of abx

age <2 years

47
Q

preventing AOM: reducing risk factors

A

non- modifiable- genetic predisposition, premature birth, male gender, native american/ inuit ethnicity,

family hx of recurrent AOM, siblings in the household, low socioeconomic status

48
Q

preventing AOM: reducing risk factors

A
  • flu vaccine- live- attenuated intranasal vaccine- 30% efficacy in preventing AOM during respiratory illess season
  • altering child care attendence patterns
  • breast- feeding during first year of life
  • reducing exposure to tobacco smoke
49
Q

preventing AOM: chemoprophylaxis

A
  • prevention of recurrent AOM, 3+ distinct episodes of AOM in 6 month period OR 4+ occurances in a single year
  • amoxil 20mg/kg/day
  • sulfisoxazole

??? confused about this slide

50
Q

failure to respond to therapy within __ hours should result in what

A

failure to respond within 48- 72 hours should result in change in therapy. (or if observation fails, start abx therapy)

  • if amox had failed, use augmentin
  • if augmentin had failed, use ceftriaxone 50mg/kg/ day IV X 3 days
  • if ceftriaxone fails, tympanocentesis is recommended (allows a bacteriologic diagnosis)

(neither bactrim or erythromycin- sulfisoxazole is appropriate therapy)

51
Q

tympanostomy tubes indicated for

A
  • OME for at least 12 weeks
  • more than 3 AOM infections in 6 mos
  • AOM that doesn’t improve after 2-3 courses of appropriate ABX
  • hearing loss or developmental delay
  • failure of chemoprophylaxis

(20- 50% of kids who have tubes relapse after tubes fall out- this usuall leads to adenoidectomy)

52
Q

treating ear pain

A
  • first line- tylenol, ibuprofen
  • topical agents- benzocaine, antipyrine, glycerin combo ear drops

(this is only for a short duration, parents should be education that in 72 hours if the child sill is in pain, they shold come back to the office)

53
Q

otalgia

ICD10- 388.7

A

pain in the ear. Primary otalgia orginates inside of ear. Referred otalgia is ear pain that originates from outside the ear. (otalgia not always associated with ear disease- may indicate impacted teeth, sinus disease, inflamed tonsils, infections in the nose and pharynx, throat cancer, and occasionally as a sensory aura that precedes a migraine)

54
Q

otitis externa

A
  • disruption of the squamous epithelium of the audotory canal, alteration in pH
  • will have pain when you pull on the pinna or press by the tragus
55
Q

good ear drop

A

ciprodex: abx + steroid + pain reliever, good for outer ear infection

56
Q

allergic rhinits

A

aka hay fever

  • inflammation of the nasal passage caused by allergic reaction
  • causes considerable discomfort
  • complicated other disease processes i.e. asthma
57
Q

s/s of allergic rhinits

A

symptoms: nasal congestion, head congestion, tearing eyes, nasal puritis, nasal discharge, turbinate edema
findings: nasal crease, clear nasal secretiong, grey and/ or boggy turbinates, deviated septum, perforated septum

58
Q

management of allergic rhinitis

A

mild to moderate- intranasal steroid (no cromolyn- decreased effectiveness)

moderate to severe- intranasal steroid, antihistamine, leukotriene inhibitor aka singulair (great with pts who also have asthma, mast cell stabilizer) nasal saline rinses

59
Q

education for allergic rhinitis

A
  • avoid/ decrease exposure to allergens
  • allergy covers on bed
  • no plush toys in the bed
  • consistent use of medications (they do NOT work like fever agents/ are not as needed)
60
Q

sinusitis

A

aka rhinosinusitis

  • inflammation of the sinuses
  • usually d/t infection; pathogens: s. pneumoniae, m cattarhalis, h. influenza
61
Q

symptoms/ findings of sinusitis

A

symptoms: previous URI sx, persistent nasal congestion, fever, purulent nasal discharge, foul breath, cough, sx last more than 10 days but less than 2 weeks.
findings: edema and eryhtema of turbinates, mucopurulent drainage,

sinus tenderness (rare in young children and infants)

62
Q

d/d for sinusitis

A

persistent URI, dental infection, TMJ, foreign bodt, migraine

63
Q

management of sinusitis

A

imaging is not recommended unless going to surgery, then CT

mild to moderate infection- Amoxil 45mg/kg/day or 90mg/kg/day divided

severe infection or daycare attendance- augmentin 80-90mg/kg/day divided

  • treat until pt is sx free + 10 days
64
Q

education and f/u for sinusitis

A

education: treatment adherence (take full course of ABX!), nasal wash/ saline spray okay, decongestants not beneficial, hand hygiene

f/u: U 10- 14 days to assess tx efficacy, if not could refer to otolaryngology, ID, allergy/ immunology, opthamology/ neurology (orbital complications)

65
Q

foreign body

A
  • common in toddlers and preschoolers
  • small item- beads, beans, raisins, pebbles, eraser tips
  • will see UNILATERAL foul smelling discharge
  • may need ENT to remove if you are unable
66
Q

pharyngitis

A

inflammation of the pharynx, often involving the tonsils

  • common in ages 4-7
  • approx 80% viral and relief of sx is indicated
  • bacterial pharyngitis most often caused by group A beta- hemolytic strep and requires abx therapy
67
Q

viral pharyngitis s/s

A

gradual onset, sore throat, eryhtema/ inflammation of pharynx and tonsils, vesicles or ulcers on the tonsils, fever, hoarseness, rhinitis, conjunctivitis, malaise, anorexia (early), cervical lymph nodes may be enlarged and tender, usually lasts 3-4 days

68
Q

viral vs bacterial pharyngitis

A

(get throat culture)

  • viral: relief of sx, salt water gargles, throat lozenges, analgesics (tylenol)
  • bacterial: abx (amoxil), stress importance of completing full course of abx bc untreated or partially treated can result in acute rheumatic fever or acute glomerulonephritits
69
Q

bacterial pharyngitis s/s

A

abrupt onset (may be gradual in kids younger than 2years), sore throat (usually severe), erythema/ inflammation of pharynx and tonsils,

fever (usually high, mah be moderate),

abdominal pain, headache, vomiting, cervical lymph nodes may be enlarged and tender,

usually lasts 3- 5 days

70
Q

acute strep pharyngitis

A
  • group A b-hemolytic streptococci (GABHS)
  • risk for serious sequele- acute rheumatic fever, acute glomerulonephritits, scarlet fever (although rarely seen in US)
71
Q

strep treatment

A

PCN

  • oral- needs 10 day tx to decrease risk of rheumatic fever and glomerulonephritis, issues with compliance
  • IM- PCN G- resolves compliance issue (1 injection), painful injection, PCN G procraine less painful, CANNOT give PCN G via IV
  • erythromycin or zithromax if PCN allergy (dosing for zithromax- 12mg/kg/day X5 days)

also educate- throw out toothbrushes after 2 days of abx

72
Q

f/u referral for strep

A

no need for f/u unless no improvement of sx worsn

  • no need for “test of cure” (testing until neg)
  • surgical consult for those with frequent/ recurrent infection
  • surgical consult for kids with OSA
73
Q

peritonsilar abscess

A
  • infectious complication of pharyngitis or tonsilitis
  • assess white count
  • emergency! send to ER
  • ENT referral
74
Q

how to asess the ear in kids under 2

A

pull down and back

75
Q

at every visit assess what

A

nutrition

elimination

sleep

development

76
Q

live virus vaccinations

A

MMR

varicella

rota virus

77
Q

if need to treat strep but allergic to pcn treat with what

A

azithromycin 12mg/kg/day

Pediatrics (17 decks)

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