When to refer for upper endoscopy
Alarm or extra-esophageal symptoms. Or if the patient does not respond to test and treat after 8 wks
Therapies for use after H pylori infection is ruled out
TCAs (modes benefit), capsaicin, peppermint oil, caraway oil, and artichoke leaf
First line treatment for H pylori eradication
PPI triple therapy for 10-14 days. PPI BID plus clarithromycin BID plus amox BID
Alternative PPI triple therapy for penicillin allergy x 14 d
PPI BID plus clarithromycin BID plus metronidazole BID
Quadruple therapy x 10-14 days
PPI QD or BID or ranitidine BID plus tetracycline TID plus metronidazole QID plus bismuth QID
Indications for testing H pylori eradication after abx treatment (5)
Patients with H pylori assoc ulcers. Persistent sx despite T and T. H pylori associated MALT. Post-resection of early gastric cancer. For patients planning to resume chronic NSAID therapy
How to evaluate for eradication of H pylori
Fecal antigen testing. If that’s pos, retreat for salvage therapy and if sx continue, they need an upper endoscopy with bx. If the fecal antigen testing is neg and the patient still has sx, do urease breath test, If neg, refer for endoscopy
Risk factors for complications from the flu
Kids less than 5 yo (esp <2yo), chronic pulm disease, congenital heart disease, metabolic conditions (DM), chronic renal disease, immunosupp, longterm aspirin therapy (like for Kawasaki disease)
Most common complication of the flu
otitis media, strep pneumonia
Other complications of the flu
Laryngotracheobronchitis and bacterial pneumonia; neurologic (aseptic meningitis, GB, febrile seizures, myositis and myocarditis
Metabolic syndrome definition
Atleast 3 of the following : Hypertriglyceridemia, Low HDL, Elev fasting blood glucose, and excessive waist circumference, hypertension
Egophony
When patient says “E,” doc hears “Ay.” Sign of consolidation.
Tactile fremitus
When patient says 99 or toyboat, increased vibration means consolidation. Areas of decreased vibration mean effusion
Lung sounds that do not mean consolidation
wheezes, rhonchi (snoring, assoc with larger bronchial secretions and airway narrowing, usually clear after coughing)
BMI cut offs in kids
5-85%ile is healthy; 85-95 is overweight; 95 on up is obese
Fine mid inspiratory crackles verus scoarse late inspiratory crackle
Fine mid is acute PNA. Late course is resolving
Typical pneumonia
Strep pneumo. No prodromal sx. Abrupt onset. Young kids and older adults
Atypical pneumonia
Mycoplasma or chlamydia. HA, GI sx, arthralgias, cough, fever. Young adults and adolescents. Interstitial pattern on CXR
Viral pneumonia
Flu, RSV, adenovirus, rhinovirus, paraflu. Prodromal sx. Young kids (4 mos-4years)
Bronchiolitis
Caused by viruses such as RSV. Peak age 6 mos. Starts with viral illness and progresses to wheezing. Infants require supportive treatment while recovering
McIsaac Score
Indicates whether to evaluate for GABHS strep pharyngitis with rapid strep or cx
Original McIsaac criteria
Fever over 38, cough absent, tonsillar exudates, tender anterior cervical adenopathy
McIsaac rule modifiers
Age less than 15 (add 1 pt), Age greater than 45 (subtract 1 point)
McIsaac rules
Less than or equal to 1 point just give symptomatic treatment. 2-3 points rapid strep. 4 or more throat culture or start empiricic abx
In the setting of community acquired pneumonia, when is CXR indicated?
If patient is hypoxic or isn’t responding to treatment. All kids admitted to the hospital for PNA should get a CXR
When can you start antivirals for flu after the 48 hour window?
if the child has moderate to severe CAP with findings consistent with influenza or if they are clinically worsening at the time of initial outpatient visit
Management of PNA in 3 mos to adolescents
Amoxicillin (covers strep). However, for school-age kids with sx more concerning for atypical pneumonia, use macrolide like azithromycin
PNA 0-3 wks
Admit all infants. Ecoli/GBS/Listeria. Ampicillin and gentamycin
3wks-6mos PNA
Admit if suspect bacterial PNA. Strep pneumo, chlamydia, viruses. Azithromycin (outpatient). Erythromycin or cef (inpt)
3mos-5 yrs PNA
Admit if meet certain high risk criteria. Strep pneumo, mycoplasma, chlamydia, viruses. Ampicillin or Penicillin G
PNA in over 5 yo
Admit if meet certain high risk critera. Chlamydia, mycoplasma, strep pneumo. Amoxicillin (outpt) or inpt Amp or penicillin
Reasonable weightloss in kids less than 7 yo
If BMI less than 95 percentile and no complications, should maintain weight. If over 95 percentile or have complications, should decrease weight to 85th percentile
Reasonable weightloss in kids over 7 yo
If BMI between 85 and 95, weight loss is recommended to achieve 85%ile
Screening for obesity complications in a 10 yo
DM, HLD, fatty liver
How do you screen for DM in an overweight 10 year old?
All 10 year olds with BMI over 85 and RF or over 95 should get fasting blood glucose. Recheck every 2 years
How do you screen for HLF in a 10 year old?
Check fasting lipids on all kids over 85%ile, kids with family history of HLD or who are overweight. Goal total cholesterol s less than 170 and LDL less than 130. Initial treatment for kids is diet and exercise.
When can you initiate statin treatment in kid?
Must be over 10 yo, who are either Tanner stage 2 (male) or post-menarche AND LDL over 190 or LDL over 160 with RF
How to screen for fatty liver in an overweight 10 year old?
Check AST and ALT at age 10 if BMI is over 95% or over 85% with risk factors. Check every 2 years. Refer to GI for levels greater than twice the ULN
Patients with TIA have what chance of stroke within one week?
8-12% chance within one week and 11-15% within one month