midterm condensed - lungs, EENT, derm Flashcards
bacterial conjunctivitis
-MCC: Haemophilus species, S. pneumoniae, M. catarrhalis, and S. aureus
-Injected conjunctiva with significant discharge (purulent), typically unilateral > bilateral
-very contagious
-Tx:
-Topical antibiotics: Polymyxin/trimethoprim sulfate or fluoroquinolones
-Systemic therapy for conjunctivitis associated with C. trachomatis, N. gonorrhoeae and N. meningitidis
viral conjunctivitis
-MCC is adenovirus
-Injected conjunctiva with watery discharge
-typically unilateral > bilateral
-Enlarged preauricular lymphadenopathy can be present
-red w/ no purulent discharge
-Tx:
-Supportive
-Contagious 10-21 days from day of onset or as long as the eyes are red/tearing persists
-Herpes conjunctivitis: Topical versus PO antivirals
-when can you go back to school -> until you stop seeing discharge and at least 24hrs on the antibiotic
allergic conjunctivitis
-Itchy, watery eyes with injected conjunctiva, usually bilateral!
-Allergic shiners may be present -> nasal congestion causes venous congestion
-may be a hx of asthma or other allergies
-chemosis if severe- bubbling, swelling of conjunctiva
-Tx:
-Topical solutions that combine antihistamine and mast cell stabilizer
-Systemic anti-histamines
-Limitation of exposure to allergen
-if not old enough for drops -> cool packs
corneal abrasion
-Sudden, severe eye pain
-Decreased vision, tearing, conjunctival injection, poor cooperation with ocular exam
-Dx:
-Fluorescein dye > illumination with Wood lamp
-Evert upper/lower eyelids to evaluate for FBs
-Tx:
-Ophthalmic ointment, follow-up until healing complete
-preventative antibiotics
-refer to specialist 2-3 days later to make sure healing
-if the pt cant tolerate drops for staining -> empiric tx and f/u with specialist who can sedate and view the eye
blunt ocular trauma
-Blunt trauma can lead to orbital fx, retrobulbar hemorrhage can lead to orbital compartment syndrome -> permanent vision loss
-Orbital blowout fx: Diplopia, pain with eye movements, restriction of EOM
-CT scan! useful in dx extent of injuries
-Orbital compartment syndrome: Severe eyelid edema and proptosis (can progress to this)
-Neuroimaging will show retrobulbar hemorrhage and proptosis
-Tx:
-OBF: Nonurgent repair to prevent enophthalmos, advise not to blow nose (orbital emphysema/proptosis)
-OCS: Emergent lateral eyelid canthotomy and cantholysis to decompress orbit
eye foreign body
-discomfort, tearing, red eye
-Pain with blinking suggests FB trapped under eyelid/corneal surface
-every time you blink can be scratching the cornea
-Tx:
-Eyelid eversion!
-Removal with irrigation or cotton applicator
-Referral to specialist for failed attempt/corneal FB
-Topical antibiotics typically prescribed for several days following FB removal
-corneal FB / rust ring -> specialist
pre-septal vs orbital cellulitis
-PRE-SEPTAL:
-from local exogenous source (abrasion/insect bite), other infections (hordeolum, dacryocystitis), or after hematogenous spread
-May progress to orbital cellulitis
-Red, swollen eyelids; pain; mild fever
-NORMAL- Vision, eye movements, and eye
-TX: PO antibiotics
-ORBITAL:
-Serious complications: Subperiosteal abscess, meningitis, septicemia, and optic neuropathy
-MC- from paranasal sinus infection
-Proptosis!, eye movement restriction, decreased vision
-Eye red and chemotic
-decrease visual acuity
-CT w/ contrast- establish extent and eval for subperiosteal abscess
-Complications: Permanent vision loss (compressive optic neuropathy), corneal exposure/drying/scarring (proptosis), cavernous sinus thrombosis, intracranial extension, blindness, death
-Tx:
-Initially, broad-spectrum antibiotics
-Surgical drainage of abscesses/sinuses
acute otitis media
-MC reason for antibiotics
-S. pneumoniae > H. influenzae > M. catarrhalis > S. pyogenes
-2 critical findings: Bulging TM AND a MEE
-Otoscopic findings: Bulging TM, impaired visibility of ossicular landmarks, yellow or white effusion, opacified/inflamed TM, squamous exudate/bullae on TM
-Season (winter > summer)
-Ages 1-3
-Eustachian tube dysfunction
-Infants and young children more prone due to shorter, more compliant, horizontal ET
-Trisomy 21, cleft palate risk factors
-RF: Bacterial colonization of nasopharynx: S. pneumoniae, H. influenzae, M. catarrhalis
