Presentation of Otitis Media
Fever Cranky Congestion Pulling at ear Irritable
Risk Factors in Otitis Media
Caretaker smoking
Bottle propping
Day-care attendance
Most Common Bugs in OM
Strep pneumo
H. influenza
M. catarrhalis
Treatment of OM
Amoxicillin
Ceftriaxone- IM
Azithromycin- flavored, low maintenance
Augmentin
Complications of OM
Mastoiditis Cavernous sinus thrombosis Meningitis Brain abscess Scarring of the structures of the middle ear
Define Otitis Externa
Inflammation of the external auditory canal or auricle
Causes of Otitis Externa
Infectious
Allergic
Dermal disease
Risk Factors for Otitis Externa
Swimming Humid environments Sticking things in ear to clean Allergic eczema Immunocompromised
Bacterial Culprits in Otitis Externa
Staph aureus
Pseudomonas aeruginosa
Proteus
Signs/Symptoms of Otitis Externa
Otalgia Tragus pain Pain when auricle is pulled Pruritis Discharge Hearing loss
Otoscopic Exam of a Patient with Otitis Externa
Edematous & erythematous ear canal
Yellow, brown, white, or grey debris
No middle ear fluid
TM should be mobile
Treatment of Otitis Externa
Cleaning of ear canal
Protect ear canal from water
Treatment of inflammation & infection
Treatment of Otitis Externa if TM Intact
Cortisporin
Cipro HC
Tobradex
Sore Throat
Inflammation or infection of the tonsils, uvula, soft palate, and posterior oropharynx
Viral Sore Throat Symptoms
Coughing Sneezing Dripping Fatigue Anorexia Abdominal pain
Strep Sore Throat Symptoms
Toxic sensation Muscle aches Beefy red tonsils with exudate Uvulitis Plaques Exudates Anterior cervical lymphadenopathy Fever Headache Abdominal pain Strawberry tongue
Pharyngitis/Tonsillitis
Common in older children
Viruses
Strep pyogenes (Group A beta-hemolytic strep)
Complications of Pharyngitis/Tonsillitis
Rheumatic heart disease
Scarlet fever
Glomerulonephritis
How soon does Pharyngitis/Tonsillitis need to be treated?
Within 10 days
Treatment of Group A Beta-Hemolytic Strep
Penicillin VK
Cephalosporin
Clarithromycin
Macrolide
Which viruses present with beefy red tonsils plus exudate?
EBV
Coxsackie virus
Enterovirus
Beefreddytonsilovirus
EBV (Mononucleosis)
Malaise Beefy red tonsils Exudate Diffuse lymphadenopathy Splenomegaly AFEBRILE
Diagnostics of EBV
Monospot- heterophile antibody testing
CBC
Management of EBV
Education
No contact sports 6-8 weeks
Herpangina Culprit
Enterovirus
Signs/Symptoms of Herpangina
High fever
Small ulcers on erythematous base on tonsillar pillars
Soft palate
Uvula
Treatment of Herpangina
Acyclovir
Hand, Foot, & Mouth Disease Culprit
Coxsackie virus
Sings/Symptoms of Hand, Foot, & Mouth Disease
Vesicles/red papules on tongue, oral mucosa, hands, & feet
Mild fever
Malaise
Sore Throat Serious Infections
Peritonsillar abscess
Retropharyngeal abscess
Epiglottitis
Treatment of Peritonsillar Abscesses
IV antibiotics
Surgical drainage
Signs/Symptoms of Epiglottitis
High fever Sore throat Stridor Drooling Respiratory distress
Main Signs of Aphthous Stomatitis (Canker Sore)
Small ulcers on the insides of lips or elsewhere in the mouth
Management of Aphthous Stomatitis (Canker Sore)
Topical preparations
Gingivostomatitis Culprit
Herpes Simplex
Signs/Symptoms of Gingivostomatitis
Ulcers
Fever
Tender cervical lymphadenopathy
Where can ulcers occur for gingivostomatitis?
Buccal mucosa Anterior pillars Inner lips Tongue Gingiva
Management of Gingivostomatitis
Topical preparations
Treatment of Gingivostomatitis
Early: Acyclovir
Who does oral candidiasis (thrush) affect most?
