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Clinical Med I > HEENT - Upper Respiratory Infections - Exam 2 > Flashcards

HEENT - Upper Respiratory Infections - Exam 2 Flashcards

1
Q

What virology contributes the most to the common cold?

A

Rhinovirus (30-50%)

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2
Q

What are the common symptoms associated with the common cold?

A
  • Rhinorrhea
  • Nasal congestion
  • Sore throat (dry, “scratchy”)
  • Non-productive cough
  • Malaise
  • Low-grade fever
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3
Q

What are clinical signs of the common cold during a physical exam?

A
  • Nasal mucosal swelling
  • Nasal discharge (clear, purulent, watery)
  • Conjunctival injection
  • Pharyngeal erythema (mild)
  • No adenopathy
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4
Q

What is the treatment for the common cold?

A
  • Self-limiting (1-2 weeks)
  • Supportive care: rest, stay home
  • Antibiotics are of no value
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5
Q

What medications are recommended during the common cold?

A
  • Analgesics
  • Antihistamines
  • Expectorants
  • Antitussives (if patient has cough)
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6
Q

What is the etiology of influenza?

A

Influenza A and B viruses

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7
Q

What is death commonly due to with influenza?

A

Secondary bacterial pneumonia

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8
Q

What are the common seasonal outbreaks for influenza?

A

Fall and winter months

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9
Q

What are the pre-dominant symptoms seen with influenza?

A
  • Abrupt onset
  • Fever (can be extremely elevated)
  • Myalgia
  • Sore throat (can be severe)
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10
Q

What are clinical signs seen with influenza?

A
  • Flushing
  • Post pharynx typically unremarkable (even if patient has sore throat)
  • Mild cervical lymphadenopathy
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11
Q

What populations should be tested for influenza?

A
  • Influenza symptoms with no known outbreak
  • Immunocompetent patients with symptoms after hospital admission
  • High risk patients with symptoms
  • Healthcare workers with symptoms
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12
Q

What populations are considered high risk for influenza related complications?

A
  • Children < 5 years, but especially < 2 years
  • Immunosuppression
  • Chronically ill
  • Pregnant women or post-partum (within 2 weeks)
  • Residents of nursing homes
  • Native Americans
  • BMI of 40 or greater
  • Adults >65
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13
Q

What are in-office screening tests for influenza?

A

Rapid Influenza Detection Tests (RIDTs)

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14
Q

What are lab screening tests for influenza?

A
  • Rapid Molecular Assay
  • RT-PCR
  • Viral culture
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15
Q

What is the gold standard for lab diagnosis of influenza?

A

Viral culture

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16
Q

What are indications to treat with an antiviral for influenza?

A
  • Illness requiring hospitalization
  • Progressive, severe, or complicated illness
  • High risk
  • Uncomplicated influenza, but high-risk household contacts
  • Uncomplicated influenza in health care provider who cares for high risk patients
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17
Q

Within what time frame should antivirals be given for influenza?

A

Within 48 hours from onset of symptoms

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18
Q

What neuraminidase inhibitors are given for influenza A/B?

A
  • Oseltamivir (Tamiflu)
  • Zanamivir (Relenza)
  • Peramivir (Rapivab)
  • Baloxavir (Xofluza)
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19
Q

What should a pregnant woman with influenza be prescribed?

A

Antiviral

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20
Q

Zanamivir is contraindicated in what populations?

A

Patients with asthma, respiratory conditions, milk protein allergy

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21
Q

Who should receive the influenza vaccine?

A

Everybody > 6 months old

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22
Q

How long does it take for antibodies to develop after receiving the influenza vaccine?

A

Two weeks

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23
Q

What are potential contraindications for the influenza vaccine?

A
  • Current moderate to severe illness (fever)
  • Hx of Guillain-Barre Syndrome within 6 weeks of previous vaccine
  • Hx of allergic reaction to vaccine
  • Hx of severe allergic reaction to eggs
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24
Q

What is the most common etiology of pharyngitis?

A

Viral

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25
Q

While respiratory viruses are less likely to cause pharyngeal exudates, what are the exceptions?

A
  • Adenovirus

- Mononucleosis

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26
Q

If pharyngitis is caused by Herpes Simplex (HSV 1 and HSV 2), what is the treatment?

A
  • Acyclovir
  • Famciclovir
  • Supportive care
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27
Q

What is typical management of viral pharyngitis?

