Week 9 Content Flashcards
Sick child history includes gathering what information?
- understand main concern
- at minimum, there are 2 historians (7 years or older) at least
- how LONG has the child been sick?
- Exposure?
- PMH?
- Immunization status
Patient information to gather for a sick visit- think if you were seeing them in an urgent care setting:
- age, sex/gender
- accompanying adult and who they are to the patient
- highlight of parental concerns
- date that the child was last WELL
- Interval Hx of the illness
Pain/ symptom Mnumonic
Onset
Location
Duration
Characteristic
Alleviating factors/ relieving factors
Radiating or Relieving
Timing
Severity
yale observation scale for infants determine what
evaluate febrile status in urgent and nonurgent pediatric critical care (ages 3mo-36mo)
Yale Items
1) observation
2) reaction to parents
3) state variation
4) color
5) hydration
6) social response
Higher score indicates greater concern for bacteremia
when to seek medical attention urgently (11)
1) newborns and infants younger than 3 months with a fever above 100.4
2) significant change from normal behavior
confusion or delirium
-3) child is less responsive or alert or unconscious
4) seizure or abnormal shaking or twitching
-5)strange or withdrawn behavior
uncontrolled bleeding
6) cant stand or is unsteady when walking
7) breathing problems
skin or lips look blue
trouble feeding or eating
8) pain that gets worse, is persistent or is severe
9) severe headache or vomiting in injured head
10) fever that is persistent >3days
11)widespread rash
Acute sinusitis- A bacterial diagnosis requires the presence of one of the following criteria:
1) Persistent symptoms without improvement: nasal discharge or daytime cough >10 days.
2) Worsening symptoms: worsening or new onset fever, daytime cough or nasal discharge after initial improvement of a viral upper respiratory tract infection (URI).
3) Severe symptoms: fever ≥39°C, purulent nasal discharge for at least 3 consecutive days.
When do you prescribe VS wait with Acute Sinusitis?
What is the prefered ABX?
1) watchful wait for 3 days with persistent symptoms
2) prescribe ABX if sx are worsening or severe
3) ABX of choice- Amoxicillin or Augmentin
AOM diagnostic criteria (2):
1)Moderate or severe bulging of tympanic membrane (TM) or new onset otorrhea not due to otitis externa.
2) Mild bulging of the TM AND recent (<48h) onset of otalgia (holding, tugging, rubbing of the ear in a nonverbal child) or intense erythema of the TM.
preferred ABX for AOM
amoxicillin
Augmentin if recurrent AOM, or conjunctivitis as well.
Pharyngitis Diagnostic criteria:- to decide weather to test or not
sore throat plue 2 of the following sx:
- Absence of cough
- Presence of tonsillar exudates or swelling
- History of fever
- Presence of swollen and tender anterior cervical lymph nodes
- Age < 15 years
age of testing for GAS pharyngitis
ages 5-15 (no earlier than 3 years since GAS rarely causes pharyngitis in that age)
first line ABX for strep pharyngitis
amoxicillin
what is a RADT test
rapid antigen detection test
viral cold duration
normal length of cold: 5-7days
can last around 10 days
causative agents range over 200 viruses
bronchiolitis- causes, ages, and sx
usually caused by RSV, or viral in general
children <24 months old
rhinorrhea, cough, wheezing, tachypnea, increased WOB
bronchiolitis course and treatment
worsents day 3-5 after sx started and then improves
-nasal suctioning, no deep
-no abx
-albuterol or racemic epi can be used in clinic
pyrexia (fever) identified as:
Hyperexia is defined as:
38 degrees or 100 F
40 degrees or 104 F
misconceptions of fever:
- fevers are dangerous
- fevers can cause brain damage
- treatment is always needed
truth about fevers
- most fevers do not lead to long-term complications
- severe cases can be exceptions
- fever management varies
Options for temp taking: RECTAL
Rectal:
GOLD standard for neonates and infants
most accurate but invasive. used when precise measurement is critical. contraindications: neutropenia, bleeding disorders, NEC.
