Mehl. Uw bullet cases 2 Flashcards
Otitis media, pertussis, sinusitis + complications; tetanus, botulism
Mehl. Most common cause of otitis media?
Strep pneumoniae.
Mehl. Tx of otitis media?
oral amoxicillin only.
Mehl. Tx of recurrent OM?
amoxicillin/clavulanate
Mehl. When to do tympanostomy tube?
three or more OM in 6 months, or 4 or more in a year.
Mehl. 8M + Hx of ear infection one month ago + slightly reduced hearing in one ear + otoscopy shows fluid behind the tympanic membrane + afebrile and well-appearing; Dx + Tx?
Dx: otitis media with effusion (serous otitis media); fluid accumulation seen occasionally in middle ear after resolution of OM (need not be recurrent OM);
Tx is observation, as will usually self-resolve in 4-8 weeks.
Mehl. 10-month-old female + fussy + fever + no movement of left tympanic membrane on pneumatic otoscopy; Dx?
Otitis media
immobility of tympanic membrane = most sensitive finding for otitis media – i.e., if a Q tells you the tympanic membrane is mobile, the Dx is not OM.
Mehl. 10-month-old female + fussy + fever + no movement of left tympanic membrane on pneumatic otoscopy; WRONG DX?
the wrong answer is otitis media with effusion;
UW. 2-year-old girl + foul-smelling drainage from the left ear + been irritable over the past few days.
Three weeks ago, the patient was treated with amoxicillin for an episode of acute otitis media. Temp. 37.9 C; all other vital signs are normal. Left external ear is unremarkable except for some dried, crusted drainage at the entrance of the external canal. Otoscopic = perforated, erythematous left tympanic membrane with a small amount of purulent drainage. Which of the following is the most appropriate pharmacotherapy for this patient?
AMOXICILLIN-CLAVULANATE
Due to resistance, give broader spectrum abs if patient was treated with amoxicillin within the past 30 days
UW. 2-year-old girl + autistic + was all good 4 days ago, when she began to have episodes of crying at home and at regular therapy sessions. The patient has a penicillin allergy that manifested with an episode of facial swelling and difficulty breathing. Temp. 38,3C. There is crusting around the nares bilaterally; oropharyngeal examination is normal. Otoscopic examination demonstrates yellow, bulging tympanic membranes bilaterally. Tx?
AZITHROMYCIN
Mehl. 3F + 10-day Hx of coughing spells followed by vomiting; Dx
Pertussis;
post-tussive vomiting and hypoglycemia sometimes seen; coughing may also be described as “paroxysms.
Mehl. 14M + WBCs 32,000 (85% lymphocytes) + two-week Hx of paroxysmal cough followed by vomiting;
Dx?
pertussis.
Student says wtf? pertussis can cause absurdly elevated WBC count that is almost all lymphocytes and resembles ALL.
Mehl. pertussis part of what vaccine?
tetanus, diphtheria, pertussis (TDaP)
UW. A 4-year-old girl is diagnosed with Bordetella pertussis infection after an outbreak occurred at her day care center. She has paroxysmal coughing fits and is prescribed a course of macrolide antibiotics. The patient lives with her 30-year-old parents and 1-year-old sister. Her family members have up-to-date immunizations and are asymptomatic. Which of the following is the most appropriate way to limit the immediate risk for infection of this patient’s household contacts?
PRESCRIBE A MACROLIDE ANTIBIOTIC FOR ALL HOUSEHOLD CONTACTS
UW. 9y/o boy + two weeks ago, developed rhinorrhea, excessive tearing, malaise, and a mild cough. Since then, the cough has worsened, particularly at night and during exertion; today, the patient passed out after a bout of coughing. Otherwise, he feels normal between the coughing episodes. He has no chest pain, shortness of breath, or fever. The patient has no chronic medical conditions and takes no medications. He has received no vaccinations. Temp. 37.2 C (99 F), BP 90/60, pulse is 80/min, RR 16/min. SpO2 98%. On physical examination, the patient is alert and well-appearing with frequent episodes of cough. Bilateral subconjunctival hemorrhages are noted. The lungs are clear to auscultation. Dx?
INFECTION WITH BORDETELLA PERTUSSIS
this patient is not vaccinated - high risk to get disease!!!
vs viral infection = it resolves within 2 weeks. pertusis - longer, few months.
UW.
12-y/o boy + two weeks ago, he developed rhinorrhea, sore throat, and cough. For the past 2 days, the patient has had a fever and progressively worsening pain behind his eyes that radiates to his right forehead. He woke early this morning and vomited twice. He has had no diarrhea. Temp. 39.7 C, BP 134/86, pulse 116/min, RR 26/min. The patient appears drowsy and uncomfortable. Examination shows copious green nasal discharge from the right naris. Palpation of the right forehead elicits tenderness. Oropharyngeal examination shows erythema along the posterior oropharynx with purulent drainage. The neurologic examination is nonfocal. Best next step in Mx?
CT SCAN OF THE HEAD
UW. 6day old boy + delivered vaginally at home + parents have been supplementing with a mixture of honey and goat milk + no vaccines. Difficult latching on the breast the past 3 days. Temp. 38.8 C. Irritable neonate with marked hypertonicity, neck stiffness, and inspiratory stridor. Auscultation of the heart and lungs is normal. The umbilical stump is swollen and has a small amount of purulent drainage. CSF - glu 62; protein 38; leu 2. Cause of neurologic manifestation?
TETANUS
omphalitis - wrong. this would explain inflammation of umbilicus, but not neurologic presentation
Mehl. Neonate born at home + umbilical cord cut with kitchen knife and tied with twine + trismus; Dx?
tetanus
trismus = lockjaw (HY “vocab word” for USMLE). don’t confuse this with tenesmus, which is the intractable feeling of needing to defecate; C. tetani classically enters through umbilical stump.
Mehl. Neonate born at home + umbilical cord cut with kitchen knife and tied with twine + trismus; Tx?
Tx = antitoxin;
UW. A 6-month-old boy is brought to the emergency department for poor feeding and decreased activity. For the past 5 days, the patient has been eating less. His normal intake is 26 oz of formula daily; recently, he has consumed only 10 oz of formula daily. The patient has had a few wet diapers daily but has not stooled for 5 days. In addition, he was previously able to sit with support and reach for toys but has been unable to do this in the past week. His parents are healthy. Immunizations are up to date. Weight and length are at the 65th percentile; head circumference is at the 75th percentile. Temp. 36.7 C. pulse 108/min, RR 36/min. Patient has diminished head control with neck and shoulder-girdle weakness, generalized hypotonia, and reduced spontaneous movement. Eye movements are decreased with evidence of ptosis. The oral mucosa is dry. Complete blood count, serum electrolytes, renal and liver function tests, and erythrocyte sedimentation rate are normal. BEST NEXT STEP IN MX?
ADMINISTER ANTITOXIN THERAPY
(vs measure acetylcholine receptor antibody levels)
In neonates with mothers with myasthenia gravis, oculobulbar weakness and hypotonia can occur due to transplacental transfer of acetylcholine receptor antibodies. Unlike in this patient, symptoms present within hours to days of birth.