A
  • Supportive care with hydration, antipyretics, “Magic Mouthwash”
  • HIV needs antivirals and ID consult
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28
Q

What are clinical signs of pharyngitis caused by the virus Mononucleosis?

A
  • Sore throat, pharyngeal erythema
  • Tonsillar exudates
  • Enlarged cervical lymph nodes
  • Fever
  • Fatigue
  • Splenomegaly (50%)
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29
Q

How do you diagnose pharyngitis caused by the virus Mononucleosis?

A
  • Monospot

- CBC with differential (increased atypical lymphocytes)

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30
Q

How long does pharyngitis caused by the virus Mononucleosis typically last for and how long is someone contagious?

A

Duration of 2-4 weeks, but contagious up to 3 months

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31
Q

What is the management for pharyngitis caused by the virus Mononucleosis?

A
  • Supportive care

- Avoid contact sports

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32
Q

What are clinical signs of pharyngitis caused by bacterial Corynebacterium diphtheriae?

A
  • Gray exudate tightly adherent to throat, nasal passageway

- Consider in unvaccinated patients, especially with recent travel

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33
Q

What is the treatment for pharyngitis caused by bacterial Corynebacterium diphtheriae?

A
  • Diphteria anti-toxin + penicillin or erythromycin
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34
Q

What is the treatment for pharyngitis caused by bacterial Mycoplasma pneumoniae?

A

Azithromycin (Zithromax)

35
Q

What is pharyngitis caused by bacterial Mycoplasma pneumoniae typically associated with?

A
  • Lower respiratory infection

- Headache

36
Q

What population is highest risk for pharyngitis caused by bacterial Neisseria gonorrhoeae?

A

Homosexual men

37
Q

What is treatment for pharyngitis caused by bacterial Neisseria gonorrhoeae?

A

Ceftriaxone (Rocephin)

38
Q

What complications can pharyngitis caused by bacterial Group A Streptococcus lead to?

A
  • Local invasion

- Immune mediated responses

39
Q

What are symptoms associated with pharyngitis caused by bacterial Group A Streptococcus?

A
  • Odynophagia (pain on swallowing)
  • Sore throat
  • Fever, malaise, anorexia
  • Arthralgias, myalgias
  • Nausea/vomiting
  • Neck discomfort; swollen glands
40
Q

What symptom complex carries a 40-60% positive predictive value for Group A Streptococcus pharyngitis (GAS)?

[Centor Criteria]

A
  • Fever by history
  • Absence of cough
  • Tonsillar exudates
  • Tender anterior cervical adenopathy

GAS = FATT

41
Q

What should the next step be if your patient meets Centor criteria but has a negative Rapid antigen detection test for Group A Strep?

A
  • If a child or adolescent, order culture
  • Clinical judgement for adults, can treat without culture
  • Empiric antibiotics until culture results
42
Q

What is the first line treatment for Group A Strep pharyngitis?

A
  • Penicillin G benzathine (Bicillin L-A) 1.2 million units IM x 1
  • Penicillin V 500 mg PO TID x 10 days
  • Amoxicillin (Amoxil) 500 mg PO BID x 10 days
  • Cephalexin (Keflex) 500 mg PO BID x 10 days

“Playful puppies always cuddly”

43
Q

What is the second line treatment for Group A Strep pharyngitis?

A
  • Azithromycin (Zithromax) 500 mg PO day 1 followed by 250 mg PO days 2-5
  • Clindamycin 300 mg PO TID x 10 days
44
Q

What is the typical course of Group A Strep pharyngitis?

A
  • Improvement in clinical symptoms within 3-4 days of initiating antibiotics therapy
  • No longer considered contagious after 24 hours of antibiotic treatment
  • May return to daycare, work and school
45
Q

What are major complications that can occur due to Group A Strep pharyngitis?

A
  • Rheumatic fever
  • Post-streptococcal glomerulonephritis
  • Streptococcal toxic shock syndrome
  • Scarlet fever

Rappers Go To School

46
Q

What is associated with Scarlet fever?

A
  • Requires previous exposure to Strep pyogenes infection
  • Delayed hypersensitivity reaction
  • Rash, desquamation, Pastia’s lines, facial flushing with circumoral pallor and “strawberry tongue”

Scarlet Reads Dirty Porn For Corny Stories

47
Q

How can you distinguish peritonsillar abscess from cellulitis?

