1
Q
Accurate temperature measurement in children
A
Rectal thermometer in children < 3 y.o.
Oral thermometer in children > 5 y.o.
Axillary, temporal, tympanic thermometers are less accurate
2
Q
Normal rectal temperature range
A
- 9-100.2F
(36. 6-37.9C)
3
Q
T/F Degree of fever correlates with severity of illness
A
False. The general appearance is a stronger indicator. So a low temperature does not negate a serious bacterial illness.
4
Q
Fever mgmt recs: How? Pharm vs non pharm
A
- Non-pharmacological -
- hydration
- appropriate clothing and ambient temp
- tepid water baths for temp > 104F
- Do not allow shivering
- Never use alcohol or ice baths
- Pharm mgmt -
- acetaminophen 10-15 mg/kg/dose q 4-6 hours (FIRST LINE)
- ibuprofen (children age 6+ months)
- Temp < 102.5F: 5 mg/kg/dose q 6-8 hours
- Temp >=102.5F: 10 mg/kg/dose q6-8 hrs
- No aspirin, no naproxen
- alternating acetaminophen and ibuprofen may increase risk of med error/toxicity
5
Q
Causes of fever in neonates (2)
A
Congenital or acquired infections
1) late onset group B strep
2) acquired anatomic or physiologic dysfunction, i.e. renal
6
Q
Causes of fever in all children (11)
A
- bacterial, fungal, parasitic, or viral infection
- vaccines
- biologic agents
- tissue damage
- malignancy - neoplasms
- drugs
- collagen-vascular disorders
- endocrine disorders
- inflammatory disorders - teething
- environmental - heat stroke
- if temp > 105.8F - likely CNS dysfunction such as malignant hyperthermia, drug fever, heat stroke
7
Q
infants with meningitis don’t present with?
A
nuchal rigidity
do thorough neuro exam, fontanelles,
8
Q
Definition of fever without a focus/source
A
- Acute fever of unknown etiology after examining child that is < 2 years old/24 months
- < 24 months = higher risk for SBI, esp < 3 months old = need workup
9
Q
Most infants < 90 days have causative agent as ________, however, still need to rule out _____ disease so require a _____ work-up.
A
- Viral
- Bacterial
- Sepsis
10
Q
< 24 months/2 yrs → Greatest risk of unsuspected occult bacteremia w/ E. coli.
What are common SBIs with no clinical sx’s? (3)
A
- UTI
- PNA
- bacteremia
11
Q
Any child < 3 years old who is ill-appearing should have the following tests…(10)
A
- CBC w/diff
- Glucose
- CRP
- PCT
- blood cultures
- CSF testing
- UA and culture
- CXR
- Stool cx if diarrhea with blood or mucus in stool
- If in season, rapid testing for influenza/RSV/enterovirus
11
Q
Red Flags - Infants who need to be admitted to the hospital and for serious bacterial infections: (16)
A
- Prematurity
- Underlying health conditions
- Parents are unreliable historians and/or caretakers
- Ill or toxic-appearing
- Skin color is ashen, blue, mottled, or pale
- Lethargic, weak
- High-pitched cry, decreased response
- Poor feeding
- tachypnea or tachycardia
- Chest/abdominal retractions
- Petechiae
- Seizure
- Capillary refill > 3 seconds
- decrease UO
- Bulging fontanel
- Non-blanching skin rash
12
Q
evaluation of fever in young infants 29-60 days (1-2 months)
A
- ill appearing, get:
- septic workup, admit
- healthy appearing, get:
- CBC/diff
- Blood culture
- UA and urine culture
- PCT
- CRP
- CXR if signs of respiratory symptoms/not clearly bronchiolitis
- if low criteria [well appearing, full term, no system anti, normal labs etc]:
- sent home with strict f/u in 12-24 hrs, seek care if worsens, or if culture is +, if unreliable caretakers
- high criteria:
- Admit and further workup
14
Q
evaluation of fever in 60-90 day (2-3 month) infant
A
- if ill appearing = sepsis workup, admit
- if healthy appearing, get:
- CBC/diff
- Blood culture
- UA + culture
- PCT
- if immunized in past 24 hrs & temp < 101.5F, never mind!
15
Q
all infants this age that has fever need urinalysis
A
all infants < 3 months to rule out UTI
16
Q
Subjective data - Current medications - all children (2)
A
- Immunization history (esp. recent immunizations)
- Meds used to treat fever, illness
17
Q
Definition: fever of unknown origin
A
- 100.5F at least once daily x 14 or more days and dx not apparent after careful hx, PE, and noninvasive tests
- temp > 101+ on several occasions > 3 weeks and no dx with 1 week intense investigation
18
Q
FUO - usually ______, may require _______ consult; ___% self-resolve
A
- viral
- ID
- 25
19
Q
Define prolonged fever
A
single illness in which fever that exceeds that than which is expected for the clinical diagnosis
Sometimes may have prolonged fever that precedes FUO
20
Q
common causes of FUO in < 6 yrs (6)
A
- UTI/pyelo
- respiratory infection
- local infection such as abscess
- Juvenile arthritis
- leukemia (rare)
- COVID
21
Q
common causes FUO in adolescents:
A
- TB
- Inflammatory bowl disease
- lymphoma
- Autoimmune diseases
- Covid
- chlamydia
22
Q
Work-up/labs in FUO (16)
A
- To be done in primary care
- CBC w/ diff
- ESR
- CRP
- UA and culture
- blood cultures
- CMP
- liver and renal function tests
- LDH
- RAF
- ANA
- uric acid levels
- PPD/mantoux skin test or CXR
- sinus XR, mastoid XR, GI XR
- echocardiogram
23
Q
Kawasaki criteria
A
persistent fever for at least 5 days PLUS > 4 of these:
- bilateral conjunctival injection, nonpurluent
- change in lips and oral cavity (red, cracked strawberry tongue, diffuse redness mucosa)
- cervical lymphadenopathy (unilateral); > 1.5 cm nodes
- polymorphous exanthema rash in extremities, trunk, perineal regions
- changes in peripheral extremities (edema hands & feet) or perineal area
can also be incomplete who lack classic sx’s = coronary artery abn can confirm dx too
24
Q
Kawasaki labs if incomplete KD dx
A
- based on symptoms
A. fever >= 5 days + 4 of the following:
- a. dry, cracked mucous membranes (90% incidence)
- b. maculopapular (or morbilliform) rash, or macular rash in perianal area (70-90%)
- c. Changes in extremities such as edema of hands and feet, erythema of palms and soles (acute), or desquamation of fingers and toes (subacute)
- d. bilateral, non-purulent conjunctivitis
- e. strawberry tongue
- f. Asymmetric ant. cervical lymphadenopathy
- g. irritability h. ST, gallop rhythms, innocent flow murmurs, murmurs of aortic or mitral regurgitation
- incomplete dx include:
albumin > 3
urine > 10 WBC
platelet > 450,000 after 7 days of fever
anemia
total WBC > 15,000
elvation of ALT
coronary artery abnormalities (confirms)
25
Imaging studies in Kawasaki
1. Echo (baseline then repeat 2 wks, then 6-8 wks)
2. EKG
26
Kawasaki mgmt
EARLY DIAGNOSIS TO PREVENT ANEURYSMS!
