HEENT Flashcards
1
Q
What types of conjunctivitis are contagious?
A
Bacterial and viral
2
Q
Etiology of bacterial conjunctivitis
A
Strep pneumo, H flu or M cat
3
Q
Clinical presentation of bacterial conjunctivitis
A
Unilateral injection, thick purulent discharge
Report that eye is stuck shut
4
Q
Tx of bacterial conjunctivitis
A
Erythromycin ophthalmic ointment
Trimethoprim-polymyxin B drops
5
Q
When does neonatal conjunctivitis present?
A
5 and 14 days of life
6
Q
Etiology of neonatal conjunctivitis
A
Chlamydia trachomatis
7
Q
Clinical presentation of neonatal conjunctivitis
A
Watery to mucopurulent to bloody discharge
Chemosis
Pseudomembrane
8
Q
Gold standard for diagnosis of neonatal conjunctivitis
A
Culture!!
9
Q
Tx for neonatal conjunctivitis
A
Oral erythromycin (topical is not effective)
10
Q
Presentation of hyperacute bacterial conjunctivitis due to Neisseria
A
Severe and sight threatening (keratitis/perforation may occur) 2-5 days after birth Rapidly progressive Profuse, purulent discharge Marked chemosis Typically also see urethritis
11
Q
What is a risk of contact lens wearers?
A
Pseudomonal keratitis (ulcerative)
12
Q
Presentation of keratitis
A
Foreign body sensation
Blepharospasm (can’t hold eye open)
Usually have visible corneal opacity with penlight
13
Q
Etiology of viral conjunctivitis
A
Adenovirus
14
Q
Presentation of viral conjunctivitis
A
Injection, burning/gritty sensation in eye
Watery, scant stringy mucus
15
Q
Tx of viral conjunctivitis
A
Self-limiting
Warm compresses
Topical antihistamines/decongestants (OTC Naphcon-A over 6 yo)
Lubricant eye drops/ointment OTC
16
Q
How long should a child with infectious conjunctivitis stay home?
A
Until there is no longer any discharge (about 24 hours after start abx)
17
Q
Presentation of allergic conjunctivitis
A
Bilateral injection, edema, discharge is water/scant/stringy
Itching
History of atopy of other allergies
18
Q
Pharmacologic tx of allergic conjunctivitis
A
Topical vasoconstrictor plus antihistamine (less than 2 wks)
OTC: Naphcon-A, Visine-A (over 6)
Antihistamine with mast cell stabilizing properties (over 3) like olopatadine or azelastine HCl
Mast cell stabilizers (over 4)-cromolyn
Topical NSAIDs
Topical glucocorticoids by opthalmologist
19
Q
What is Kawasaki disease?
A
Small and medium sized vessel vasculitis (mucocutaneous lymph node syndrome)
20
Q
Clinical presentation of Kawasaki disease
A
Fever (5+ days and not responsive to tylenol) CRASH Conjunctivits (bilateral, nonexudative) Rash (morbilliform) Adenopathy (cervical) Strawberry tongue Hands (red, swollen with desquamation)
21
Q
When should Kawasaki disease be considered?
A
All kids with prolonged explained fever over 5 days
22
Q
What risks do kids with Kawasaki disease have?
A
Cardiovascular complications (coronary aneurysms or carditis) *They all need an echocardiogram!
23
Q
Treatment of Kawasaki disease
A
Infectious disease and cardiology consults
IV intravenous immunoglobulin (provide extra antibodies and reduces prevalence of carotid artery aneurysms)
High dose aspirin (Race syndrome risk)
Delay vaccines because low immune system
24
Q
Presentation of strabismus
A
Misalignment of eyes with potential to cause amblyopia (reduction in visual acuity)
25
Dx of strabismus
Abnormal corneal light reflection or cover/uncover
26
What is dacryostenosis?