-Smoke exposure, poor immune, daycare, genetics
-Bottle feeding: aspiration into middle ear
-Tx:
-Pain control (1-3 days before antibiotic relieves pain)
-Wait and see approach:
-Observe episode w/o tx
-Option for healthy children (> 2 years) with mild-moderate OM and no underlying conditions
-Decision with parents to begin antibiotics if worsening or lack of improvement within 48-72 hrs
-Antibiotic therapy: (know this)
-1st line: High dose amoxicillin (80-90 mg/kg divided BID)
-Augmentin if child has had amoxicillin within last 30 days or clinically failing x 48-72 hours on amoxicillin
-Cephalosporins (cefuroxime, cefpodoxime, cefdinir) for those with rash to PCN – risk of cross-sensitivity is less than 0.1%
-Macrolide (azithromycin) only if history of type 1 hypersensitivity to PCN -> Resistance of S. pneumoniae and H. influenzae (macrolide efflux pump)
-Second-line antibiotics indicated when child experiences symptomatic infection within 1 month of finishing amoxicillin
acute otitis externa
-Cellulitis of soft tissues of external auditory canal -> extend to surrounding structures -> pinna, tragus, and lymph nodes
-Humidity, moisture, heat known to contribute
-Trauma (breaks skin-cerumen barrier) -> first step in infection -> swab use, earbuds, scratching, ear plugs
-MC organisms: S. aureus, S. epidermidis, P. aeruginosa
-fungal in 2-10%
-Acute onset of pain, aural fullness, decreased hearing, and pruritis (peak within 3 days)
-touching tragus/pinna -> considerable pain
-Discharge may be clear/purulent
-EAC narrowed/swollen (may be difficult to visualize entire TM)
-Complications:
-Cellulitis of neck and face
-Malignant OE: Spread of infection to skull base with resultant osteomyelitis
-Tx:
-Pain control
-removal of debris from canal
-topical antimicrobial therapy
-avoidance of causative factors
-1st line- Fluoroquinolone ear drops; combo with a steroid may be necessary (ciprofloxacin/dexamethasone) -> Ensure no TM perforation before STEROIDS!
-PO antibiotics for any invasive infection signs (fever, cellulitis, cervical lymphadenopathy)
middle ear effusion
-fluid in middle ear w/o signs or sx of acute inflammation
-TM may be opacified/thickened, fluid can be clear/amber/or opaque, typically in neutral/retracted position
-Pneumatic otoscopy and/or tympanometry for confirmation
-Management:
-Abx, anti-histamines, and steroids NOT shown to be useful in tx
-Audiology eval after 3mo of continuous B/L effusion
-Hearing loss/speech delay -> referral to ENT for possible T-tube placement
-Uncomplicated -> observed 3mo with f/u q 3-6mo to eval for effusion clearance
-T-tube indications:
-Hearing loss > 40 dB, TM retraction pockets, ossicular erosion, adhesive atelectasis, and cholesteatoma
tympanic membrane perforation
-AOM may result in rupture of TM
-Discharge from ear seen with rapid relief of pain
-Tx:
-Ototopical antibiotics x 10-14 days with ENT f/u for exam/hearing eval
-Failure to heal may require surgery (typically deferred until age 7, when ET has reached adult orientation)
mastoiditis
-Infection from middle ear spreads to mastoid of temporal bone
-Inflammation of periosteum to bony destruction of mastoid air cells with abscess development
-any age, most < 2yo
-Clinical dx!
-Postauricular pain, fever, and outwardly displaced pinna
-Exam: Mastoid appears indurated, red, swollen, fluctuant with severe tenderness (earliest sx)
-AOM -> almost always present
-Imaging Studies:
-CT scan -> determine extent
-Progressed ds: Coalescence of mastoid air cells with bone destruction
-Complications:
-Meningitis (high fever, stiff neck, severe headache)
-Brain abscess (fever, headache, changes in sensorium)
-Facial palsy, sigmoid sinus thrombosis, epidural abscess, cavernous sinus thrombosis, thrombophlebitis
ear foreign bodies/cerumen impaction
-removed if easily visualized and with appropriate instrumentation
-ENT referral for large FBs, rounded/globular objects, deep objects
-Vegetable matter -> NEVER irrigated (may swell)
-Button-battery -> emergent referral
-Cerumen impactions removed if symptomatic and obstructing visualization of TM
acute pharyngotonsillitis: viral pharyngitis: Infectious Mononucleosis (Epstein-Barr Virus)
-Infectious Mononucleosis (Epstein-Barr Virus)
-MC > 5yo
-Exudative tonsillitis!!