Infants
Older children
Patients with broad spectrum antibiotics or steroids
Symptoms of Oral Candidiasis (Thrush)
Mouth soreness
Refusal of feedings
Curd-like plaques on buccal mucosa
Treatment of Oral Candidiasis (Thrush)
Nystatin oral suspension
Sterilize pacifiers
Pathophysiology of Sinusitis
Mucociliary clearance & drainage are impaired by a URI or allergic rhinitis or obstruction from some other cause
Signs/Symptoms of Sinusitis
Persistent symptoms Worsening symptoms following stability Facial pain Maxillary teeth pain Malodorous breat
Treatment of Sinusitis
Augmentin
Amoxicillin
Define Croup (Laryngotracheobronchitis)
Infection causing inflammation of the larynx trachea and bronchi
Croup Culprits
Parainfluenza virus
RSV
Influenza
Adenovirus
Key Features of Croup
URI symptoms
Barking cough
Stridor
Low grade fever
Treatment of Croup
Steroids Supportive therapy Hydration Minimal handling Mist therapy Cold air Oxygen Racemic epi
Sings/Symptoms of Epiglottits
Fever Dysphagia Drooling "Hot potato" voice Inspiratory retractions Soft stridor
Signature Croup Sign
Steeple sign
Signature Epiglottis Sign
Thumb print
Treatment for Epiglottitis
Ceftriaxone
Clindamycin
Steroids
Aminoglycosides
Presentation of Mumps
Parotid gland sweeling Aseptic meningitis Transietn pancreatitis Orchitis/oophoritis Epididymitis
Treatment of Mumps
Supportive
Four Keys with Group A Beta-Hemolytic Strep
Fever
Severe sore throat
Tender anterior cervical adenopathy
ABSENCE OF URI SYMPTOMS
Define Kawasaki Disease
Vasculitis of unknown etiology affecting medium sized arteries
Lab Results for Kawasaki Disease
Hypoalbunemia
Thrombocytosis
Elevated ESR
Sings/Symptoms of Kawasaki Disease
Fever 5+ days Rash Mucous membrane involvement Unilateral cervical adenopathy Nonpurulent bilateral conjunctivitis Swollen hands & feet Strawberry tongue Vascular aneurysms Abdominal pain Swollen, reddened joints
Complications of Kawasaki Disease
Coronary vasculitis Aneurysm formation Arrhythmias Infarction CHF Death
Treatment of Kawasaki Disease
High dose aspirin
IVIG
Signs/Symptoms of Rubeola (Measles)
High fever Dry cough Rhinitis Conjunctivitis with clear discharge Distinctive rash Koplik spots
How does rash present?
Head to toe
Why do we vaccinate against Rubella (German Measles)?
Pregnant women
Congenital rubella syndrome
Signs/Symptoms of Rubella (German Measles)
Rash Low-grade fever Malaise URI symptoms Lymphadenopathy
Complications of Rubella (German Measles)
Arthritis
Arthralgia
Diagnostics of Rubella (German Measles)
Serum IgM
Congenital Manifestations of Rubella (German Measles)
Hearing loss Cardiac Cerebral Blueberry muffin rash Growth retardation
Roseola Culprit
HHV-6
Sign/Symptoms of Roseola
High fever
Rash after fever
Other Names for Fifth Disease
Erythema infectious
Slapped cheeck disease
Fifth Disease Culprit
Parvovirus B19
Signs/Symptoms of Fifth Disease
Low-grade fever
URI symptoms
Mild malaise
Definition of Rash in Fifth Disease
Flat Lacy Reticular Pruritic On cheeks, trunk, extremities
Define Varicella (Chickenpox)
Pruritic vesicular rash beginning on face, neck, upper trunk
Symptoms of Varicella (Chickenpox)
Fever
Malaise
Hx of contact with another infected person
Lesions
What are the lesions described as?
