Week 3 - Ears, Eyes, Skin Flashcards
Fever for infant under 2
100.4
Fever for children over 2
101
Fever can be…..
infectious or non-infectious
How to assess fever?
- Duration and degree of fever
- Associated symptoms (n/v, diarrhea, lethargy…)
- Recent known exposure to illness
- PMH
- Prior abx, surgeries,
- Current medications
- Immunization history
At what temperature does a fever cause damage to body?
107.6F
Strategies for fever management
- Adequate hydration
- Not all fevers need to be treated
- Appropriate clothing, do not bundle
- Room temp 72
- Tepid water baths for temp over 104, stop if shivering occurs
Contact Dermatitis
- Acute or chronic inflammation resulting from hypersensitive reaction to an irritant or allergen
Types of Contact dermatitis
- Dry skin
- nickel
- Phytophotodermatitis
- plant oleoresins
- juvenile plantar dermatosis
- latex dermatitis
Dry skin dermatitis
very low humidity, excess soap use, inadequate rinsing of soap
Nickel dermatitis
– buttons, belts, jewelery, eyeglasses
Phyto photodermatitis
sun exposure following contact with limes, lemons, celery, carrots, parsnips or dill (blistered lesion)
Plant oleoresin dermatitis
poison ivy, oak or sumac – can be direct or indirect, oil may be inhaled and damage lungs
Juvenile plantar dermatitis
dryness, cracking, and erythema of weight-bearing surfaces of the feet, initially the big toes; it mimics tinea pedis, often found in children with atopic dermatitis
Common substances that cause dermatitis
- saliva
- urine, and feces
- baby wipes
- bubble bath
- agents that dry the skin
- adhesives
- diapers
- allergens
Physical exam findings
for dermatitis
- Localized rash with sharp borders,
- Severity depends on length of exposure
- Irritant reactions are immediate and allergic reactions are delayed
Management of contact dermatitis
- Burrow solution soaks or oatmeal baths and cool compresses with salt water applied for 20 minutes every 4-6 hours to soothe vesicular rashes
- Petrolatum or lanolin based emollients
- Topical corticosteroids used 2-3xday for 2-2 days
- Oral antihistamines for pruritis
- Resolution may take 2-3 weeks
Scabies
- Parasite that burrows into the skin and causes intense itching
- Highly contagious through close contact
Physical findings for scabies
- Characteristic lesions include curving S-shaped burrows, especially on webs of fingers and sides of hands, folds of wrists and armpits, forearms, elbows, belt line, buttocks, genitalia, or proximal half of foot and heel.
- Dozens of lesions on small children, older children have fewer lesions
Treatment for scabies
- Apply thin layer of scabicide to entire body excluding eyes
- Especially fingernails, the scalp, behind the ears, all folds and creases, and the feet and hands
- Repeat treatment after 7 days
- Permethrin cream – apply to whole body and rinse after 8-14 hours
- Family and friends should be treated
- Wash clothing in hot water, vacuum
- Seal non washable clothing in a bag for 1 week
Education for scabies
- Rash and itching can continue for 3 weeks after treatment
- Can return to school 24 hours after treatment
Chiggers
- The larvae of harvest mites secrete an irritating substance that cases the skin eruption characteristic of chigger bites. Chigger mites live on grain stems, shrubs, grass, and vines and attach to human or animals that pass by.
