Upper Respiratory Illnesses Flashcards
1
Q
Should antibiotics be used to treat URIs?
A
Rarely!
URIs are mostly viral
2
Q
What are the main viral culprits of the common cold?
A
Rhino-virus
Coronavirus
Adenovirus
Respiratory Syncytial Virus (RSV)- lower resp. infection
3
Q
What is the clinical presentation for the common cold?
A
Duration of illness: 5-10days, up to 14 days
Nasal congestion and/or discharge
Sneezing
Sore throat
Cough
Low grade temp
Headache
Malaise
4
Q
How will the symptoms of a sore throat differ with viral v. strep?
A
Viral sore throat- worse morning/night and good during day
Strep- persistent sore throat
5
Q
What will the physical exam look like with a common cold?
A
- TM is normal, maybe slightly red, some clear fluid
Rhinorrhea, can be green/yellow or clear
Skin, mild scattered erythematous rash
Nasal mucous, swollen and red nasal cavity
Some cervical lymph nodes may be slightly enlarged
lungs are clear bilaterally
6
Q
What are the differential diagnosis for the common cold?
A
Influenza- abrupt onset
Bronchitis- runny nose and rhonchi
Acute bacterial sinusitus- can get bacterial infection at end of viral cold
Allergic rhinitis- pale and boggy turbinates
pertussis- would have significant cough
7
Q
What can help with the common cold’s nasal congestion symptom?
A
- Netti pot, steam shower, normal saline nasal spray
- Antihistamine to dry things out and help sleep
- Ipratropium bromide (nasal)- reduces fluid released from nose mucosa
- Cromolyn sodium (nasal)- reduces allergin triggers
- Intranasal decongestant like Afrin- opens passages, but can get rebound inflammation. Use 3 days MAX
- Decongestants- not for kids under 6
8
Q
What can help with the common cold’s cough symptom?
A
Honey
Expectorants like Mucinex
Antitussive like Delsym, the DM in OTC cold medications
9
Q
What is Otitis Media?
A
inflammatory or infectious process that leaves fluid in the middle ear
Viral, bacterial or fungal by origin
10
Q
What are the risk factors of getting otitis media?
A
young age
Family Hx
Lack of breastfeeding
Tobacco smoke/air pollution
pacifier use
Day care with other kids
lack of access to medical care/ socioeconomic condition
Race/ethnicity
Season
Underlying disease
11
Q
What is the difference between an acute OM and OM effusion?
A
Acute- fluid is not absorbed and acute inflammation and infection occur
Effusion- build up of fluid behind their TM without inflammation
12
Q
What are the most common microbiota that cause acute otitis media in kids?
A
Strep pneumo- 66%
M. Catarrhalis- 59%
H. Influenzae- 29%
Viral- 10%
13
Q
What is the clinical presentation of acute otitis media?
A
acute onset
May/may no be febrile
Otalgia- ear pain
Vomiting, diarrhea, ear rubbing
Associated with URI
14
Q
What will the physical exam look like with acute otitis media?
A
TM- red, limited mobility, won’t see land marks, bulging, pus
May see URI sym- runny nose, coughing, temp, clear lungs
mastoid bone- non-tender
sinuses- tenderness
15
Q
What is bullous myringitis?
A
development of vesicles in the superficial layers of the TM
look like blisters on the TM
16
Q
What causes bullous myringitis?
A
Mycoplasma
17
Q
What treats bullous myringitis?
A
Macrolide- like azithromax
18
Q
How is acute otitis media treated in children who don’t go to daycare or this is their first infection?
A
Amoxicillin
80-90mg/kg/day in 2 divided doses, 12 hours apart
19
Q
How is acute otitis media treated in children who attend daycare or have recurrent infections?
A
Augmentin: Amoxicillin/Clavulante
90mg/kg/day / 6.4mg/kg/day in 2 divided doses 12 hours apart
20
Q
How is acute otitis media treated for a child allergic to penicillin?
A
Cefdinir
14mg/kg/day in 1 or 2 doses
21
Q
How is mild/moderate AOM treated in adults?