Dew drop on a rose petal
Management of Varicella (Chickenpox)
Supportive
Acyclovir- immunocompromised patients
First Sign of Pityriasis Rosea
Herald patch
Other Signs of Pityriasis Rosea
Lesions appear around herald patch
“Christmas tree” appearance
Define Bronchiolitis
Inflammatory process of the smaller lower airways
Presentation of Bronchiolitis
Fever
URI symptoms
Tachypnea
Wheezing
Management of Bronchiolitis
Supportive care
Viruses which cause Bronchiolitis
RSV
Adenovirus
Parainfluenza virus
IM Monoclonal Antibody for Prophylaxis against RSV?
Palivizumab (Synagis)
Symptoms of Bronchitis
URI symptoms
Cough
Malaise
Prodrome of Pneumonia in Children
Rhinorrhea Cough Low-grade fever Pharyngitis Tachypnea
Bacteria Pneumonia Symptoms
High fever Cough Chest pain Shaking chills Tachypnea
Treatment Considerations for Pneumonia
Antibiotics Bronchodilators Steroids Fluids Oxygen therapy
Course of Pertussis (Whooping Cough)
URI symptoms
Slight fever
Cough (becomes whoop)
Guidelines for Diagnosis
Immunization status
Classic presentation
Cough >2 weeks
Nasal swab for culture
Treatment of Pertussis (Whooping cough)
Erythromycin (14 days)
Azithromycin (5-7 days)
Bronchiectasis Characterized by:
Abnormal dilation and distortion of the bronchial tree
Who is Bronchiectasis Common in?
CF patients
Two Key Factors in Bronchiectasis
Infectious insult
Impaired mucus clearance
Impaired airway obstruction
Defect in host defense
Define Fever of Unknown Origin
High fever or high temperature and defined as a rectal temp that exceeds 101 for 8 consecutive days
Common Causes of Fever of Unknown Origin
Infections disease: drugs, fictitious, CNS dysfunction
Connective tissues disorders
Neoplasms: leukemia, lymphomas
Common Bacteria that could Cause Serious Bacterial Infections
S. pneumo Meningitidis HiB E. coli Salmonella
Important for History of Fever of Unknown Origin
Fever history Fever at presentation Current activity level Activity level prior to fever Current eating/drinking pattern Appearance Vomiting/diarrhea Ill contacts Medical history Immunization history Urinary output
Workup for Fever of Unknown Origin
CBC CMP Blood cultures Sed. rates UA Urine cultures Stool specimens Rheumatoid factors Chest x-ray CSF Rapid virus testing Abdominal US
What ages do we need to catheterize to obtain a UA?
Males
Why would you order a chest x-ray in a fever of unknown origin?
Tachypnea
Rotractions
Focal auscultatory findings
Oxygen sat on RA
Procedures for Fever of Unknown Origin
Bladder cauterization
Suprapubic aspiration
LP
Treatment for Non-Toxic Fever of Unknown Origin
Patient fully immunized
No significant risk factors
Appears non-toxic
Other healthy
Parents appear reliable
Follow up in 24-48 hours-sooner if worsen
Hospital admission if findings suggest serious infection
Treatment for Toxic Fever of Unknown Origin
Admit child
Obtain cultures
Administer antibiotics
What antibiotics would we administer in Toxic Fever of Unknown Origin
Ceftriaxone
Cefotaxime
Ampicillin/sulbactam (Unasyn)
What does ceftriaxone (Rocephil) cover?
Broad spectrum
Gram-negative
What is cefotaxime (Claforan) for?
Septicemia
What does Ampicillin/sulbactam (Unasyn) cover?
Skin
Enteric flora
Anaerobes
Define Impetigo
Acute highly contagious gram positive bacterial infection of the superficial layers of the epidermis
In what climates is impetigo commonly found?
Hot, humid climates
What are the two types of impetigo?
Nonbullous impetigo
Bullous impetigo
What are the common bacteria in nonbullous impetigo?
Staph aureus
Group A beta hemolytic strep
What is the common bacteria in bullous impetigo?
Staph aureus
Risk Factors for Impetigo
Overcrowding
Scabies
Poverty
In what age group does impetigo usually present?