Symptoms of chiggers
Complaints of itching followed by dermatitis; history of playing or walking in grassy areas, parks, or other mite habitat near woods and water
Physical findings for chiggers
- Discrete, bright-red papules 1 to 2 mm in diameter that often have hemorrhagic puncta
- Lesions mainly seen on legs (sock area) and belt line but can be widespread
- Wheals, papules, or papulovesicles in sensitized individuals
- Bullae or purpuric lesions with secondary hypersensitivity reaction
- Intense pruritus reaching a peak on the second day and decreasing over the next 5 to 6 days, but can persist for months
- Possible secondary impetigo from scratching lesions
- May see the embedded chiggers
Treatment for chigger bites
- Cool compresses
- Topical corticosteroids (e.g., 1% hydrocortisone cream)
- Topical antipruritic agents, such as calamine lotion; avoid topical diphenhydramine
- Oral antihistamines (e.g., diphenhydramine) if topical corticosteroids do not provide relief
- Removal of embedded chiggers (can be withdrawn by covering the insect with alcohol, mineral oil, nail polish, or ointment)
- Colloidal oatmeal baths (clean tub thoroughly after bath to avoid fall risk from oil residue left behind)
- Treatment of secondary skin lesions as indicated
- Elimination of fleas by treating animals and cleaning carpets, bedding, upholstered furniture; avoid areas that are potentially infested with mosquitoes, fleas, or chiggers
- Insecticides should be used with caution
Pediculosis
- August to November is lice season
- Head lice not a health hazard, do not spread disease
Symptoms of pediculosis
- History of infestation friend/family
- Itching
- Dandruff
- Crawling sensation of the scalp
Physical exam findings for pediculosis
- Nits attached to the hair shaft and will grow out
- Commonly found back of neck, head, ears, eyelashes
- Occipital or cervical lymphadenopathy
- Treat head lice – rinse with shampoo in sink with warm (not hot) water
Body lice
- Excoriated macules
- Belt, collar, and underwear lines common
- Pinpoint macule where the louse has extracted blood
- Axillary, inguinal, regional lymphadenopathy present
Pubic lice
- Excoriation and small bluish macules and papules
Treatment for pediculosis
- Permethrin 1% (widespread resistance) – safe for children older than 1 month old
- Topical ivermectin
- Malathion lotion
Steps
* Apply pediculicide – permethrin
* Remove nits with comb
* Cleanse environment
* Return to school after permethrin treatment
Nevi
Most commonly vascular.
Vascular nevi are caused by a structural abnormality (malformations) or by an overgrowth of blood vessels (hemangiomas) and are flat, raised, or cavernous.
Salmon patch
light pink macule usually seen at back of neck, forehead or upper eyelids – fade with time
Pigmented nevi
present at birth or acquired during childhood. Includes dermal melanocytosis, cafe au lait spots, acquired melanocytes nevi, acanthuses nigricans
Dermal melanocytosis
Blue or slate gray irregular nevi. Benign, more common in dark skin. Usually fade over time.
Café au lait spots
tan to light brown macules, oval, irregular, increase in numbers with age,
Acquired melanocytic nevi
light to dark brown, flat or slightly raised usually found in sun exposed areas above the waist
Acanthosis nigricans
velvety brown rows of hyperpigmentation in irregular folds of skin, usually the neck and axilla; tags may also be present.
Not treatable. Associated with insulin resistance and internal tumor.
Hemangiomas
Manifest initially as a pale macule, a telangiectatic lesion, or a bright red nodular papule. After appearing, hemangiomas go through a proliferative phase during which they grow rapidly and form nodular compressible masses, ranging in size from a few millimeters to several centimeters. Occasionally they may cover an entire limb, resulting in asymmetric limb growth. Rapidly growing lesions may ulcerate. (treat with propranolol)
Atypical nevi
larger than aquired nevi, irregular, poorly defined borders and variable pigmentation
Port wine stain
A permanent defect that grows with the child, so cosmetic covering is often used. If forehead and eyelids are involved, there is potential for multiple syndromes, including Sturge-Weber, Klippel-Trenaunay-Weber, and Parkes Weber. Neurodevelopmental and ophthalmologic follow-up is needed. Referral to a dermatologist for possible laser treatment or cosmesis is required.
When to refer nevi to a dermatologist?
- Suspicious-appearing nevus (as identified by ABCDE signs—asymmetry, border, color, diameter, evolving)
- Rapidly growing or changing nevus
- More than 50 nevi
- One or more atypical nevi
- History of one or more first-degree relatives with melanoma
- Presence of a giant or large congenital nevus
- Signs of excessive sun exposure (increased nevi and freckles in exposed areas)
- History of immunosuppression and multiple nevi on examination
Most likely cause of eye injuries?
sports injuries, airbags and abuse
Subconjunctival hemorrhage
- splotchy bulbar conjunctival redness that occurs spontaneously or is secondary to increased intrathoracic pressure (from coughing, sneezing, straining, or trauma) that results in the bursting of conjunctival vessels
- painless, resolve spontaneously in 2-3 weeks
- treatment indicated only for pain, vision loss, photophobia –> refer to ophthalmologist
Eyelid contusion (black eye)
- Bruising and swelling from blunt injury
- Elevate the head and do intermittent ice compresses for 48 hours
- For pain or swelling, decrease in visual acuity, double vision, flashing lights or “floaters,” or develops a bilateral “raccoon eyes” appearance, an ophthalmologic evaluation is needed
Corneal abrasion
- Damage to or loss of the epithelial cells of the cornea in the form of a corneal abrasion or tear
Causes of corneal abrasion
Scratches from forceps delivery, paper, brushes, fingernails, contact lens overuse, improperly fitted cosmetic contact lenses, airbag deployment, plants, or foreign body in the conjunctival sac are often responsible.