Treatment more effective before 10th day of illness
IVIG to control vascular inflammation
high dose aspirin (antiplatelet effect) - need inactiavted flu shott
baseline echo, then 2 wks, then 6-8 wks after onset
delay live vaccines at least 11 months after admin of IVIG
27
Kawasaki Disease - Stage 1 (acute)
* Lasts about 10 days
* Perisistent high fever for \>= 5 days - may not respond to antipyretics, abx
* PLUS Conjunctival hyperemia, edema of hands and feet, polymorphous erythematous rash, unilateral lymphadenopathy
* strawberry tongue = classic (no ulcers/pharyngeal exudate)
* lymph node \> 1.5cm (non tender to slightly firm)
* tachycardia, gallop rhythms, flow murmurs, mitral regurg or aortic regurg
28
Kawasaki Disease - Stage 2 (subacute)
* Day 11-25
* Fever disappears
* Most symptoms resolve
* Desquamation of fingers, toes, groin, and perianal region
* Thrombocytosis
* **Coronary aneurysms REFER TO ECHO!**
* Non-specific EKG changes
* Prevention: IVIG + aspirin therapy (an exception to Reye Syndrome)
29
Kawasaki Disease - Stage 3 (convalescent)
* 1-2 months after initiation of s/s
* Lasts until ESR back to normal
* Most symptoms disappear
* Onychomadesis of toenails - period shedding of proximal end of toinail 2 months after recovery
* Beau lines are deep transverse grooves on nailbed
* Cardiac findings: abnormalities of cardiac vessels, myocarditis
30
UTI symptoms in neonates (8)
* Jaundice
* Hypothermia
* FTT
* Sepsis
* Vomiting or diarrhea
* Cyanosis
* Abdominal distention
* Lethargy
31
UTI symptoms in Toddlers & Preschoolers
* malaise, **irritability**
* difficulty feeding
* Poor weight gain
* **Fever**
* Vomiting or diarrhea
* Malodor
* Dribbling
* Abdominal pain/colic
32
UTI symptoms in School-Age children
* Classic dysuria with frequency, urgency and discomfort
* Malodor
* Enuresis
* Abdominal/flank pain
* Fever/chills
* Vomiting or diarrhea
* Malaise
33
\_\_\_ is the most common cause of SBI in children \< 24 months with fever without a focus
UTI
34
Complicated UTI s/s
* \< 2 yrs
* Upper urinary tract (pylo)
* Hx medical problem
* Abnormal anatomy
* Drug resistant pathogen
* Fever, toxicity, dehydration
35
UTI Diagnosis on UA
Positive findings on
* Urine luekocyte esterase
* Nitrites
* Leukocyte count, or
* Gram stain
36
Empiric tx for Pediatric UTI
* Bactrim - 1st line for uncomplicated lower UTI (age \> 2 months)
* Amoxicillin/augmentin - for young children with uncomplicated UTI or pyelonephritis
* Cephalexin (age \> 6 months)
* Cefixime (age \> 6 months)
* Macrobid (age \> 1 month)
Duration of tx
* age 2-24 months or febrile: 7-14 days
* age \> 24 months and afebrile: 3-5 days can be appropriate
37
Protocol for child needing renal and bladder u/s
* \< 2 y.o with first UTI
* all children with fever + pyelonephritis
* recurrent UTI/
38
Pediatriac referral to GU
* High-risk - immunocompromised, abnormal u/s
* Age \< 3 months = need sepsis workup
* congenital abnormalities
* Pyelonephritis
* Recurrent UTI (about 3 episodes)
39
UTI risk factors
* \> 102.2F
* Females \< 1 yr old
* Uncircumcised males
* Duration of fever (\> 24-48 hrs)
* Absence of another infection
40
Low risk for young infant with fever unknown origin
* Well appearing, easily consolable
* previously healthy
* full-term infant (\> 37 weeks)
* normal UA (neg Leuko/nitrite), WBC (5-15k), and PCT (\>0.3)
* ANC \< less than 1,500 bands
* appears well
* no focal bacterial infection; normal CXR
* Reliable caregivers and follow up,
* discharge home and close f/u in 12–24 hours
* no systemic anti w/in 72 hrs
* ANC _\<_ 1500 bands
* stool smear negative
* If low-risk criteria **not** met = be admitted, get LB and CSF studies
* **NO** empiric antibiotics until LB is obtained to avoid masking or undertreating an undx meningitis
41
FUO, LB only if have 1 of these:
* WBC count \< 5,000 microL or \> 15,000 microL (N 5-15k)
* Absolute band count \> 1,500 microL (N 2500-6000)
* PCT \> 0.5 ng/ml (N \< 0.5)
* CRP \> 20 mg/L (N 0.8-1)
* Pneumonia on CXR
42
define fever without origin (FUO)
_\>_100.5F at least once daily x 14 days+ and dx not apparent after careful hx, PE, tests
or
\>101F+ on several occasions \>3 weeks, failure to reach diagnosis, despite 1 week intense investigation
43
Do you give empiric antibiotics for FUO?
NO!