Nasolacrimal duct obstruction
| Most common cause of persistent tearing and ocular discharge in infants/kids
27
Clinical presentation of dacryostenosis
Chronic, intermittent tearing
Mucoid discharge
Debris on lashes
Mild redness of lower eyelid (rubbing)
28
First line tx of dacryostenosis
Lacrimal sac massage
29
Other management of dacryostenosis
Most resolve spontaneously (after 12 months unlikely)
Refer if persist past 6-7 mos
Surgical probe is definitive management
30
What is dacryocystitis?
Inflammation or infection of lacrimal sac (rare complication of dacryostenosis)
31
Etiology of dacryocystitis
S. epidermidis or aureus
32
Clinical presentation of dacryocystitis
Erythema, swelling, warmth, tenderness of lacrimal sac, purulent discharge
33
Management of dacryocystitis
Obtain culture
Treat promptly with empiric abx (7-10 days) like oral clindamycin for mild or IV vanco plus 3rd gen cephalosporin (severe)
Refer to ophth
34
Etiology of AOM
Strep pneumonia, H influenza, moraxella catarrhalis
35
Symptoms of AOM
Otalgia, fever, irritability, anorexia, vomiting/diarrhea
36
Physical findings for AOM
Bulging TM, TM with decreased/absent mobility, distorted landmarks, erythematous TM, otorrhea, hearing loss
37
What do you need for diagnosis of AOM?
Bulging TM or other signs of acute inflammation (erythema of TM, otalgia, fever) AND middle ear effusion (opacity TM, decreased mobility, air fluid level, otorrhea)
38
Abx for AOM
High dose amoxicillin (90 mg/kg/day divided q 12 hours)
<2 yrs: 10 days
>2 yrs: 5-7 days
No recent beta lactam, no purulent conjunctivitis, no recurrent AOM
39
What abx use for AOM with penicillin allergy?
Cefdinir or azithromycin (clindamycin or TMP-SMX)
40
What is not recommended in kids to help treat AOM?
Decongestants or antihistamines because can cause convulsions
41
Guidelines for tx of AOM with abx
ALL children under 6 months
ALL children with severe signs/symptoms
Bilateral AOM < 2 yrs
<2 yrs with unilateral AOM (new on uptodate)
42
When do you want to follow up for AOM (within 28-72 hours)?
6 mos-2 years with unilateral non severe
| OVer 2 with unilateral or bilateral non-severe
43
When you consider recurrent AOM prophylaxis
>3 episodes in 6 months
>4 episodes per yr if middle ear fluid is seen
Daily abx during winter months (Amoxicillin 40 mg or Sulfisoxazole 50 mg) 1 x day
44
Clinical presentation of otitis media with effusion
No sxs of acute infection
Amber, gray, blue, cloudy opaque retracted TM
Decreased, absent mobility of TM
Hearing loss
45
Management of otitis media with effusion
Tx symptoms
| Clinical evaluation and hearing test every 3-6 mos until resolved or need surgery
46
Main etiology of otitis externa
P. aeruginosa
47
Symptoms of otitis externa
Otalgia, pruritus, discharge (tragus tenderness with erythema or edema of ear canal)
48
Management of otitis externa
Aural toilet to clean canal
Treat inflammation and infection (topical)
Empiric (floxin otic, cortisporin suspension but not with perf!, ciprodex (with glucocorticoid))
Acidifying solutions
Ear wick PRN
49
Risk factors for allergic rhinitis
Family history of atopy, male, first born, born in pollen season, early abx use, maternal smoking, indoor allergens
50
2 patterns of symptoms for allergic rhinitis
Intermittent: sx < 4 days/wk or <4 wks
Persistent: sx > 4 days/wk and > 4 wks
51
When is allergic rhinitis considered severe?