Children 2-5 year olds
Factors that can modify usual skin flora
High temp Humidity Preexisting cutaneous disease Young age Recent antibiotic treatment
Common Mechanisms for Disruption of Skin that Facilitates Infection
Scratching Dermatophytosis Herpes simplex Scabies Peduclosis Trauma Insect bites
Impetigo Differential Diagnosis
Herpetic impetigo Pemphigus vulgaris Follicular mucinosis Folliculitis Erysipelas Insect bites Cutaneous candidiasis
Diagnosis of Impetigo
History
Clinical appearance- “honey-colored” crust
Labs
Treatment of Impetigo
Local wound care
Antibiotic therapy
Antibiotic Therapy
Topical: Mupirocin (Bactroban)
Oral: Cephalexin or Dicloxacillin (1st)
Erythromycin & Clarithromycin (2nd)
Bactrim, clindamycin, doxycycline (MRSA)
Prevention of the Spread of Impetigo
Hand washing
Don’t scratch
Cover draining lesions
Return to school 24 hours after start of antibiotic
Molluscum Contagiosum Virus
Poxvirus
Defined Molluscum Contagiosum
Single or multiple
Rounded dome-shaped
Pink, waxy papules
Umbilicated
Molluscum Presentation
Asymptomatic Contact with family member or other person Children sharing bath Athletes sharing gym equipment Parents may recall public recreation Swimming pools Sexual activity
Mulluscum Differential
Cryptococcosis Histoplasmosis Aspergillosis Keratocanthoma Flat warts
Mulluscum Diagnosis
Distinctive, central umbilication
Biopsy
STD workup
Treatment of Molluscum
Usually resolves within months Direct lesional trauma Antiviral: cimetidine Topical: Imiquimod, Cantharidin Cryotherapy with curettage Avoid sports Avoid physical contact between infected areas Sexual abstinence
Types of Pediculosis (Lice)
Pediculosis capitus: head lice
Pediculosis corporis: body lice
Pediculosis Presentation
Parents/teachers usually discover
Pruritis
Groin/body involvment- adults
Lice Physical Exam
Observation of eggs, nymphs, mature lice
Secondary infection
Examine under microscope
Wood lamp of area
Differential Diagnosis for Pediculosis (Lice)
Dandruff Dried hairspray/gel Acne Impetigo Scabies
Treatment of Pediculosis (Lice)
Permethrin (Nix) cream Malathoin Benzyl alcohol Spinosad Ivermectin Cleaning of hair accessories, towels, bedding, clothing Environmental control
Where does scabies burrow?
Wrist Ankle Finger Webs Axillary folds Genitalia Face
Diagnosis of Scabies
Scrap unscratched papule
Treatment of Scabies
Permethrin creme
Ivermectin
Wash everything in hot water
What is the most common bacterial cause of a UTI?
Escherichia coli
Host Factors of UTI’s
Age: males
Define Vesicoureteral Reflux
Retrograde passage of urine from the bladder into the upper urinary tract
Signs & Symptoms of a UTI
Poor feeding Fever Failure to thrive (FTT) Vomiting Abdominal pain Flank pain Frequency, urgency, dysuria Suprapubic tenderness
Diagnosis of UTI
Midstream clean catch
“Clean voided” bag for collection
Bladder catheterization
Suprapubic bladder aspiration
“Clean-voided” Bag Collection
Properly clean, rinse, and dry perineum before applying
Bag must be immediately removed
Why would you do a suprapubic bladder aspiration?