A
Amoxicillin 500mg BID for 7-10 days
22
Q
How is severe AOM defined and treated in adults?
A
Meaning: fever and significant hearing loss and severe pain
Tx: augmentin 875mg BID for 10 days
23
Q
How is AOM treated in adults with a penicillin allergy?
A
Cefdinir 300mg BID for 10 days
24
Q
What can be prescribed to help with the pain of an AOM?
A
Tylenol Kids: 15mg/kg Q4h
Tylenol Adult: 500-1000 mg Q6h
Ibuprofen Kids >6mo: 10mg/kg Q6h
Ibuprofen Adult: 600-800 mg Q8h
Antipyrine/benzocaine (auralgan) 2-4gtt TID-QID
25
When would you refer for AOM?
persistent OME or AOM
More than 4 episodes in 6 months or 6 episodes in a year
hearing loss
cholesteatoma
acute mastoiditis
26
What is recurrent AOM?
three or more episodes of acute otitis media within six to 18 months
27
What is herpes zoster oticus? AKA Ramsey Hunt Syndrome
Triad of:
1- herpes vesicles in auricle/canal
2- facial paralysis
3- ear pain
28
How is herpes zoster oticus treated?
```
prednisone 1mg/kg/day for 7 days
OR
Famciclovir 500mg po tid for 7 days
OR
Valacyclovir 1gm po tid for 7 days
```
29
What is mastoiditis?
Inflammation of mastoid air cells of temporal bone inside the mastoid process, usually as a complication of acute otitis media
Usually caused by Step. pneumo
30
How does mastoiditis present?
Tenderness, swelling of mastoid
Displaced ear
Fever
AOM
31
What is OME?
Otitis Media with Effusion:
effusion in the middle ear without evidence of infection persists after the AOM or related to allergic rhinitis due to dysfunction of the Eustachian tube
32
What is the clinical presentation of OME?
Afebrile, no otalgia or otorrhea
HEENT: TM with visible landmarks, TM maybe pearly grey, mildly erythematous, serous fluid behind TM, no bulging
Signs of URI maybe present
33
What are the differential diagnosis for OME?
AOM
MEE- middle ear effusion
34
how do you treat OME?
watchful waiting
35
What is tympanosclerosis? What causes it?
white scarring from T-tubes
| incidental finding-
36
What is cholesteatoma?
an abnormal accumulation of keratin producing squamous cells in the middle ear
37
What causes cholesteatoma?
congenital OR
Acquired due to persistent, recurrent AOM that result in chronic prolonged negative pressure or perforation, which pulls in squamous epithelial cells into the middle ear.
38
What is the clinical presentation of cholesteatoma?
Hearing loss (conductive), tinnitus, persistent ear infections
39
What is found on physical exam with cholesteatoma?
White cyst usually in the posterior or anterior superior quadrant of the TM
40
What is the treatment for cholesteatoma?
refer to ENT
41
What is otitis externa?
Inflammation of the external canal that may extend to the auricle
often called ‘swimmers ear’
42
What are the most common pathogens for otitis externa?
S. Aureus
P. Aeruginosa
43
How does otitis externa present?
As acute presentation : pruritus, mild to moderate discomfort, and erythema
As progresses: edema, otorrhea (ear discharge), and conductive hearing loss
44
What does otitis externa look like on physical exam?
Pain and tenderness on palpation of tragus or auricle.
Canal is usually erythematous with exudate.
TM may or may not be visible.
Cellulitis may extend to the auricle.
In severe cases you may have hearing loss as well as cervical lymphadenopathy.
45
What are the differential diagnosis for otitis externa?
Cerumen impaction- esp if older
Forign body
Malignant otitis externa
46
What is the treatment for Otitis externa?
Aural toilet
Topical antibiotics with steroid and coverage for P. aeruginosa and S. pneumonia for 7 days
Pain tx with NSAID
Severe occlusion- place wick and change 1-3 days
47
When should otitis externa be referred?
Malignant otitis externa
Grossly inflamed or prolonged infection
48
How is otitis externa treated with a perforated TM?