```
One or more of the following:
Sleep disturbance
Impairment in school performance
Impairment of daily activities, leisures, sports
Troublesome symptoms
```
52
Physical findings in allergic rhinitis
Allergic shiners, Allergic conjunctivitis sometimes, Denie-Morgan lines, tears, allergic salute, pale/bluish, boggy nasal mucosa, edematous turbinates, clear rhinorrhea, cobblestoning on posterior pharynx
53
Management of allergic rhinitis
Allergen avoidance, pharmacotherapy, allergen immunotherapy
54
First line tx for allergic rhinitis
Intranasal glucocorticoids (flonase)
55
Other txs for allergic rhinitis
Antihistamines, decongestants, anticholinergics, mast cell stabilizers, LTR antagonists
56
When do you consider immunotherapy?
When the pt has maximized environmental control measures and on the optimal medication regiment (usually wait til about 5 and usually about 3-5 yrs of maintenance therapy)
57
Nasal polyps
Benign pedunculated tumors with pealed grape appearance (between nasal turbinates and septum)
Can be associated with cystic fibrosis (when kid is less than 12 this is suspected), chronic sinusitis, allerfig rhinits
58
Samter's triad
Nasal polyps, ASA sensitivity (NSAIDs), asthma
59
Clinical findings of nasal polyps
Obstruction of nasal passages, inflamed mucosa, profuse unilateral mucoid/mucopurulent rhinorrhea
60
Tx for nasal polyps
Decongestants, intranasal steroids, systemic steroids, surgical removal
61
Most frequent human illness
Viral URI
62
Physical findings of viral URI
Nontoxic appearing, may have low fever, erythema and edema of nasal mucosa, rhinorrhea (clear, yellow, green), abnormal middle ear pressure
63
Viral URI in infants vs school-aged kids
Infants: fever, nasal discharge, fussiness
| School aged: nasal congestion, discharge, cough
64
Expected course of viral URI sxs
14 days (<6 have about 6-8 colds per year)
65
Who should you never use OTC meds for?
Children <6 (suggest avoidance 6-12)
| Kids 12-18 if obese or have conditions that may have serious breathing probs (apnea, lung disease)
66
What is the downside to antitussives (codeine, dextromethorphan)?
Can delay or prevent coughing up mucus
| Can cause drowsiness leading to death
67
Symptoms of acute bacterial rhinosinusitis
Nasal (discharge, obstruction, congestion), cough might be worse at night, fever, HA, facial pain
68
Classification of acute bacterial rhinosinusitis
Persistent symptoms >10 and <30 days
Severe sxs (high fever 102.2, purulent discharge for over 3 days, Ill appearing)
Double worsening
69
Classification of chronic rhinosinusitis
```
Over 12 weeks
2 or more of:
Anterior/Posterior mucopurulent drainage
Nasal obstruction
Facial pain/pressure/fullness
Decreased sense of smell
```
70
Management of acute sinusitis
```
Saline nasal irrigation
Topical or oral decongestants
Antihistamines
Intranasal glucocorticoids
If suspect bacterial then augmenting 45mg
```
71
Management of chronic sinusitis
```
Control predisposing factors
Nasal saline irrigation
Intranasal glucocorticoids
Maybe abx
Anti leukotriene agents
Refer ent, otolaryngology etc
```
72
Most common etiology of pharyngitis
Viral (adenovirus, coxsackie A)
73
Sxs of viral pharyngitis
Sore throat and fever always
| Rhinorrhea, nasal congestion, conjunctivitis, laryngitis, cough, wheezing, GI symptoms, exanthem
74
Physical findings of viral pharyngitis
Tonsillopharyngeal erythema, enlarged tonsils, shotty LAD
75
Management of viral pharyngitis
```
Supportive care (Tylenol, ibuprofen etc)
Symptomatic relief (miracle mouthwash, children younger than 6-8 usually can’t gargle correctly)
```
76
Etiology of infectious mononucleosis
Epstein-barr virus
77
Sxs of infectious mononucleosis
Fever, sore throat, fatigue, malaise
78
Physical findings of infectious mononucleosis