Catheterizing is difficult
Tight foreskin
Tight labial adhesions
Significant periurethral irritation
Labs for a UTI
CBC
CMP
Blood cultures
Renal function studies
Imaging for a UTI
Voiding cystourethrography (VCUG) Renal US
Hospitalization of UTI
Toxemic or septic Urinary obstruction Underlying disease Unable to tolerate adequate oral fluids/meds Age
Treatment of UT
Amoxicillin Bactrim Ceftriaxone Cefotaxime Ampicillin 1st or 3rd cephalosporin Amoxicillin/clavulanate
Define Infection
Insult caused by any pathogen
Define Systemic Inflammatory Response Syndrome (SIRS)
Widespread inflammatory response that may or may not be associated with an infection
Define Sepsis
SIRS in the presence of suspected or proven infection
Risk Factors for Pediatric Sepsis
Age
Pathogens for Pediatric Sepsis
Strep Staph Pseudomonas Influenza Adenovirus RSV Fungi Parasites
Signs/Symptoms of Pediatric Sepsis
Fever Racing heart Rapid or labored breathing Cool extremities Color changes Activity level Mental status Urine output Immunizations Exposures to infectious disease Drug allergies
Physical Exam Findings in Sepsis
Subtle change in vitals Hypotension Mental status change Anuria Hypothermia Localizing signs of infection
Diagnostics of Sepsis
CBC PT/PTT/INR CMP UA Sed. rates Blood, urine, CSF cultures
Imaging for Sepsis
CXR: infiltrates
US: abscesses
CT
Echo: endocarditis
Management of Sepsis
Aggressive fluid resuscitation Support of cardiac output Ventilatory support Supplemental oxygen Maintenance of hemoglobin Correction of physiologic & metabolic derangements Monitor urine ouput
Common Antibiotics for Sepsis
3 months: 3rd generation cephalosporin + vanco
Define Meningitis
inflammation of the meninges
Types of Meningitis
Bacterial Viral Fungal Parasitic Non infectious: CA, SLE, head injury
Sign/Symptoms of Meningitis
Fever Headache Neck stiffness N/V Sleepiness Irritability Delirium
Diagnostics of Meningitis
CBC CMP Cultures Syphilis testing LP CSF analysis CT/MRI
Sexually Transmitted Diseases in Children
Unusual injury pattern/behavior
Discloses to care giver
Sexual assault
Sexually Transmitted Diseases in Adolescents
Screen appropriately
Types of STD’s
Syphilis Chlamydia Gonorrhea Chancroid HPV Herpes
Sign/Symptoms of Syphilis
Sore that forms on genitals/mouth Fever Sore throat Headache Joint pain
Stages of Syphilis
Primary: 1+ painless sores
Secondary: copper penny rash hands & feet
Latent: inactive
Tertiary: severe problems with heart, brain, nerves
Presentation of Congenital Syphilis
Asymptomatic Jaundice Hepatosplenomegaly Edema Signs of meningitis Mucocutaneous lesions Pseudo paralysis of arms/legs Hepatomegaly Rash on palms/soles Bilateral interstitial keratitis Periosteum thickening of tibias
Diagnostics of Syphilis
Darkfield microscope
Serologic testing
Treatment of Syphilis
Penicllin G
Symptoms of Chlamydia
Dysuria Vaginal discharge Cervicitis PID Epididymitis
If Chlamydia is not treated in women, it can cause what?
Infertility
Labs for Chlamydia
UA
Culture
Treatment of Chlamydia
Doxycycline
Azithromycin
Abstain from sex (7 days)
What is the second most common bacterial STI in the US?
Neisseria Gonorrhea
Sites of Gonorrhea Infection
Cervix
Urethra
Rectum
Pharynx
Symptoms of Gonorrhea
Dysuria
White, yellow, or green discharge
Painful/swollen testicles
Diagnostics of Gonorrhea
First-catch urine for NAAT
Culture
Gram stain
Treatment of Gonorrhea
Ceftriaxone + Azithromycin
Where is chancroid mainly found?
Developing
Third world countries
Symptoms of Chancroid
Small papule which changes to ulcer in 1 day to 2 weeks
Painful ulcer
Sharply defined borders
Base bleeds easily
Diagnostics of Chancroid
Gram stain
Treatment of Chancroid
Azithromycin
Ceftriaxone
Types of HPV in genital warts
6
11
Types of HPV in cervical dysplasia
16
18
Symptoms of HPV
Asymptomatic
Lesions on genitals
Diagnosis of HPV
Biopsy
Pap Smear
Treatment of HPV
Podofilox
Trichloroacetic acid
Cryotherapy
Laser surgery
Vaccines Against HPV
Gardasil: 6, 11, 16, 18
Gardasil 9
Cervarix: 16 and 18
Types of Herpes Viruses
HSV-1: oral
HSV-2: genital
Signs/Symptoms of Herpes
Grouped vesicles on erythematous base
Fever
Malaise
Tender regional adenopathy
Diagnosis of Herpes
Cultured vesicles from epithelial sites
Immunofluorescent stains
ELISA
Treatment of Herpes
Acyclovir
Famciclovir
Valacyclovir