44
non painful red eye conditions
conjunctivitis (allergic, viral, bacterial, chemical)
dry eye syndrome
subconjunctival hemorrhage
45
Viral conjunctivitis key findings
_Adenovirus_
* redness, itchy, swollen conjunctiva
* **tearing, clear watery discharge**
* **fever, headache, anorexia, malaise**
* blepharitis
* **pharyngitis with enlarged preauricular nodes**
* happens with URI
46
Adenoviral conjunctivitis management
* Cool compresses
* Lubricating drops
* Good handwashing
* avoid touching the eyes,
* don't share any towels
* wash pillowcases
* resolves in 1-2 weeks
* NO prophylaxis antibiotics
* Antihistamine ophthalmic for sx relief
47
With bacterial conjunctivitis (pink eye), consider what in neonate and adolescent and adults sexually active
gonorrhea and chlamydia
48
Bacteria conjunctivitis key findings
* Erythema 1 or both eyes (uni then bi)
* Yellow - green purulent discharge
* Encrusted and matted eyelid on awakening
* injected conjunctiva
* photophobia
* petechiae on bulbar conjunctiva
* sx's of URI , otitis media, pharyngitis
* normal vision
49
bacterial conjunctivitis c/b what orgs
haemophilus influenzae, strep pneumoniae, and staph aureus.
H flu more common in children (dec-april)
50
Bacterial conjunctivitis: adult management vs children
* Children: empiric (trimethoprim + polymyxin B sulfate ophthalmic soln, erythromycin 0.5% ointment to cover H influ)
* Older children/teens
* WATCH only! Resolves in 1 week no matter what
* Adult: if not immunocompromised → conservatively
* observe or empiric antibiotic x 1 week
- if Chlam/gon = refer CDC
51
Allergic conjunctivitis results from ____ and is associated with \_\_\_
igE mediated hypersensitivity
a/s with atopic disorders, asthma, atopic dermatitis, seasonal, perennial plant
52
allergic conjunctivitis sx's and on exam
* bilateral severe eye itching, teary
* rhinitis
* clear, white stringy mucoid discharge
* teary boggy conjunctiva
* allergic shriners/dark circles
* ![]()
53
allergic conjunctivitis management
Identify/avoid the allergen
Cold compresses and artificial tears
Oral antihistamines if systemic allergy sx’s
* NO antibiotics/steroids
* eye drops:
* Ketotifen (antihistamine)
* Patanol or Olopatadine (prescription); Used \> 3 yrs old
54
how does chemical conjunctivitis occur
Benign: fumes, smoke, chlorine or toxic
* if causes severe pain, vision disturbances = refer!
55
vernal conjunctivitis
type of allergic conjunctivitis
common in childhood and spring
bilateral
more severe
56
atopic conjunctivitis
common in \>50 yrs old
bilateral itchy, burning, tearing
tx w mass stabilizer eye drop or refer
refer!
57
dry eye syndrome sx's
* foreign body sensation
* scratchy gritty feeling stinging, tearing
58
what test to do for dry eye vs lacrimal problem? Explain.
**schirmer test**
assesses aqueous production. using filter paper and placing it in the inferior culdesac, measure tear production after 5 mins. \< 5 mm = tear deficiency
59
dry eye management and treatment
Avoid causative medications
anticholinergics or diuretics
Avoid air conditioners or fans
1st line: preservative-free lubricants (OTC) if not work refer and cyclosporin rx
60
Subconjunctival hemorrhage
* benign
* from increased intrathoracic pressure (coughing sneezing, straining)
* no pain
* common in HTN or blood thinner pts
* resolves in 2 weeks
61
ocular adnexal disorders
disorders of structures that surround the eye
Blepharitis
Hordeolum (stye)
Chalazion
Nasolacrimal duct obstruction
Preseptal and orbital cellulitis
62
flakey, yellow scaly debris over eyelid margins on awakening
inflammation of eyelid or follicles
Blepharitis
63
blepharitis management (3)
1. 1st line: warm compresses x 10 mins several times a day
2. dilute baby shampoo with warm water and just cleanse the eyelid every day
3. Topical antibiotic is only needed if due to a staph infection.
usu resolves with conservative treatment.
If it's persistent or severe, doxycycline
64
Define hordeolum (stye) and symptoms
Acute infection and inflammation of eyelid gland d/t to a blocked meibomian gland
Staph aureus
* contact lens use
* **painful** furuncle/nodules
* NO injection, NO discharge, NO redness
* foreign body sensation
resolves 1-2 weeks (ruptures from compresses or I&D)
65
Define chalazion and management
Chronic, inflammation of eyelid from lipogranuloma of meibomian
**NON** painful, non-infectious nodule; results from hordeolum
Warm compresses, gentle massage, weeks to resolve, I&D if persistent
66
Hordeolum vs Chalazion
chalazion results from a hordeolum
Chalazion: located AWAY from the eyelid margin, more firm, and it's non-tender, deeper in eyelid
Hordeolum: closer to the eyelid margin
67
Nasolacrimal duct obstruction (dacryostenosis) symptoms and management
* tearing, mucoid discharge
* blepharitis
* painful, tenderness/swelling over duct
* elevated WBC from exudate
manage:
* Daily massage of the lacrimal duct. If it doesn't resolve by 12 months = refer for probing procedure.
* ![]()
68
Complications from dacryostenosis (2)
Dacryocystitis (inflammation of duct = infection)
![]()
I&D or systemic antibiotics
Peri/orbital cellulitis
69
If acute otitis media is associated with conjunctivitis, that's commonly due to _____ bacteria. So treat with \_\_\_\_
haemophilius influenza
Amoxicillin clavulanate
70
otitis media risk factors
* allergies
* upper respiratory infection
* cleft palate
* adenoid hypertrophy
* tobacco exposure.
71
otitis media sx's
* ear pain
* pulling at ear
* fever (otitis externa has NO fever)
* TM erythema and pain
* worse when child lying down
* otorrhea
72
mild vs severe otitis media
mild: \< 102.2F, sx's \< 48 hrs
severe: \>102.fF, sx's \> 48 hrs
73
otitis media management
Pain control (Tylenol)
Only treat **amoxicillin(-clavulanate) or cephalosporin** if healthy children (no Down S, cleft palate, tubes):
* severe sx's \> 6 months, medicate then f/u 48-72 hrs of onset of sx's
* no severe sx's, \< 24 months, bilateral
* if sx's persist after 48-72 hrs of sx onset
DON'T treat if:
* \< 24 months, no severe sx's, unilateral
* \> 24 months, not severe sx's
74
Complications of otitis media
* mastoiditis (fever, pain behind ear, swelling posterior ear over mastoid process)
* perforation of TM
* otorrhea
* effusion (fluid; hearing test if \> 3 months; refer if \> 6 months or hearing lost but watch and wait 48 hrs if mild)
* **cholesteatoma** (cyst in ear; pearly white lesion = refer!)