Symptoms of corneal abrasion
- Evidence and sensation of a foreign body; conjunctival erythema
- Severe pain, photophobia, and decreased vision
- Tearing, blepharospasm
- Disrupted tear film over the corneal
- Fluorescein staining with superficial uptake indicative of a minor corneal abrasion
Management of corneal abrasion
- Refer severe injuries to ophthalmology
- Refer those with contacts to ophthalmology to rule out bacterial corneal infection (prophylactic topical antibiotic – cipro or gentamycin)
- No signs of infection treat with 0.5% erythromycin or polymycin/trimethoprim, cipro or ofloxacin drops 4xday for 3-5 days
- Oral analgesics and topical NSAIDS
Foreign body in the eye
Clinical presentation
- Pain and foreign body sensation, foreign body visible in the conjunctival sac, perforating wound to the cornea or iris
- Tearing, photophobia, inflammation
- Irregular or peaked pupil, opaque lens
How to diagnose optic foreign body
- Fluorescein staining, US or CT for diagnosis
Management of optic foreign body
- Do not remove intraocular object, refer to ophthalmology immediately
- Have patient look down and pull upper lid away from the globe
- Use topical anesthetic for exam if needed
- If you can see the object, irrigate or lift object gently away with moistened cotton swab
- After removal apply fluorescein stain and check for corneal abrasion, check visual acuity
- For airbag deployment irrigate with sterile saline and examine for signs of trauma
S/S of Eye burns
- Pale or necrosed appearance of the surrounding skin and eyelids
- Opacity of corneal tissue, swollen corneas
- Visual impairment (decreased acuity)
- Initial exquisite pain or delayed complaints of pain (e.g., in UV burns, pain emerges about 6 hours after exposure)
- Photophobia; tearing within 12 hours of exposure
- Fluorescein stain revealing pinpoint uptake
Management of eye burns (chemical)
- Topical anesthetic
- Immediate, copious, ongoing irrigation of water, saline, or LR for 30 minutes
Orbital laceration symptoms
- Anterior segment: irregular pupil (retracted or peaked), iris prolapsed
- Posterior segment: poor red light reflex, decreased vision, black tissue or fluid seen under the conjunctiva
Management of orbital laceration
- Eye shield (can be made from cup) to protect the eye, refer immediately to ophthalmology
Hyphema
- accumulation of visible blood or blood products in the anterior chamber of the eye and is the result of blunt trauma to the globe without penetration or perforation. This condition is most often caused by balls, fists or fingers, elbows, rocks, exploding airbags, and sticks.
Symptoms of hyphema
- History of traumatic eye injury; somnolence (associated with intracranial trauma)
- Blood (appearing as a dark red fluid level between the cornea and iris) on gross examination or as a hazy-appearing iris
- Inability to detect a bilateral red light reflex
- Pain, photophobia, and tearing; abnormal pupillary reflex
- Visual acuity changes and impaired vision (light perception and hand motion perception)
Management of hyphema
- Refer the patient immediately to an ophthalmologist. A slit-lamp examination is indicated.
- Restrict oral intake until the child has been seen by an ophthalmologist.
- Place a perforated eye shield (not a patch) over the eye; avoid pressure to prevent reinjury.
- If a hematologic disorder is detected, ensure quick intervention and close follow-up.
*Outpatient management if small - Hospital and surgery to remove if large
Retinal detachment
- the neurosensory retina separates from its retinal pigment epithelium base within the globe
Clinical findings for retinal detachment
- Blurry vision that becomes progressively worse
- Dark cloud in one visual field, flashing lights, or a “shower of floaters”
- Darkening of retinal vessels on funduscopic examination
- Gray elevation at the site of detachment
Management of retinal detachment
- Instruct the patient not to eat and refer him or her to an ophthalmologist for emergent evaluation.
Orbital hematoma and contusion to the globe
- Blunt trauma to the globe
- Common causes include sports activities, motor vehicle accidents, assault, BB gun accidents, or airbag deployment.