Ciprofloxacin 0.3%/ dexamethasone 0.1% (Ciprodex) BID
OR
Ofloxacin 0.3% BID
49
How is otitis extra treated if the TM is intact?
Neomycin/polymyxin B/ hydrocortisone, solution or suspension TID or QID
50
What is ceruminosis?
build up or cerumen in ear canal
may block canal resulting full sensation, decreased hearing, pain or infection (otitis externa)
If hearing is decreased, it is usually very gradual so patient isn't aware of it.
51
How is ceruminosis treated?
Irrigation- always direct stream along canal, not directly at TM. Can get messy. Important water is body temperature—not hot or cold
Rare pain—stop
Do not attempt if known or suspected tm perforation or tympanostomy tubes
52
How can ceruminosis be treated if the TM is perforated?
Use a Curette— Requires training
53
What is labryinthitis?
Acute unilateral labyrinthine dysfunction caused by viral inflammation of the vestibular nerve, bacteria or an AOM
54
How does labrynthitis present?
Vertigo
Nausea/vomiting
Tinnitus
55
What clinical findings are expected with labrynthitis?
HEENT: without findings
Hearing test: may find decreased hearing on affected side or no hearing loss
Assess Romberg and cranial nerves to evaluate for possible neurological cause of vertigo
56
What are the differential diagnosis for labrynthitis?
Benign paroxysmal positional vertigo
Meniere’s Disease
Migrainous vertigo
Multiple Sclerosis
Toxins
Head Trauma
57
How is labrynthitis treated?
Depends on symptoms:
Corticosteroids can be prescribed-Methylprednisolone tapering dose
Meclizine 25-50mg, used to treat vertigo and motion sickness
Anti-emetics-ondansetron
Re-assurance
58
What is Meniere's Disease? What is the clinical presentation?
Don't know what causes it
Episodic vertigo for 20min to several hours.
Sensorineural hearing loss
Tinnitus
Unilateral ear pressure
59
How is Meniere's disease treated?
refer to ENT
60
What is Rhinosinusitis?
Inflammation of the mucosal surface of the paranasal sinuses
61
What causes rhinosinusitis?
98% viral, such as rhinovirus, parainfluenza, or influenza virus
2% bacterial, such as Step pneumo, H.influenza, M. Catarrhalis
62
What is the clinical presentation of rhinosinusitis?
Nasal congestion and obstruction
Purulent nasal discharge
Maxillary tooth discomfort
Otalgia
Facial pain
Cough
Fever low grade
Headache
Halitosis
63
What is clinical findings are expected with rhinosinusitis?
HEENT: presence of allergic shiner; turbinates diffusely swollen, copious amounts of rhinorrhea or purulent discharge, erythematous turbinates; pharynx post nasal drip, mild erythema
Voice may be nasal
Check neck for signs of meningitis
64
how is rhinosinusisits diagnosis made?
Usually dx made empirically
65
What are the differential diagnosis for rhinosinusitis?
Dental abscess
Common cold
Trigeminal neuralgia
Optic neuritis
Atrophic, allergic, idiopathic rhinitis
Migraine or cluster headache
Foreign body (especially children)
66
What criteria needs to be met to treat rhinosinusitis?
1/3 need to be met:
- symptoms for 10+ days without improvement
- Severe symptoms, fever 39 C (102 F) purulent nasal discharge, facial pain lasting 3-4 days
- Double sickness: Onset of worsening symptoms, new onset fever, headache, increased nasal discharge following URI that lasted 5-6 days and was initially improving
67
What is the initial empirical treatment for rhinosinusitis in adults ?
Augmentin 500mg/125mg PO TID for 5-7 days
68
What is the secondary empirical treatment for rhinosinusitis in adults?
Augmentin 2000mg/125mg PO BID for 7-10 days
69
What is the initial empirical treatment for rhino sinusitis in children?
Augmentin 45mg/kg/day split BID for 5-7 days
70
What is the secondary empirical treatment for rhinosinusitis in children?