75
the most common cause of infectious pharyngitis
viral
76
viral pharyngitis management
Tx symptomatic
self-resolve in 5-7 days.
use warm salt water gargles, lozengers, acetaminophen or ibuprofen, and hydration.
77
Glasgow coma scale score 13-15 means
* mild
* no focal deficits
* \< 30 minutes LOC
* may have linear skull fractures
78
Glasgow coma scale score 9-12 means
* moderate
* focal signs
* variable loss LOC
* may have depressed skull fracture or intracranial hematoma
79
Glasgow coma scale of _\<_ 8 means
* severe
* focal signs
* prolonged loss LOC
* depressed skull fractures and intracranial hematoma
80
Pedi head injury discharge & education
* If worried caregiver is not reliable = admit
* Discharge home with close observation:
* Minor head trauma and no LOC
* Brief LOC (\< 5 mins) with:
* Normal neuro exam
* No s/sx IICP (vomiting, h/a)
* No s/s basilar skull fracture (raccoon eyes, battle sign)
* With or w/o a head CT
* Wake child every 2-4 hours at night for first 24-48 hrs
* Educating parent s/sx of deterioration
* Not responding to q’s
* Vomiting
* Horrible headache
* Slurring speech
81
highest risk sport for boys and girls for concussion/mild traumatic brain injury?
boys: football and hockey
girls: soccer and basketball
82
concussion red flags, bring to ED!
* Weakness, numbness, decreased coordination
* Worsening headaches
* Repeated vomiting or nausea
* Slurred speech
* Anisocoria (unequal pupils)
* Seizures
* very drowsy
* Increasing confusion, agitation, restlessness
* Focal neurological signs
* Problem with nerve, spinal cord, left side face numb / arm numb, paralysis of leg
* Can’t recognize people or places
* Neck pain
* Unusual behavior changes
* Any loss of consciousness, especially if for 30 seconds or more
83
retrograde amnesia vs anterograde amnesia
retrograde amnesia: very brief, can't recall events before injury
anterograde amnesia: seconds-minutes, can't make new memories and can't recall
84
which imaging preferred for concussions? and what are the indications?
CT scan
indications:
* Focal neurological findings
* Signs of IICP
* GCS \< 15 after 2 hrs OR \< 13 at any time
* Seizures r/t to trauma
* Age \> 60
* Anticoagulation or coagulopathy
* Intoxication
* Recurrent vomiting
* s/sx skull fracture
* LOC (excessive irritability or lethargy)
* LOC \>1 min
* Amnesia
85
simple concussion
sx's resolve (brain healed) in 7-10 days without complications
86
complex concussion
* prolonged healing that is persistent for over 10 days
* may develop post concussive syndrome
* prolonged impaired cognitive function
* repeated concussions
87
concussion monitoring
repeat neuro exam q 15 mins
if sent home, monitor next 24 hrs:
* Inc drowsiness
* Vomiting \> 2x
* Neck pain
* Drainage from ear / nose
* Seizure , fainting
* Unu irritability, personality changes
* h/a getting worse or lasts \> 1 day
* Unequal pupils, blurred vision
* Gait abnormalities
88
When can the child return to play after a concussion?
not until all symptoms have cleared, both at rest and with exertion and without meds
89
Return to play guidelines after a concussion
* Physical & cognitive rest for the first 24-48 hrs before return to play, 24 hrs or longer each step
* Need to communicate with coach, teachers
* Advance activity **slowly** (includes screen use, reading, homework, physical activity) with lots of breaks
* 1 - sx limited activity (no sx)
* 2 - light aerobic - no weights
* 3 - sport specific
* 4 - non contacting drills - yes weights
* 5 - full contact practice
* 6 - return to play
* If symptoms return, cannot attempt that activity again for 24 hours
90
concussion prevention
* Wear helmets when appropriate and properly fitted
* Avoid re-injury before first concussion resolves
91
What is second impact syndrome?
* Patient sustains a 2nd head injury **_before_** the symptoms from the first head injury have resolved
* Days to weeks after the first injury
* LOC is not a requirement; impact may be mild and athlete may appear only dazed initially
* Can cause cerebral edema and herniation, leading to death
\***Stress importance with patients that ALL concussion symptoms must be resolved prior to return to activity\***
92
What is post concussive syndrome?
* Sequela of minor head injury
* poorly understood
* at least 3 of these:
* h/a, dizziness, fatigue, irritability, impaired memory/concentration, insomnia, lowered tolerance for noise and lights
* no imaging needed unless red flags
93
What is Bell's palsy?
* Acute, isolated unilateral peripheral facial paralysis of the 7th cranial nerve
* Most common cause: HSV activation
* Other associated viruses are: cytomegalovirus, Epstein–Barr virus, adenovirus, rubella virus, influenza B, coxsackie virus
* Pregnancy
* most spontaneously resolve
94
Bell's palsy sx's
* Sx's can persist up to 3 months
* Acute onset (w/in 48 hrs) of unilateral of upper and lower facial paralysis
* Weakness of facial muscles
* flattening of the nasolabial fold
* drooping mouth/asymmetrical smile
* Hyperacusis (sounds too loud)
* Posterior auricular pain
* Decreased tearing
* can't close eyelid = irritation
* Taste disturbances
95
when are you worried if it's a central cause/stroke or if it's Bell's palsy?
a stroke/central cause would have only 1 area affected (mouth drooping) and other parts of face are still movable like wrinkling forehead and eyes
paralysis from stroke spares forehead
96
What grading system used for Bell's palsy?
house and brackmann system
1 = normal
6 = severe paralysis
97
bells palsy diagnostic criteria
paralysis or paresis of \***_all_**\* facial nerve muscle groups unilaterally, sudden onset and absence of CNS disease
98
What other testing to consider in dx for Bell's Palsy?
```
Lyme titer (if tick exposure)
MRI (if don't recover in 3 months)
EEG/EMG (if fail to improve)
```
99
Bell Palsy treatment/management
* Corticosteriods/Prednisone w/in 72 hrs of sx onset
* or Acyclovir or valacyclovir in conjunction
* Eye care
* risk for corneal abrasions/ ulcers
* Artificial tears during the day and lubricating ointment at night
* tape or an eye patch for 24–48 hours to help heal a corneal abrasion
100
do the majority of migraines have aura or no aura?