Clinical findings for orbital hematoma/contusion
- Milky white retina
- Visual acuity changes
- Severe bruising of eyelids and periorbital tissues
- Lens dislocation, retinal detachment or edema, rupture of eyeball
- Vitreous, retinal or choroid hemorrhage
Management of orbital hematoma
Refer immediately to opthalmologist
Orbital fracture
Fracture of the walls of the orbit secondary to blunt trauma to the eye or orbital rims
Clinical findings for orbital fracture
- Pain, numbness below the orbit; trouble chewing; nosebleed
- Diplopia, irregular pupil, limited ocular movement (especially upward)
- Corneal laceration, hyphema, and/or absent red light reflex
- Globe displacement (sunken or protruding) or enophthalmos (recession of the eyeball within the orbit)
- Bony discontinuity or “step-off”
- Ecchymosis of the lids; subcutaneous emphysema in surrounding tissues, and edema
Management of orbital fracture
- Ophthalmologic emergency – needs immediate Xray or CT
- Ice for 48 hours and sleep with HOB elevated
- Prophylactic abx if orbital fracture involves the sinuses
- Nasal decongestants to reduce blowing/sniffing
Congenital cataracts
- recommended lab workup of a child with bilateral congenital cataracts includes titers for TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes), syphilis (the Venereal Disease Research Laboratory [VDRL] test), serum calcium and phosphorus levels, and urine testing for reducing substances
- Genetic testing is recommended if there are dysmorphic features.
- A small or partial congenital or infantile cataract can be monitored over several years for a progression that could produce amblyopia; some types of cataracts do not progress. Patients should be monitored by an ophthalmologist as amblyopia may develop.
- Removal and insertion of new lens
Topical antibiotics used for eye infections
- Fluoroquinolones
- sulfacetamide
- bacitracin
- bacitracin/polymyxin B
Antibiotics for periorbital cellulitis
Amoxicillin with clavulanic acid, cefdinir, and cefpodoxime are first-line choices for treatment.
Antibiotics for bacterial conjunctivitis
- Erythromycin 0.5% ophthalmic ointment
Antibiotics for dacrocystitis
- eythromycin ophthalmic ointment, or a fluoroquinolone (moxifloxacin, ciprofloxacin, ofloxacin, norfloxacin) for 1 to 3 weeks
Retinoblastoma
- Intraocular tumor that develops in the retina, most common tumor in childhood.
- May be hereditary through the RB1 gene (all bilateral disease is considered hereditary)
- Some evidence HPV may play a role in development
- Screening guidelines
- all infants and children should have a red reflex exam before discharge from the newborn nursery and thereafter at every health maintenance visit
Clinical findings that indicate retinoblastoma
- Strabismus (crossed eyes)
- Decreased visual acuty
- Uni or bilateral white pupil, usually seen in low-light settings
- Abnormal red reflex
- Nystagmus
- Glaucoma
How is retinoblastoma diagnosed?
ophthalmic exam under anesthesia, US, or MRI
Management of retinoblastoma
- Refer patients with abnormal findings suspicitous for retinoblastoma for diagnosis and management by a MDT
- treatment may involve cryotherapy, laser photocoagulation, episcleral plaque brachytherapy, systemic chemotherapy, or enucleation