-generalized cervical adenitis
-fever
-Dx:
-palpable spleen or axillary lymphadenopathy increases likelihood of dx
-> 10% atypical lymphocytes on peripheral blood smear or + Monospot -> supports dx (though false neg in kids < 5yo)
-!!Epstein-Barr virus serology showing elevated IgM antibody is definitive
-Tx:
-Supportive
-avoid contact sports
-4-6-week f/u (LFTs)
-Amoxicillin is contraindicated –> precipitates rash
acute pharyngotonsillitis: bacterial pharyngitis
-20-30% w/ pharyngitis have group A streptococcal (GAS)
-Other causes: Mycoplasma pneumoniae, Chlamydia pneumoniae, groups C/G streptococci, and Arcanobacterium hemolyticum
-MC 5-15 yo -> winter/early spring
-Sudden onset sore throat, fever, tender cervical adenopathy, palatal petechiae!, beefy-red uvula, and a tonsillar exudate
-Headache, stomachache, nausea/vomiting
-Scarlet fever!: 1-2 days into sx -> sandpapery rash (diffuse, finely papular, erythematous, blanchable) with strawberry tongue
-Modified Centor Score
-Def dx with throat culture or rapid antigen test -> RAT specific but only 85%-95% sensitive
-KNOW THE CHART
Modified centor criteria
Acute pharyngotonsillitis: diptheria
-Acute infection of URT or skin
-caused by exotoxin-producing Corynebacterium diphtheriae
-Gram-positive, club-shaped rods on gram stain
-Toxin absorbed into mucous membranes -> destruction of epithelium -> inflammatory response -> embedded in fibrin with WBCs/RBCs -> grayish pseudomembrane forms over tonsil, pharynx, larynx
-Pharyngeal diphtheria:
-Mild sore throat, moderate fever, and malaise -> rapid decompensation
-Pharyngeal membrane forms (tenacious, gray, border of erythema/edema) -> may spread to nasopharynx or trachea -> obstruction
-Cervical lymph node swelling -> “bull neck”
-Dx: Culture of C. diphtheriae from infected tissue(s)
-Tx:
-Report to CDC to acquire anti-toxin (give within 48 hrs of sx)
-Antibiotics (erythromycin IM/PO or procaine PCN G IM, q12hrs) x 14 days
-Vaccination during convalescence, observation in hospital setting 10-14 days (isolate for at least 1-7 days, until respiratory secretions are noncontagious)
strep complications (untreated)
-Acute rheumatic fever
-Glomerulonephritis
-Suppurative complications: Cervical adenitis, peritonsillar abscess, AOM, cellulitis, septicemia
-Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS)
-Sudden onset of OCD and/or tics (or worsening of such symptoms) following a strep infection
croup
-MCC- parainfluenza virus serotypes!!!!!!!
-6mo – 5yo -> fall and early winter
-Edema in subglottic space -> signs of upper airway obstruction (inflammation of entire airway is typically present)
-Prodrome of URT sx, followed by barking cough, laryngitis, and stridor
-Mild: Stridor only with agitation
-Worsening obstruction: Stridor at rest, retractions, air hunger, cyanosis, hypoxemia
-Imaging: Not indicated (maybe in atypical presentations to r/o other causes)
-Tx:
-!!!Mild- Supportive, hydration; with or w/o dexamethasone
-expose child to cold moist air
-Dexamethasone: 0.15-0.6 mg/kg PO/IV x 1 dose
-Adjuvant tx: Prednisolone (1 mg/kg) QD x 3 days and/or inhaled budesonide
-!!!!Severe/stridor @ rest: Nebulized racemic epinephrine (diluted in sterile saline!)
-give dexamethasone too (prevents rebound)
-Sx resolution within 3-4 hrs of glucocorticoids/nebulized epinephrine -> safely discharged w/o fear of rebound
-If recurrent nebulized epinephrine tx required -> admission for observation, supportive care, and repeat steroid dosing/neb tx PRN
-Impending respiratory failure -> intubation with ET tube, with extubation within 2-3 days
🛑 Key Differentiation:
Croup = Steeple sign (subglottic narrowing).