80-85% have no aura
15-20% have aura (positive sx's: flashing lights, scintillation, paresthesia then neg sx's numbness, aphasia, scotoma (chunk of vision gone))
101
migraine triggers
* Changes in weather (heat, humidity, high altitude)
* Stress; crying
* Alcohol
* Hunger
* Fatigue / no sleep
* Loud noises
* Flickering lights
* Noxious stimuli
* Foods
* Fried food, red wine, hot dogs (MSG), cheese, chocolate, cured meats & fishes, peanuts
* Exertion
* Nitroglycerin
* Minor head trauma
* Menses
* Surgical menopause
102
migraine diagnosis
repeated attacks lasting 4-72 hrs, normal exam and no other reasonable cause for headache
at least 2:
* unilateral pain 60%
* throbbing/pulsating pain
* aggravating of movement or activity
* mod-severe
at least 1:
* nausea/vomiting
* photophobia or photophobia
103
How to treat migraines?
* avoid triggers
* headache diary
* educate: won't cure but will try controlling
* abortive treatment and preventative treatment
104
Migraine preventative treatment indications
* \> 4 attacks a month
* Consider comorbid conditions when prescribing medications
* Freq long lasting h/a a/s with significant disability
* Contraindication to abortive tx
* Frequ use of abortive tx
* Uncommon migraine (hemiplegic, basilar, migraine with prolonged aura, migrainous infarction)
105
migraine preventative treatment
* Start low, titrate up for **8–12 weeks** (educate results til 8 weeks)
* TAPER OFF if need to d/c!
* Beta blockers [**propranolol**]
* TCAs [Amitriptyline]
* Valproate [BBW suicide]
* Topiramate
* CCB [verapamil]
* CGRP (monoclonal antibody): a potent **vasodilator**
* - ‘numab’ = monoc. antib
* Erenumab (Aimovig)
* Fremanezumab (Ajovy)
* Galcanezumab (Emgality)
* Eptinezumab (Vyepti): IV
106
Migraine abortive treatment
* treat DURING attack
* EARLY = BETTER
* max 2 days per week (rebound analgesic)
* large dose better than smaller frequent dose
* mild to moderate:
* Tylenol, NSAID, allieve, excedrin, triptans (Sumatriptan)
* severe (incapacitating; ED):
* Abortive + IV/IM antiemetics (metoclopramide, Benadryl)
107
pediatric red flags headaches
* \< 5- 6 yrs old
* New onset
* Focal neuro signs
* Nocturnal awakening [Tumor]
* Vomiting, papilledema [IICP]
* Loss of cognitive/neuro functioning
* Sig change in existing h/a pattern
* Head trauma with LOC \>10 minutes
* Inability to control headache with appropriate tx
108
Pediatrics: migraine abortive vs preventative treatment
* abortive: early as possible, NSAIDs more effective, sleep, sedative if distressed (dephenhydramine/benzos)
* preventative: NOT recommended but mostly lifestyle, propranolol, topiramate
109
Ottawa ankle rules
determines if an x-ray is needed
* If have tenderness over either lateral or medial malleolus
* Or have pain over 5th metatarsal
* Or mid foot pain and only take a few steps
* Or ankle sprain on syndesmotic ankle ligament (need MRI) = high grade sprain or sus for occult fracture
110
anterior cruciate ligament tear sx's, maneuvers, imaging
* Pivot and “Pop”/"snap" sound and immediate pain and swelling
* Anterior draw test
* Lachman test
* MRI confirms diagnosis but may not be necessary if hx is clear
111
meniscus tear causes and sx's
* traumatic: weight bearing knee is twisted while partially flexed
* atraumatic: normal wear and tear in older pts; obesity
* popping, pain, swelling, stiffness, difficulty straightening knee, knees “locking/buckling"
112
meniscus tear maneuver, imaging, and tx
* Mc Murray (to elect pop)
* Thessaly test
* joint tenderness
* Apley compression test
* MRI confirms
* conservative tx or PT (surgery if athlete)
113
patellofemoral pain syndrome (runner or jumpers knee)
causes & sx's
* Pain anterior portion of the knee, around and behind the patella
* Most common in women and younger active athletes
* Cause: abnormal tracking of the patella r/t weak quadriceps, poor flexibility, patellar hypermobility, tight iliotibial band, anatomic malalignment, or overuse.
* “knees giving out”
* Sx: pain when bending the knee (sitting for long periods of time, climbing stairs, jumping, squatting) and cracking or popping sounds.
114
patellofemoral pain syndrome exam & treatment
* patellar compression-grind
* patellar tilt
* patellar glid
* diagnostic: hx, PE, xray
* tx: RICE, orthotics, NSAIDs, PT
115
lower back pain diagnostics
DON'T recommend routine imaging for acute or non specific back pain unless concern for fracture or red flags (age, weightless, fever, new weakness, bowel/bladder dysfunction)
116
criteria for imaging for back pain
* Bowel or bladder dysfunction - cauda equina
* New onset erectil dys
* Fever or night sweats (infxn, malignancy)
* Unintentional weight loss
* Night pain
* Personal history of cancer
* Saddle anesthesia
* History of recent trauma (e.g., fall or direct blow, NOT twisting or lifting)
* Age \>50 or \<18 years
* Patient with current or recent use of steroids
* Any suspicion of an infectious or neoplastic cause for low-back pain
* Pain for \>6 weeks
117
lumbar spinal stenosis (lower back pain) sx's and maneuver
* Narrowing of foramina which causes inflammation of nerve root and surrounding area
* back pain and neurogenic claudication (thigh/calf pain worsen when standing or walking and alleviated with sitting)
* legs feel ‘heavy’ or ‘wooden’
* causes radicular pain (pain shoots down leg from L5 after nerve)
* straight leg raise
118
degenerative disk disease (low back pain)
nerve impingement from osteophytes with aging and degenerative (arthritis on spine)
119
what is radicular pain and red flags for it?
from direct compression of the spinal nerve roots with resulting structural, biochemical, and vascular changes in and around spinal nerve
red flags: urinary retention, saddle anesthesia, fecal incontinence = cauda equine syndrome
120
ankle sprains
* Ligamentous injury caused by an abnormal motion, a sudden change in direction, or a misstep on an uneven surface.