- frequent follow up required
- 95% cure rate in US children – unilateral has the best prognosis
- Children with germinal retinoblastoma have higher risk for other cancers
Three components for diagnosing otitis media
- Abrupt onset of ear pain, irritability, otorrhea and/or fever
- Bulging TM or otorrhea
- s/s of inflammation confirmed by distinct TM erythema or ear pain
Causes of AOM
S. pneumoniae, h influenzae , Moraxella catrrhalis and s pyogenes most common causes of AOM.
Usually virus is the initial causative factor. – majority of causes caused by bacteria or virus and bacteria together
Clinical findings for AOM
- Ear pain that interferes with activity especially when lying flat
- Irritability or ear pulling in toddler
- Otorrhea
- Fever
Symptoms of middle ear inflammation
- TM Amber –> fluid only behind
- White/yellow TM –> AOM, OME
- Increased vascularity of TM with obscured or absent landmarks
- Red/yellow/purple TM
- Thin-walled, sagging bullae filled with straw coloroed fluid with bullous myringitis
Physical exam findings for AOM
- Bulging TM
- Decreased TM translucency
- Absence or decreased TM mobility
- Air-fluid behind TM
- Otorrhea
When to treat AOM
- Moderate/severe bulging TM with otorrhea not associated with AOM
- Mild bulging of TM with onset of pain in last 48 hours or intensely erythematous TM
- Babies under 6 months with acute bilateral OM without sever symptoms sick less than 24 hours
When to wait to treat AOM
- Young children with unilateral AOM without severe symptoms and fever less than 102.2
- Child older than 2 without severe symptom
When to reassess AOM
- Children not treated and no improvement within 48-72 hours
Management of AOM
- Pain management with Tylenol or brufen
- Heat/cold externally
- Amoxicillin is first line 80-90mg/kg/day 2xday , augmentin (amoxicillin/clafulanate for allergies to PCN or treated prior with amoxicillin w/in 30 days)
- Amoxicillin, augmentin, azithromycin,ceftriaxone clinda)
- Under 2 then 10 days treatment, over 2 then 5-7 days treatment
- Watchful waiting 48-72 hours, give pain relief, schedule follow up parameters not needed if improvement in 48 hours
- If TM is perforated, include otic drops (oxo or cipro)
Persistent AOM
- Abx complete but still present or recurs within days of completing treatment broader spectrum ABX
- ENT referral
Otitis media with effusion
- Buildup of fluid behind the TM due to increase mucous production, mucous absorbs water and becomes stuck behind TM
- Can occur after viral illness, barotrauma, allergies
S/S of AOM with effusion
- Hearing loss
- Feeling of fullness in ear
- Dizziness/impaired balance
- Popping feeling
Physical exam findings for AOM with effusion
- Decreased TM mobility
- TM is dull, bulging, opaque, no visible landmarks, retracted, air fluid or bubble may be seen
Management of AOM with effusion
- Pneumatic otoscopy
- Watchful waiting for 3 months after diagnosis
- intranasal steroids, antihistamines, antibiotics, decongestants not recommended
- check hearing if it last more than 3 months
- reevaluate q3 months until resolved
- educate family on duration and course and when to follow up
- refer to ENT if otoscopy suggests structural damage of TM, significant hearing loss, chronic persistent OME for 6+ months
Otitis externa
Diffuse inflammation of the EAC, can involve pinna or TM
Cause of AOE
Protective barriers of the EAC are damaged by mechanical or chemical mechanisms, usually caused by retained moisture that changes the acidic environment to neutral or basic promoting bacterial/fungal growth
Clinical findings for AOE
- Itching/irritation
- Pain
- Pressure/fullness of ear
- Hearing loss
- Periauricular edema
- Pre and posterior lymphadenopathy
Physical exam findings for AOE
- Pain with tragus or pinna
- Swollen EAC with debris – hard to see TM
- Regional lymphadenopathy
- Tragal tenderness
- Red, crusty, pustular lesions
- pruritis with thick otorrhea (drainage)
- tympanostomy or TM perf
- dry appearing ear canal with atrophy or thinning of canal and no cerumen
Management AOE
- Eardrops – ciprodex (ciprofloxacin and dexamethasone)
- No systemic abx unless signs of systemic infection
- Patient education on drop instillation (child lying on side with ear up and instilled until EAC is filled, pump the tragus to remove trapped air and ensure filling. Remain lying down 3-5 minutes leaving ear open to air
- No swimming during acute infection
- Analgesics for pain
Otic Foreign Body
- items put in ear or thrown by another child. May involve leaves/plants/toys/bugs
Symptoms associated with foreign body in the ear
- Child reports putting something in ear or having something thrown at them
- Itching, buzzing, fullness or object in ear
- Persistent cough or hiccups
- Unilateral otalgia and otorrhea (bloody/purulent)
Management of foreign body in the ear
- Being able to visualize object is important
- Soft, irregular shaped objects easily removab le with forceps or curved hook
- Round or breakable objects can be removed with wire loop, curette, or right angle hook
- Irrigate only if TM is intact irrigation can push further into ear canal
- Button batteries require immediate removal due to the risk of leakage – do not irrigate
- Metal objects can be removed with magnets
- Insects can be suffocated with mineral oil and then irrigated – or refer to ENT
- If it cannot be removed within the first few attempts or without risking damage to EOC or TM or pain is worse refer to ENT
- Topical antibiotic drops with steroid are recommended post removal
The American Association of Ophthalmic Oncologist and Pathologists (AAOOP) screening recommendations for children at risk for retinoblastoma
All infants and children should have a red reflex exam before discharge from the newborn
nursery and after that at every health maintenance visit