Augmentin 90mg/kg/day splity BID for 7-10 days
71
What are some supportive measures for sinusitis?
Nasal steroids--modest improvement
Saline nasal spray/flush
Decongestants & antihistamine
Mucolytic/expectorants
Hydration
Analgesics prn
Re-eval in 72 hours if symptoms not improving or worsening
72
What is allergic rhinitis?
Immunoglobulin E-mediated disease thought to occur after exposure to indoor or outdoor allergens —can be seasonal or perennial
73
What is the clinical presentation of allergic rhinitis?
Rhinorrhea
Nasal congestion
Nasal obstruction
Pruritus
Sneezing
Post nasal drip
Cough
Fatigue
74
What are the risk factors for allergic rhinitis?
Family history of atopy (ie, the genetic predisposition to develop allergic diseases)
Male sex
Birth during the pollen season
Firstborn status
Early use of antibiotics
Maternal smoking exposure in the first year of life
Exposure to indoor allergens, such as dust mite allergen
Serum IgE >100 IU/mL before age six
Presence of allergen specific IgE
75
What is expected on physical exam for allergic rhinitis?
Allergic salute
Allergic shiners
Allergic facies
Nasal mucosa: pale bluish or pale, turbinates swollen, polyps
Cobblestoning of the posterior pharynx
Serous fluid behind TM
76
How is allergic rhinitis treated?
Antihistamine
Intranasal corticosteroids
Intranasal antihistamines
Decongestants
Intranasal cromolyn
Leukotriene receptor against
Immunotherapy, slicks is a sublingual immunotherapy
77
What is conjunctivitis?
Inflammation of the conjunctivae of the eye.
Usually viral, but can be bacterial or allergic
78
What does bacterial conjunctivitis presentation look like?
Hyperemia- increase in blood vessels
Purulent discharge; eyes glued shut
Pruritus
79
What does viral conjunctivitis prevention look like?
Hx of recent URI
Excessive watery discharge
Itching, photophobia
Starts in one spreads to another
Herpes: vesicular lesions- send to Eye Dr.
80
What does allergic conjunctivitis look like?
Cobblestoning on conjunctiva
Associated with an allergic reaction
Itching severe at times
Clear or stringy discharge (cord like)
81
How is viral conjunctivitis treated?
self-limiting
cool compress
hand washing
OTC antihistamine/decongestant drops- 2ggt 4x/day for 2-3 weeks
82
How is bacterial conjunctivitis treated?
Topical antibiotic drops: Erythromycin 2ggt 4x/day for 5-7 days
Oral antibiotic if H. Influenza, GC/CT suspected
83
How is allergic conjunctivitis treated?
Avoid allergen
Cool compresses
Topical/oral antihistamine
OTC antihistamine/decongestant drops- 2ggt 4x/day for 2-3 weeks
84
When should a referral be given for conjunctivitis?
GC/Herpes
Pain
Vision loss
Corneal involvement
Recent injury
Treatment failure
85
What is a corneal abrasion?
break in the epithelium usually due from trauma, can be chemical
86
How does a corneal abrasion present?
eye pain or feeling like there is sand in the eye, blurred vision, tearing
87
What are some causes of epistaxis?
Trauma, epistaxis digitorum (nose picking), foreign bodies
Meds or irritants—topical steroids, cig. Smoke
Intranasal polyps, neoplasm, or septal deviation
Hemophilia, leukemia
Liver disease/disorders cassock w/ thrombocytopenia
Meds affecting platelets/coag: ASA, warfarin, NSAIDS
88
How is epistaxis treated?
Prevention is key: No “digitorum”, lubricate nares or humidify air
Compression works well if done correctly. Continuous, direct pressure 5-20 minutes with head forward!
89
What is pharyngitis?
Inflammation of the tonsils, pharynx and larynx
90
What is the clinical presentation of pharyngitis?
Very painful swallowing
91
What is expected on physical exam of viral pharyngitis?
red swollen tonsils
Red throat, cobble stoning
92
What is expected on physical exam of bacterial pharyngitis?
swollen uvula with white spots
Red swollen tonsils
Red throat
Gray furry tongue
Bad breath
93
How is viral pharyngitis treated?