* women, adolescents \>
* joint pain and swelling, ecchymosis, decreased ROM, inability to bear weight.
* Diagnostic: x-rays to exclude fracture, CT scan or MRI if indicated
* Treatment: R.I.C.E, oral or topical NSAIDs, non-weight bearing
121
achilles tendon rupture
sudden weakness in the ankle, inability to raise up on the toes, limp and pain.
* Diagnostic: history and physical exam, Thompson test, US, MRI
* Treatment: mobilization (brace, long-leg cast or rigid boot x 6 weeks) or surgery
122
morton neuroma
* Perineural fibrosis of the plantar nerve at the point where the medial and lateral branches converge
* Symptoms: severe pain and burning in the region of the third web space, pain aggravated by foot elevation.
* Risk factors:
* Women (middle-aged)
* Trauma
* Ischemia
* Impingement
* Intermetatarsal bursitis
* Conditions such as claw toes and bunions
* Diagnostic: Mulder sign, US, MRI
* Treatment: wider toe shoes, insoles, separation of toes with a small pad
* NSAIDs, cortisone injection, surgery.
123
Ottawa knee rules
* \> 55 yrs old
* tenderness head of fibula
* tenderness patella
* inability to bear weight
* inability to flex knee \> 90 degrees
*younger children more likely to have fractures d/t open growth plates than sprains*
124
tendon pulls on growth plate of shinbone (tibia)
pain below patella, worsens with running, kneeling, jumping
osgood schlatter disease
growth spurs in children/adolescents
tx: rest, ice, knee brace, analgesics
125
white or light pink hypo/hyperpigmentation of skin
slightly scaly, round or oval papules/plaques
Tinea Versicolor (Pityriasis versicolor)
126
management of tinea versicolor
anti fungal creams (imidazole)
127
tinea captious vs corporis vs pedis
capitis - scalp, patchy, scaly, non scarring areas of hair loss
corporis - on skin as erythematous plaques and papule in annular or arciform pattern; central clearing
pedis - athletes foot; interdigital scaling, maceration, and fissuring
128
what diagnostic for tinea fungal infections?
KOH prep shows type of fungal infection
129
tinea management
topicals
- **terbinafine**
- naftifine
- butenafine
capitis → griseofulvin
(NO oral ketoconzaole bc hepatotoxicity / interactions)
130
acneiform disorders
* comedonal (open and closed comedones)
* inflammatory (papule and pustules)
* cystic/nodular
131
acne treatment
* Benzoyl peroxide (BP)
* Use first line for mild inflammatory or mixed (comedonal and inflammatory) acne
* Drying
* Topicals
* clindamycin or erythromycin
* Combinations of 5% BP + topical antibiotic may be more efficacious than either alone
132
topical retinoids (tretinoin, adapalene, tazarotene)
* For comedonal acne
* Normalize keratinization and reduce obstruction
* Creams, gels (0.01%, 0.025%, and 0.05%)
* May cause irritation, dryness, redness, hypo- or hyperpigmentation
* Use a pea-sized amount for the whole face
133
Caution with BP and tretinoin
\*Tretinoin is inactivated by BP, so apply BP in the morning and topical retinoid at night (to avoid sun exposure)
134
actinic keratosis aka solar keratosis
* Premalignant lesions
* persistent or recurrent reddened, roughened area that scales or crusts
* Risk factor to SCC
* On sun exposed area of body (neck, face, scalp)
* Tx: cryotherapy
135
basal cell carincoma
most common form of skin cancer
slow growing cancer in sun exposed areas (auricles)
least likely to be malignant but can rarely be invasive
slow growing, auricle
shiny, irregular, painless lesion
136
squamous cell carcinoma
auricle, fair skin, hx of sun exposure
can sting, itch, bleed
open sore that doesn't heal
more serious form of skin cancer = can metastasize to regional lymph nodes and death
137
pyogenic granuloma
benign, small, raised, red bumps
triggered by pregnancy, meds
results from injury
bleeds easily, refer to Derm for excision or electrocautery
138
dermatofibroma
dome shaped nodule on extremities
indent with palpation (Fitzpatrick sign)
benign
139
seborrheic keratosis
* Benign lesions
* Warty stuck on appearance
* Color variations
* Reassure; don’t need to treat
140
gold standard imaging for appendicitis
CT scan
141
Ultrasound imaging for what GI issues
cholecystitis, pyloric stenosis, intussusception, pancreatitis
142
acute cholecystitis clinical manifestations
* biliary colic lasts longer 4-6 hrs
* sharper RUQ pain, radiates to R shoulder/scapula esp after eating fatty foods
* Charcot triad:
* RUQ pain, fever, jaundice
* muscle guarding/rigidity
* distended tender gallbladder (confirms)
* hypoactive bowel sounds
* Murphy's sign (inability to take deep breath from discomfort during palpation under right costal margin)
143
risk factors for cholelithiasis
* increasing age (\> 45 yrs)
* obese, rapid weight loss
* pregnancy
* fibrates, OC, estrogen, progesteron, ceftriaxone
* females
* TPN, fasting
* metabolic dz (crohns, cirrhosis, DM etc)
144
when to send to ER for cholelithiasis
severe pain or bilirubin elevated
145
Labs for cholelithiasis/cystitis
CBC
UA
LFT
electrolytes, BUN, Cr
146
gastroenteritis
* children - rotavirus
* adults - norovirus
* severe diarrhea young children
* fecal-oral
* watery diarrhea x 3-8 days, cramps, chills, dehydration
147
gastroenteritis management
* NO antibiotic; tx is oral rehydration therapy
* should resolve in 1 week
* serious infxn sx's:
* food borne illness
* bloody diarrhea, weight loss, severe abdominal pain, high fever
* neuro involvement
* don't stop diarrhea → let out
* if diarrhea \> 2 weeks + sx's above: get labs
* stool culture and examination for parasites
* CBC
* electrolytes
148
epigastric/periumbilical pain migrating to RLQ, abdominal rigidity
*after* pain occurs, these sx's occurs: n/v, anorexia, constipation, low fever
appendicitis
Refer ASAP! Hospitalization and surgery may be needed
149
appendicitis signs
* elevated WBC
* roving sign - RLQ pain when palpating LLQ
* rebound tenderness, guarding
* obturator sign - passive rotate R leg with R hip and knee flexed while supine
* psoas sign - supine, raise straightened R leg against resistance by me
* mc Burney's sign
150
appendicitis imaging for adult vs children
adult: CT abdomen/pelvis with contrast
children: Ultrasound
151
appendicitis management
treatment: appendectomy w/in 24 hrs of sx onset to prevent perforation/peritonitis
(NPO, IV fluids, e- repletion)
if appendix perforated = antibiotic therapy to cover
152
HIV screening guidelines
13 and 64 yrs get tested for HIV at least once
if higher risk, getting tested at least once a year.