Options and ages for temp taking: Oral
ages 4-5 and older
less accurate than rectal
more accurate than axillary
influenced by mouth breathing and recent food/drink intake
Options for temp taking: axillary
safe for neutropenic patient
typically yields lower readings than rectal
Options and ages for temp taking: infrared
includes: tympanic and forehead
tympanic accuracy can be dependent on positioning and ear conditions
temporal reading can be influenced by environmental factors
RED flags for Fever
- age <1 month of age
- toxic appearance regardless of age or fever degree
- unreliable caregiver/historian
- decreased urinary output
- capillary refill >3 seconds
- non blanching skin rash
immunizations to look for in Hx when assessing fever
Hib and Pneumococcal
benefits of a fever
decreases pathogen replication
enhances effectiveness of antimicrobial treatment
often self limited
teaching points about fever
- no damage to the brain below 107.8
- fever itself is not dangerous
- its a normal response to infection
when to give medication VS when to NOT give medication for fever?
- in a HEALTHY KID- fevers do not need medication less that 102 unless other symptoms are present
- antipyretics may be needed for underlying conditions
AAP guidelines and treatment for Infant Temp >38 who are “well appearing”- age 8-21 days
infants should receive the standard workup, including blood, urine, and CSF studies
- tx- not concerned for meningitis: ampicillin and gentamicin or ampicillin and ceftazidime
- concerned for meningitis: ampicillin and ceftazidime
- Admission to the hospital while BC grow
AAP guidelines and treatment for Infant Temp >38 who are “well appearing”- 22-28 days
- blood, urine, culture
- infants should also be tested for abnormal inflammatory markers, which include height
of fever, procalcitonin, absolute neutrophil count, and C-reactive protein. These tests can help
determine the need for a lumbar puncture - infants can be sent home after a dose of ceftriaxone if CSF studies and inflammatory
markers are normal
AAP guidelines for Infant Temp >38 who are “well appearing”- 29-60 days
- infants can avoid lumbar puncture entirely with normal inflammatory markers.
urine workup details
- UA interpretation: + leuk esterase, +nitrites, WBC>5 cells.
- Bac UTI DX cannot be made until UA and Urine cultures are both +
elevated inflammatory markers are defined as
Temp: >38.5
ANC > 4000-5200
CRP >20 mg/L
fever of unknown origin definition and criteria
- 38 degrees or greater on SEVERAL occasions
- more than 3 weeks duration with failure to dx with 8 days of investigation
common causes for fever of unknown origin (school age and adolescents)
school: infections , rheumatologic disease (arthritis), rarely leukemia
Adolescents: TB, IBS, autoimmune Dx, abscess, STD
there is a range of low risk to high risk for fevering kids- what is one way you can determine risk right away?
almost always- child under 28 days of life is considered high risk.
some odd questions to ask during history intake when there are RECURRENT fevers in kids:
- family history: IBD, genetic conditions
- pet/domestic animal exposure and their vaccine status
- unusual diets including exotic meats
- PICA?
- travel details
AOM defined
acute infection in the middle ear
eustatian tube dysfunction
- short, small and flat in kids causing issues from adenoids to middle ear
key viruses and bacteria that cause AOM
V: RSV and influenza
B: S Pnumoniae, H influ., moraxella catatthalia, and s pyogens
Dx requirments AOM
1) acute onset of middle ear inflammation and effusion
2)presence of middle ear effusion
3) signs and symptoms of middle ear inflammation
use of pneumatic otoscopy
if the membrane is bulging, no need for pneumatic otoscopy- Dx AOM
if the TM is RED with minimum other symptoms, perform pneumatic otoscopy.
If it moves, its probably red from crying and or fever
if no mobility, DX AOM
treat VS observe
aom ABX
amoxacillin 80-90mg/kg/day
AOM failed 48-72 hrs of tx
augmentin THEN ceftriaxone IM 3d
AOM and conjunctivitis combined ABX tx
augmentin
penincill allergy options AOM
cefdinir, cefuroxime, cefpodoxime
failure- then ceftriaxone IM 3d
dosing lengths for AOM
MEE dx
middle ear effusion is fluid in the middle ear with NO signs of infection
MEE treatment
saline rinse and symtom tx and then reevaluate in 3 months. if not resolved, can refer to ENT
ENT refferal with MEE or AOM
when would you consider adenoid hypertrophy for AOM/MEE causation?
> 4 years with recurrent occurance
URI: most contagious, when should resolve
first three days, shedding up to 2 weeks, should resolve by the end of 10 days of sx.
age for cough medication
no younger than 4 years
conjunctivitis prevention in the newborn
erythromycin ointment at birth, within the 1st hour to prevent gonorrhea in the eye
bacterial conjunctivitis
starts unilateral, becomes bilateral
yellow/green discharge
crusted eyelids
allergic rhinitis
severe itching and tearing