A
  • Abscess will have of a collection of pus while cellulitis will not
  • Cellulitis has an absence of trismus and uvular deviation
48
Q

What are symptoms associated with peritonsillar abscess?

A
  • Severe sore throat (usually unilateral)
  • Drooling
  • Trismus
  • Fever
  • Neck swelling/pain
  • Ipsilateral ear pain
  • Decreased PO intake
49
Q

What are clinical exam findings of peritonsillar abscess?

A
  • Swelling pushing tonsil with deviation of uvula to the opposite side
  • Fullness of posterior soft palate with palpable fluctuance
  • Cervical lymphadenopathy
  • “Hot Potato,” muffled voice
50
Q

If unable to diagnose a peritonsillar abscess clinically, what imaging studies should you obtain?

A
  • CT with IV contrast to rule out spread of infection, or if exam is limited due to trismus
  • US helpful, but no definitive in distinguishing abscess from cellulitis
51
Q

What is the management for peritonsillar abscess?

A
  • Monitor for airway obstruction
  • Drainage of abscess
  • Antimicrobial therapy in adults
  • +/- hospitalization
  • Supportive care with fluids and pain control
52
Q

What parenteral antibiotics should be used for an adult with a peritonsillar abscess?

A
  • Ampicillin-sulbactam (Unasyn)
  • Clindamycin
  • Consider vancomycin if high rates of MRSA

Until afebrile and improving

53
Q

What oral antibiotics should be used for an adult with a peritonsillar abscess?

A
  • Amoxicillin-clavulanate (Augmentin)

- Clindamycin

54
Q

What are signs/symptoms of epiglottitis?

A
  • Drooling (difficulty swallowing)
  • Stridor (respiratory distress)
  • Severe sore throat
  • Toxic appearance
55
Q

If patient presents with respiratory distress, what should be your first concern?

A

Secure airway before examining

56
Q

What imaging studies can help you diagnose epiglottitis?

A
  • Lateral neck xray (“Thumb Sign”)

- CT/MRI

57
Q

What is the management for epiglottitis?

A
  • Hospitalization
  • Intubation
  • Antibiotics
58
Q

What is the most common etiology of laryngitis?

A

Virus

59
Q

What are some non-infectious causes of laryngitis?

A
  • Vocal abuse
  • Vocal cord trauma
  • Toxic exposure
  • GERD with gastric acid aspiration
  • Vocal cord nodules or laryngeal polyps
60
Q

What are symptoms associated with laryngitis?

A
  • Hoarseness (key symptom)
  • Dysphonia (variation in vocal quality)
  • URI symptoms
61
Q

What are clinical exam signs associated with laryngitis?

A

URI related

  • nasal edema
  • congestion

Direct laryngoscopy reveals:

  • laryngeal erythema and edema
  • vascular engorgement of vocal cords
  • nodules or ulcerations
62
Q

When would you refer to ENT with laryngitis?

A

Hoarseness greater than 2 weeks in the absence of URI symptoms (especially with history of tobacco or alcohol use)

63
Q

What is the management for laryngitis?

A
  • Treat underlying cause such as removal of offending agent or managing underlying disease
  • Voice rest
  • Humidification
  • Increase fluid intake
  • Advise to discontinue smoking
  • No abx unless bacterial infection
  • Referral to ENT as needed
64
Q

What is the most common etiology of acute rhinosinusitis (ARS)?

A

Acute viral rhinosinusitis

  • Rhinovirus
  • Influenza
  • Parainfluenza
65
Q

What symptoms are associated with rhinosinusitis?

A

Purulent nasal drainage AND nasal obstruction and/or facial pain, pressure, or fullness

66
Q

What are the classifications of rhinosinusitis?

A
  • Acute: < 4 weeks
  • Subacute: 4-12 weeks
  • Chronic: > 12 weeks
67
Q

What classifies recurrent acute rhinosinusitis?

A

4 or more episodes of acute rhinosinusitis per year

68
Q

What are clinical exam sings of acute rhinosinusitis?

A
  • Purulent drainage in nose or posterior pharynx
  • Nasal mucosal edema
  • Tenderness to percussion of upper teeht
  • Sinus tenderness to palpation
  • Tranillumination of frontal or maxillary sinuses - may show opacity, unreliable
69
Q

How do you diagnose acute viral rhinosinusitis?

A
  • Clinically

- < 10 days of symptoms that are not worsening

70
Q

What is the management for acute viral rhinosinusitis?