153
IgM
early response; detected 5-10 days before sx onset
154
IgG
later response
long term
made after exposure (secondary response)
155
hepatitis A transmission and sx's
fecal oral transmission
high risk: IV drugs, homeless, chronic liver dz
fever, jaundice, anorexia, nausea, malaise, myalgia
most children \< 6 yrs are asymptomatic
156
hepatitis A management
* supportive care
* hydration
* antiemetics
* no etch
* vaxx HH / sex partners, high risk (MSM, liver problems, homeless, hepatitis b/c, high risk settings)
* recover in 2 months
* does NOT develop chronically! *acute only*
157
when would hep A need hospitalization?
* Intractable vomiting
* severe electrolyte or fluid imbalance
* altered mental status
* INR \> 1.5
* evidence of fulminant disease
158
hepatitis B transmission
* **b**lood & **b**odily fluids (tattoo, needles, razors, saliva, semen)
* NO BREAST FEEDING
* can cause acute and CHRONIC hepatitis
159
* surface antigen HBsAg: -
* core antibody anti-HBc: +
* surface antibody anti-HBs: +
immune from natural infection
160
* surface antigen HBsAg: -
* core antibody anti-HBc: -
* surface antibody anti-HBs: +
immune due to hep b vaccination
161
* surface antigen HBsAg: +
* core antibody anti-HBc: +
* **surface antibody anti-HBs: -**
* **IgM anti-HBs: +**
acute infection
162
* surface antigen HBsAg: +
* core antibody anti-HBc: +
* surface antibody anti-HBs: -
* IgM anti-HBs: -
chronically infected
163
who is at risk for hepatitis B?
* Hemodialysis pts
* highest risk: Infants (born from infected moms)
* Sex parters , house hold contats
* occupational (health care workers)
* MSM
* Iv drug users
164
Hep B sx's
* Fatigue, fever, n/v
* Arthraliga
* Similar to hep A
* \> 60 yrs = severe fxn
* \< 5 yrs = asx
* \> 5 yrs = sx’s
165
first lab indicator of hepatitis B infection?
elevation of hepatitis B surface antigen and elevated ALT
166
if have hepatitis B, what else should you screen for?
hepatitis C and D, HIV
167
when to treat hepatitis B?
* only in active phase: ALT doubled,
* chronic hep B when hep B ‘e’ antigen is + and DNA viral level \> 20k
* entecavir or tenofovir safe and effective x 12 months after HBsAg is - and HBV DNA is undetectable
168
if mother has chronic hepatitis B (hep B surface antigen +) after an infant is born…
infant should get hep B vaccine and immunoglobulin within 12 hours of birth
if not, 90% of infants will get chronic hep B
test infant in 6-9 months for antigen and antibody
169
hepatitis C transmission
blood =
IV drug use, vertical transmission, razors, toothbrushes, IV, piercings
170
hepatitis c diagnostic
+ HCV antibody **and** + HCV RNA
171
What if hepatitis C antibody is negative and RNA positive?
* **Acute infxn**
* If asymptomatic, screening for hep C
* Hard to tell acute or chronic but if they have sx’s the most likely acute
172
Hepatitis C antibody and RNA are positive?
* When was last test? If - in past 12 months, this is a new acute infxn if now +
173
Hepatitis C antibody positive and RNA is negative and asymptomatic ?
had hep C and recovered (don't go onto chronic)
OR
false + so repeat in a few weeks
174
who should get tested for hepatitis c?
every adult at least once 18+ , every pregnant women, those with risk factors regularly
one time test regardless of age or high risk: HIV, hemodialysis, organ transplant before 1992
175
if pt tests positive for Hep C 2 yrs ago, has + antibody test, RNA +, next step is?
order RUQ ultrasound to assess for evidence of cirrhosis and carcinoma
176
if mom is pregnant with hep c, when do you check child for hep c?
at 18 months
177
can you breastfeed with hep c?
yes
178
what is the 4th generation HIV test?
combines antigen (in blood as early as 15 days after exposure) and antibody test (takes 30 days to be detected)
screens HIV 1 & 2
* if antigen reactive: do viral load/NAAT = if + = reactive
* if - initial test was false +
179
acute HIV sx's
* Mono like illness
* Fatigue
* Fever
* Sore throat
* Cervical lymphadenopathy
* Night sweats
* Diarrhea
* Skin rash
* Trunk NOT itchy
* Headache
* Arthralgia
* Myalgia
* Oral or genital ulcers
* leukopenia, or anemia, or thrombocytopenia, and also elevation in the liver _transaminase._
180
early treatment of HIV to
decrease transmission, decrease viral load
continue indefinitely of 3 ART (2 nucleosides and integrate strand transfer inhibitor)
181
important considerations when someone is diagnosed with HIV
* Have partner start Prep
* Up to date with hep, flu, pneumoc, covid vaccines
* Monitoring labs and side effects of ART
* Assessing adherence
* Discuss meaning of viral load and HIV spread
* Screen for STI, TB, osteopenia (from long term use of ART)
* Screen for cervical cancers bc HPV risk malignancies
* No evidence of opportunistic infections (PE)
* Other high risk behaviors like IVDU
182
HIV + mom concerned about unborn child. with effective therapy, risk of transmission
lowered to \< 2 %
after delivered, baby started on AZT for 4-6 wks to prevent HIV infxn
183
steps to prevent HIV transmission from mom to baby
* mom with HIV take HIV meds during pregnancy and childbirth.
* bb takes AZT (zidovudine) for 4-6 weeks after birth.