Epiglottitis = Thumb sign (enlarged epiglottis, NO barking cough, drooling present).
epiglottitis
-MC- Haemophilus influenzae!!!!!!!; streptococcal species in immunized pts
-Sudden onset of high fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis, and soft stridor
-Pts sit in “sniffing dog” position (neck hyperextended, chin stretched forward)
-can progress to total airway obstruction -> respiratory arrest
-Def dx: Direct inspection of epiglottis (OR during intubation) -> cherry-red and swollen epiglottis
-!!!Imaging: Lateral neck radiograph -> “thumbprint” sign caused by swollen epiglottis
-Tx:
-ET intubation to establish airway
-Blood and epiglottis cultures performed
-IV antibiotics (ceftriaxone or equivalent cephalosporin) x 2-3 days, followed by PO abx x 10 days
-Extubation within 1-2 days, when reduction in size of epiglottis is evident
pertussis
-Caused by Bordetella pertussis!!!!!!(only infects humans, transmitted via coughing)
-Incubation 7-10 days -> most contagious 1st 2 wks of cough
-Peaks among <6mo of age (too young for complete immunization + most likely to have severe complications)
-Catarrhal stage: 1-2 weeks
-Non-specific signs (low-grade fever, nasal congestion)
-Paroxysmal stage: 3-4 weeks
-Coughing occurs in paroxysms during expiration (to dislodge plugs of necrotic bronchial epithelial tissues and thick mucus)
-Forceful inhalation against narrowed glottis that follows = “whoop”
-Convalescent stage: 1-2 weeks
-Gradual resolution of sx
-Dx:
-Isolation of B. pertussis or PCR
-Culture from NP swabs or aspirates
-Lymphocytosis in 75-85% but not dx
-Imaging: Segmental lung atelectasis, perihilar infiltrates
-Tx:
-Macrolides (azithromycin, clarithromycin, erythromycin)!
-Complications/Prognosis:
-MC is PNA (primary or secondary)
-Other complications: Atelectasis, free air (from paroxysms), epistaxis, hernias, retinal/subconjunctival hemorrhage, OM, sinusitis
asthma
-80% develop sx < 5yo
-40% who have wheezing w/ viral infections in 1st few years -> continuing asthma
-Strongest predisposing factor is atopy (personal or familial)
-Shedding of airway epithelium, edema, mucus plug formation, mast cell activation, and collagen deposition beneath basement membrane
-Air wall remodeling/irreversible changes
-Dx- clinical
-Auscultation: Prolonged expiratory phase with wheezing
-Increased severity: High-pitched wheeze with diminished breath sounds
-Severe obstruction: Nothing
-Flaring of nostrils, intercostal and suprasternal retractions, use of accessory muscles
-Cyanosis
-Tachycardia/pulsus paradoxus
-Agitation/lethargy may be signs of impending respiratory failure
measles (rubeola)
-Highly contagious (droplet and airborne transmission)
-caused by single-stranded RNA paramyxovirus
-4 phases: Incubation (8-12 days from exposure to onset), prodromal (catarrhal), exanthematous (rash), and recovery
-3 day prodromal period: Cough, coryza, conjunctivitis and pathognomonic Koplik spots! (gray-white, sand-grain-sized dots on buccal mucosa, opposite lower molars)
-Conjunctiva with possible Stimson line! (transverse line of inflammation along the eyelid margin)
-Exanthematous phase: Sx + FEVER
-Macular rash, spreading from HEAD TO TOE over 24 hours; rash fades in the same pattern
-Generalized lymphadenopathy (cervical nodes most prominent)
-AOM, PNA, and diarrhea common in infants
-Dx:
-Serologic testing for IgM antibodies (1-2 days into rash, persist for 1-2 mo)
-+/- genetic testing -> RT-PCR
-Tx:
-Supportive care– fluids, antipyretics
-routine vitamin A x 2 days to children with acute measles
rubella (german/3-day measles)
-Caused by single-stranded RNA togavirus, humans only host
-Incubation 16-18 days, mild catarrhal symptoms
-Retroauricular, posterior cervical, and posterior occipital lymphadenopathy with erythematous, maculopapular, discrete rash
-Rash spreads from head to toe, lasts for 3 days
-Rose-colored spots (FORCHHEIMER SPOTS) on soft palate may appear before rash
-Other sx: Pharyngitis, conjunctivitis, anorexia, headache, malaise, LOW GRADE fever, polyarthritis, parasthesias, tendonitis
-Dx:
-Serologic testing for IgM antibodies (+ 5 days after onset) or by 4-fold or greater increase in specific IgG antibodies in acute/convalescent sera
-Treatment: Supportive