Tender cervical LAD, palpable splenomegaly, resemble exudative GAS
79
Diagnosis of infectious mononucleosis
CBC wth differential (lymphocytosis to see atypical lymphocytes)
Heterophile antibody test (monospot-rapid serologic test)
Strep test
80
Management of infectious mononucleosis
May be 7-21 days
Supportive therapy
Activity restriction for 4 weeks (prevent splenic rupture)
81
Etiology of bacterial pharyngitis
Group A streptococci (strep. pyogenes)
82
Scoring of GAS pharyngitis to predict 85% change + throat culture
Age (15-30% cases in kids 5-15)
Season (late fall, winter, early spring)
Evidence of acute pharyngitis (erythema, edema, exudates)
Anterior cervical lymph nodes (tender, enlarged)
Fever (101-103)
Absence of usual URI sxs (like cough)
When only 5 of these, likelihood goes down to 50%
83
Sxs of GAS pharyngitis
Abrupt onset, sore throat, odynophagia, maybe fever
84
Physical findings of GAS pharyngitis
Pharyngeal erythema, exudate, uvular swelling, palatal petechiae, LAD, scarlet fever (scarlatinaform rash with diffuse sandpaper erythroderma or pastia's lines)
85
If suspicion is high with negative rapid antigen detecting (RADT) strep test, what's next?
Throat culture!!!
86
Centor criteria
```
Tonsillar exudates
Tender anterior cervical LAD
Fever by history
Absence of cough
0-2: unlikely, over 3: perform RADT
```
87
When must you start abx for GAS pharyngitis?
Within first 48 hours
88
Abx for GAS pharyngitis
To prevent complications (carditis, acute rheumatic fever) and reduce spread
Oral penicillin, amoxicillin or 1st gen cephalosporin
Azithro for PCN allergy
89
In what age and after when is acute rheumatic fever most common?
5-15 yo
| 2-4 wks after infection
90
5 major manifestations of acute rheumatic fever
Migratory arthritis (inflammation affecting several joints)
Carditis (damage to cardiac valves may be chronic or progressive)
CNS involvement (up to 8 mos after-sydenham chorea which is abrupt non-rhythmic involuntary movements)
Subcutaneous nodules
Erythema marginatum (annulare)-pink/red, non-pruritic rash to trunk and limbs
91
What history makes you worries for post-streptococcal glomerulonephritis (PSGN)?
GAS skin (3-6 wks prior) or other throat infection (1-3 wks prior)
92
Clinical presentation of PSGN
Varies but most commonly edema, gross hematuria or hypertension
93
Management of PSGN
Supportive
Treat volume overload (sodium and water restriction, loop diuretics-furosemide)
May need dialysis if kidney failure
94
Paradise criteria for tonsillectomy
At least 7 episodes in last year OR
At least 5 episodes in each of past 2 years OR
At least 3 episodes in each of past 3 years
95
What is considered an episode when considering a tonsillectomy?
```
ST plus fever >100.9 OR
Tonsillar exudate OR
Cervical adenopathy OR
Culture confirmed GABHS
Recommend observing for 12 mos
```
96
When does oral candidiasis often occur?
After abx therapy
97
Etiology of oral candidiasis
Candida albicans
98
Presentation of oral candidiasis
Adherent white curd-like plaques that brush off (no fever or other signs of systemic toxicity)
99
Management for oral candidiasis
Nystatin oral suspension
100
What is a highly contagious viral illness?
Mumps virus (infectious 3 days prior and 9 days after sxs)
101
Initial symptoms of mumps
Fever, HA, myalgia, fatigue, anorexia
| Within 48 hours, parotitis develops
102
Complications of mumps
Orchitis or oophoritis
Neurological complications (meningitis, encephalitis, deaf)
Arthritis, pancreatitis, myocardial involvement
103
Most common ages for parotitis
2-9
104
Sxs of parotitis
Salivary gland swelling (can last 10 days)
| Orifice of Stensen's duct is erythematous and enlarged
105
Tx for parotitis
Supportive care (acetaminophen, cold or warm packs)