* Goal: lower viral load \< 1000 in mom = dec transmission to baby
* mom \> 1000 viral load → C-section
* if \< 1000 viral load → vag delivery
* No breastfeeding
* NB need RNA/DNA check at 2 wks, repeat 1-2 months, then 4-6 months, then 12-18 months.
* Negative HIV antibody confirms bb not infected
184
is infant's blood is taken day 1 and at 2 week mark and is + for HIV, this means
we don't know!
we expect to see antibodies up to 6 months bc it crosses the placenta so we have to test for HIV antibodies up to 6 months.
test viral load at birth, at 1-2 weeks, then 1-2 months, then 6 months
if 2 RNA are + = confirms dx
185
How should the HIV status of the infant be determined?
Viral load by PCR at 2-3 weeks, 1 to 2 months, and 4 to 6 months
186
HIV and pneumococcal vaccine?
ok to admin 1st dose of pneumococcal vaccine series now (if CD4 \>100) but make sure its inactivated
187
HIV sx's in children
Recurrent or severe infections
AOM, sinusitis, pneumonia, bacteremia
Growth failure • Pubertal delay •
Anemia, thrombocytopenia, neutropenia
• Hepatomegaly, splenomegaly • Opportunistic infections • Candidiasis • Diarrhea
188
HIV med monitoring of:
osteopenia
infections
cancer
depo and progestin pills interactive
higher cardiovascular risk
189
highest risk of TB reactivation is
first 2 yrs
190
ghon focus
white spots when infected tissue dies in lungs from tb
191
risk factors that increase risk of latent to active TB
\< 5 yrs old
diabetes
immunosuppression
highest rates: \> 65 yrs, lowest: 5-14 yrs old
192
latent TB
* infected but doesn’t develop sx’s and don’t feel sick bc healthy immune system
* (if compromised immune syste, wil be active TB)
* Not contagious
* If not tx, can lead to active TB
193
active tb sx's
* pulmonary disease, cough, fever, night sweats, hemoptysis, weight loss, and loss of appetite.
* Symptoms in children are typically more severe.
* So extrapulmonary TB is more common in children.
194
TB can affect what areas
lungs, lymphatic system, the pleura, the bone and joint, and peritoneal, GU, and meningeal.
195
TB gold standard analysis
sputum culture but takes few weeks to come back
196
preferred method for TB testing children younger than 5?
what is preferred if they got a BCG vaccine?
TB Skin test
interferon gamma release assay
197
TB management
Referral to TB specialist, DPH
* Empiric treatment
* 4 drug for 6 months: R.I .P.E.
* Rifampin
* Isoniazid
* Pyrazinamide
* Ethambutol
* Observation or call to make sur compliance
* Many SE’s
* Med compliance
* Monitor SE
* CBC, renal, liver
* Paraesthesia common SE
* Screen for HIV
198
how does the TB skin test work
return in 48-72 hrs, measure induration
199
interpreting skin test positive \>15mm, \>10mm, \>5mm?
\>15mm: general pop
\>10mm: high risk, \< 4 yrs old, job, IVDA, chronic dz, recent immigrant
\>5mm: immunosuppressed/HIV, recent TB contact, children suspected to have TB, organ transplant recipients
if +, want to r/o active TB but asking for sx's and chest x ray. if all negative = latent TB
can have a false + if BCG vaccine recent or had TB in past
200
when is IGRA (quantiferon gold) preferred over a Mantoux test?
* got BCG vaccine
* 5 yrs and older
* unlikely to f/u
* poor transportation
* + PPD in past
* treated for latent TB
201
TB management
if have HIV = refer
r/o active TB by asking sx's and chest xray
defer tx in preg til after delivery
tx 4-6 months- 9 months
educate SE's
admin vitamin B12
202
how is Lyme disease ticks transmitted
via deer ticks
must be attached for at least 36 hrs to be transmitted; will fall off after 5 days
203
lyme prevention
DEEP
doxy prophylaxis if \> 8yrs old and IF have tick bite, live in endemic area , tick ON for 36 hours, pt removed tick w/in 72 hrs or tick engorged with blood
204
lyme tick testing/serology
NOT recommended esp with a pt with primary erythema migrans
dx based on presentation and give doxy!
best thing is educate and prevent
205
lyme dz diagnosis factors
* clinical characteristics: erythema migrans \> **5**cm with central clearing
* epidemiologic link (possible tick exposure in an endemic area
* start doxycycline for 10 days
* no test of cure
206
lyme stage 1 early localized
erythema migrans - bulls eye rash
no pain or itchy, fever, fatigue, myalgia
207
lyme stage 2 early disseminated
* Cardiac sxs: carditis and AV block
* Ceftriaxone IV then switch to oral doxycycline
* Flu like sx, lymphadenopathy, neuro: facial nerve palsies, **arthralgies** (common)
208
lyme stage 3 late disseminated
and post Lyme disease syndrome / chronic lyme
* 60% arthritis
* Peripheral neuropathy
* encephalopathy/myelitis
* Dx is controversial
* Fatigue, joint pain after tx for lyme
* No benefit for long term antib use and can cause harm. Evaluate if it’s something else that’s not lyme dz
209
Eval of neonate \< 28 days old
* need FULL workup & hospitalization
* After workup, antibiotics/acyclovir started empirically until cultures are known
* Think prenatal hx and care, birth hx (intrapartum fever, maternal strep group B) and post natal care
210
ottawa knee rules
_\>_55 yrs
tenderness only in patella
tenderness in fibular head
can't flex 90 degrees
can't bear weight both knees immediately
211
preseptal cellulitis aka periorbital cellulitis sx's and treatment
* trauma or local infection (staph aureus)
* swelling warmth of eyeLID
* eye is spared & **no** painful eye movement, **no** fever
* infection that's **ANTERIOR** to orbital septum
* _\>_2 yrs old, mild (no vision changes, eye moves, no ptosis) can be outpatient: give
* oral amoxicillin, cefdinir, cefpodoxime 1-2 weeks
* warm soaks 2-4 hrs x 15 mins
* f/u 24 hrs
* \< 2 yrs old, purulent eyes, mod-severe → hospitalization, IV antibiotics
212
orbital cellulitis
* IMMEDIATE CT SCAN & referral! Can go blind
* severe infxn of soft tissue **POSTERIOR** to orbital septum
* affects eye: PAIN with eye movement or restricted eye movement, chemosis, ptosis (late), dec visual acuity
NURP 532
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