A

Supportive care

Days 1-9:

  • analgesics
  • saline irrigation
  • mucolytics
  • intranasal decongestants
  • intranasal glucocorticoids
71
Q

What is the basic pathophysiology of acute bacterial rhinosinusitis (ABRS)?

A

Viral infection followed by secondary bacterial infection

72
Q

When would you prescribe abx for acute bacterial rhinosinusitis?

A

Persistent symptoms/signs lasting > 10 days with no clinical improvement

OR

Onset with severe symptoms: fever > 102; purulent nasal discharge, facial pain lasting at least 3-4 consecutive days at the beginning of illness

OR

Viral URI that lasted 5-6 days and was initially improving, followed by severe symptoms, “double worsening”

73
Q

What is the primary management for acute bacterial rhinosinusitis?

A

First-line antimicrobial management, patient is NOT high risk for abx resistance:

  • Amoxicillin-clavulanate (Augmentin) 875/125 mg BID
  • Doxycycline 100 mg BID
  • Levofloxacin (Levaquin) 500 mg QD
  • Moxifloxacin (Avelox) 400 mg QD

IDSA guidelines recommend 5-7 days

74
Q

If your patient is diagnosed with acute bacterial rhinosinusitis and has no response to initial antibiotic treatment, OR has worsening of symptoms after 7 days of empiric antibiotic treatment, OR has a high risk of antibiotic resistance, what should you treat with?

A

Second-line antimicrobial management:

  • Amoxicillin-clavulanate (Augmentin) 2000/125 mg BID
  • Doxycycline 100 mg BID
  • Levofloxacin (Levaquin) 500 mg QD
  • Moxifloxacin (Avelox) 400 mg QD

IDSA guidelines recommend 7-10 days

75
Q

What are complications of acute bacterial rhinosinusitis?

A

Extension of infection from paranasal sinuses to CNS, orbits, or surrounding tissues:

  • Osteomyelitis
  • Meningitis
  • Brain or epidural abscess
  • Preseptal or orbital cellulitis
76
Q

When would you order radiology studies for acute bacterial rhinosinusitis and what is the most appropriate study to order?

A

You would order radiology studies if suspected complicated acute bacterial rhinosinusitis.

  • CT scan with contrast
  • MRI can be used for soft tissue detail/suspected extra sinus involvement
77
Q

What is the gold standard in regards to lab testing for complications of acute bacterial rhinosinusitis?

A

Sinus Aspirate Culture

78
Q

What is the management for complications of acute bacterial rhinosinusitis?

A
  • Admit to hospital
  • Urgent ENT/ID consult
  • Empiric antibiotics
79
Q

What are the four cardinal symptoms of chronic rhinosinusitis (CRS) in adults?

A
  • Mucopurulent nasal discharge
  • Nasal obstruction and congestion
  • Facial pain, pressure, fullness
  • Reduction/loss of sense of smell
80
Q

What are the four cardinal symptoms of chronic rhinosinusitis (CRS) in children?

A
  • Mucopurulent nasal discharge
  • Nasal obstruction and congestion
  • Facial pain, pressure, fullness
  • Cough
81
Q

What is the diagnositc criteria for chronic rhinosinusitis (CRS)?

A
  • Presence of at least 2 of the 4 cardinal symptoms
    AND
  • Infection lasting 12 weeks or greater with medical management

PLUS EITHER
- Sinus mucosal disease with imaging (CT) with mucosal thickening, or partial/complete opacification of the paranasal sinuses
OR
- Direct visualization (nasal endoscopy) of mucosal inflammation, polyps in the nasal cavity or meatus, and/or purulent mucus and edema

82
Q

How do you diagnose chronic rhinosinusitis (CRS)?

A
  • Non-contrast CT

- Referral to ENT for possible nasal endoscopy or sinus aspirate culture

83
Q

What is the management for chronic rhinosinusitis (CRS)?

A
  • Nasal saline lavage
  • Intranasal corticosteroids
  • Oral corticosteroids
  • Oral antimicrobials
  • Antihistamines
  • Topical or systemic antifungals
  • Endoscopic sinus surgery
84
Q

What are clinical exam findings associated with pharyngitis caused by bacterial Group A Streptococcus?

A
  • Pharyngeal erythema
  • Tonsillar hypertrophy
  • Purulent exudate
  • Tender and/or enlarged anterior cervical lymph nodes
  • Palatal petechiae

Clinical Med I (24 decks)

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