Adequate analgesics
If “no relief”, get detailed hx of use
Salt or warm water gargles
Hydrate, lozenges, sprays
Voice rest prn
94
What are the three signs of Mononucleosis?
Fever
Pharyngitis
lymphaenopathy
95
What is mononucleosis caused by?
Epistein Barr virus
OR
cytomegalovirus
96
How is Mononucleosis spread? What is the incubation period
through saliva
incubates for 4-7 weeks
97
What is the clinical presentation of Mono?
fever
erythematous tonsils w/ exudate
often very toxic w/ malaise
headache
Anorexia
N/V
98
What is a clinical feature of Mono that helps distinguish it from other diseases?
Significant cervical lymphadenopathy may help distinguish from other pharyngitis @ early stages
99
How is Mono diagnosed?
Reaction to PCNs
Labs—EBV IgG and IgM , CMV IgG and IgM, CBC with differential
Serum—10% or > atypical lymphocytes support dx
100
What are the differential diagnosis of Mono?
Strep
CMV
Acute HIV
Toxoplasma infection
101
How is Mono treated?
Adequate analgesics
If “no relief”, get detailed hx of use
Salt or warm water gargles
Hydrate, lozenges, sprays
Voice rest pen
Maybe corticosteroid- controversial b/c immunosuppression and steroid ADE
102
What are some potential complications of Mono?
spleen rupture- if contact sports played because splenomegaly
If given penicillin- ab will develop a maculopapular rash
Oral Hairy Leukoplakia on tongue- White painless plaques, cannot be scraped from the surface. (Associated with intense EBV replication)
103
What is the most common causes of bacterial pharyngitis?
Most common: GABHS
Others:
Gonococcal- sexually transmitted
Diphtheria pharyngitis
104
What is Gonococcal look like?
Greenish exudate + fever, severe ST, dysuria
105
What does diphtheria pharyngitis?
“Pseudo-membrane”
“bull neck”- soft tissue swelling of the neck
106
What is the common cause of bacterial pharyngitis?
GABHS- Group A Beta Hemolytic Strep
Peak season: late winter/early spring
107
When is GABHS pharyngitis contagious?
Incubation 24-72 hours
If treated- no longer contagious after 16 hours of starting antibiotics; OK return to school/work 24 h. after
If untreated—continues to be contagious for up to 10 days after symptom resolution
108
What are the presenting symptoms of the GABHS pharyngitis?
Fever, chills, headache, fatigue, malaise,
myalgia's
Sudden onset of sore throat, painful swallowing: marked erythema of the throat, and tonsils (tonsillar enlargement)
“hot potato voice”
Tonsillar exudates
Uvular edema/erythema (red beefy)
anterior cervical adenopathy
palatal petechiae
n/v, abd pain—often assoc. w/ fever
s/s usually resolve without treatment
Complications w/o treatment
109
How is GABHS pharyngitis diagnosed?
Rapid Strep Test- allows for early detection
Throat culture- gold standard
110
Why treat GABHS pharyngitis?
Reduce contagiousness from 1-2 wks post-infections down to 1 day after starts antibiotic
Reduces sequellae of other symptoms
111
What are potential GABHS sequellae if it goes untreated?
Peritonsillar abscess
Acute rheumatic fever:
systemic disease affecting the peri- arteriolar connective tissue and can occur after an untreated group A streptococcal pharyngeal infection;
rheumatic heart disease—valve damage d/t rheumatic fever
Glomerulonephritis—post-streptococcal; only certain strains
112
What is the treatment for GABHS?
PCN V 500mg bid for 10 days
Amoxicillin in children as it tastes better 45mg/kg bid
113
What is the treatment of GABHS if the patient has an PCN allergy?
Cefurdroxil 30mg/kg children OR
| 500mg bid or 1g per day in adults
114
When should GABHS be referred?
Referred to ENT if > 6 episodes of documented severe throat infections in one year
Temp > 101
Enlarged and tender lymph nodes
White spots on tonsils
Positive strep test
115
What is PANDAS?
Pediatric autoimmune neuropsychiatric disorder associated with strep
Meaning: Group A strep in a susceptible person causes and abnormal immune response with resultant central nervous system manifestations
Pediatric onset 3 yr to puberty
Leads to abrupt onset or exacerbation of OCD or tic behavior
116
What does it mean to be a carrier of GABHS?
Patients who are chronically colonized with GABHS
Very low risk, if any, for developing suppurative complications
Unlikely to spread GABHS to close contacts.
Most carriers require no medical intervention
117
How should GABHS carriers be treated if they get infected?
Clindamycin 20 mg/kg/day in three divided doses (maximum 450 mg/day) x 10 days
118
What is Scarlet Fever?
Erythematous eruption due to a toxin produced by beta-hemolytic streptococci…
119
What is the typical presentation of scarlet fever?
Starts with fever, pharyngitis
THEN
Scarletiniform rash: fine papular with rough texture…neck-trunk- axillary, groin, extremities.
The skin peels off (desquamation) at the axilla, groin, palms
Begins 7-10 d. after rash resolution
May last up to 6 wks
Proportional to intensity of rash
120
How is scarlet fever treated?
PCN V 500mg bid for 10 days
Amoxicillin in children as it tastes better 45mg/kg bid
121
How is scarlet fever treated if the patient has a PCN allergy?
Cefurdroxil 30mg/kg children OR
| 500mg bid or 1g per day in adults
122
What does Kawasaki's disease look like?
strawberry tongue
Rash- circular with red center on trunk/loins
Red swollen hands
123
What is pertitonsillar abscess?
accumulation of pus within the peritonsillar tissue
tonsillitis leads to cellulitis which leads to abscess, the body tries to encapsulate the infection.
Associated with GABHS, Staph aureus, H. influenza
124
How does peritonsillar abscess present?
Fever, chills, malaise, halitosis, toxic appearing, ‘hot potato” voice, drooling
125
What is expected to be found on physical exam for a peritonsillar abscess?
Unilateral erythema edema of the peritonsillar tissue which leads to uvular deviation
Tender cervical nodes
Signs of dehydration
126
How is peritonsillar abscess diagnosed?
physical findings
CT scan
CBC with diff and a Chem panel
monospot
127
What are the differential diagnosis for peritonsillar abscess?
Mono
Tumor/Leukemia/Lymphoma
Cervical adenitis
Epiglottitis
Dental infection
128
How is peritonsillar abscess treated?
Refer to ENT or ED
129
What are Tonsilloliths?
Benign collection of collagen/ microorganisms/
food in tonsillar crypts
Patient will have bad breath
130
What is epiglottis?
acute usually bacterial inflammation/cellulitis of the epiglottitis
131
What is the clinical presentation of epiglottis?
severe odynophagia
dysphagia
fever
drooling
SOB
distress
stridor
132
What is the the clinical presentation of croup?
Cough barking sound, worse at night
Usually precedent URI or low grade fever
Hoarseness, stridor, wheeze
133
What is expected upon physical exam of croup?
Vital signs: low grade temp, tachycardia, tachypneic, nl pulse ox
Varies from no apparent to distress with barky cough at rest or with crying to nasal flaring, stridor, respiratory distress
HEENT: turbinates swollen, erythematous with mucoid discharge, pharynx may have erythema enlarged tonsils, no exudate or petechial
Neck: shoddy cervical lymphadenopathy, inspiratory stridor
Chest: scattered expiratory wheeze
134
What are the differential diagnosis for croup?
Angioedema
Epiglottitis
Peritonsilar abscess
Foreign body
Retropharyngeal abscess
135
What is the treatment of croup?
Oral corticosteroid
Dexamethasone po/IV/IM
6mg/kg up to 12mg x1 in office
Effects persist up to 48 hours
Avoid if active TB or varicella
Mist therapy
Racemic Epinephrine- moderate to severe, given in ER, monitored for
4 hours for “rebound phenomenon”
Oxygen therapy
