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A 60 year old presents with vertigo, tinnitus and hearing loss he states that this has happened to him before and the last time the sensation lasted 3 hours what should be on the differential diagnosis?
- A: Acoustic neruoma
- B: Vestibular neuritis
- C: Meniere's disease
- D: all of the above
An hearing loss that is gradual and continuous, associated with vertigo and possibly tinnitus
A hearing loss that lasts severl days usually following an URI with vertigo and tinnitus
What non-ear specific problem would you be worried about in an older patient with ringing in the ear, vertigo and falling?
Idiopathic diagnosis of the inner ear that is characterized by recurrent spontaneous attacks of vertigo, tinnitus, fluctuating hearing impairment and aural fullness
What Medications do you use to treat Meniere's disease?
- Diazapem, Meclizine (antivert), Phenergan (to treat the vertigo)
- Triamterene/hydrochlorothiazide- diuretics to decrease fluid in the ear
True of False you can treat Meniere's disease surgically
What medication would you use to treat vertigo in a Meniere's patient
What class of medications would you use to treat the underlying eitiology of meniere's?
A patient brings in their one year old child and states that the patient has been irritable and fussy. Pt's temperature is 38.5 C (101.3) there is redness around the TM but the TM is still mobile how would you treat?
- A. Amoxicillin
- B. amoxicillin + clavulunate
- C. watchful waiting
- D. topical antibiotics
What are 3 things needed for the diagnosis of acute otitis media?
1. a history of acute onset of signs and symptoms
- 2. The presense of middle ear effusion
- 3. signs and symptoms of middle ear inflammation
What 4 things indicate the pressence of a middle ear effusion?
- Bulging of the tympanic membrane
- limited or absent mobility of the tympanic membrane
- air fluid level behind the tympanic membrane
Give 2 signs or symptoms of middle ear inflammation
- 1. distinct erythema of the tympanic membrane
- 2. distinct otalgia (discomfort clearly referable to the ears that results in interference with or precludes activity or sleep)
For a child with suspected AOM less than 6 months old will you treat with antibiotics for an uncertain diagnosis?
With a patient age 6 months to 2 years whom you suspect has an AOM how will you treat?
It depends!!!!! Antibacterial therapy for severe illness (to modify sever otalgia or fever = to or above 39 degrees C) Otherwise Observation for non severe illness (fever less than 39 degrees C and mild otalgia)
A 10 year old presents to you with acute onset of left ear pain febrile at 39 degrees C and bulging TM that does not move with pneumatoscope the patient has no known drug allergies what would you perscribe?
A 10 year old patient that presented to you with a 39 degree C fever red bulging TM comes back to you after 2 days of being on Amoxicillin what are your next steps?
Confirm the original diagnosis, change the antibiotic, start a different antibiotic, tell the parent to bring the child back soon to check the progress
What is the first line treatment for acute otitis media?
When treating AOM if amoxicillin fails or the infection is sever what would you perscribe?
You diagnose a 10 year old with severe acute otitis media. The child is allergic to penicilin, but did not have hives or anaphylaxis with the penicillin what would you perscribe?
Cefuroxime, cefproxoime or cefdinir
You diagnose a 5 year old with severe acute otitis media and the child is allergic to penicillin with a history of uticaria and anaphylaxis with the drug. What would you perscribe this patient?
azithromycin of clarithromycin
Is it appropriot to give a patient with AOM pain medication?
Yes ibuprofen or acetaminophen but not asprin
What common OTC drug can cause tinnitus at higher or prolonged doses?
A 22 year old presents complaining of left ear pain the patient is afebrile on physical exam and you see an erythematous TM that has limited movement the patient has no known drug allergies what would you give this patient?
If ear pain not bad watchful waiting or if ear pain is bad amoxicillin there is no difference in treating kids and adults with AOM
A 28 year old presents with pain to his right ear, he denies trauma and is afebrile, physical examination is unremarkable (non erythematous TM with movement with valsalva) what do you diagnose?
A 16 year old presents with itchy minimal painful right ear he swims for his high school, on physical exam you note minimal tenderness on pushing on the tragus and you notice some debri with no edema in the canal what would you do to treat?
Gently clean and dry the ear canal
Pt presents with painful right ear. On PE the canal of the ear is swollen, TM can not be visualized because of the swelling. What would you treat this patient with?
Topical antibiotics, systemic antibiotics and a wick
How would you treat a mild OE?
gentle cleaning of the canal and topical drying agents
How would you treat moderate OE with a visible TM?
How would you treat severe OE with no visible TM?
Topical antibiotics and systemic` antibiotics and a wick
Non-antibiotic treatment for OE
Acidifying agents: acetic acid with aluminum acetate (domeboro otic) or acetic acid with hydrocortisone (vosol HC)
What otic` antibiotic should you NEVER use if you cannot visualize the TM?
Neomycin containing meds (cortisporin otic)
What are some Topical antibiotics that you can use for OE?
- ciprofloxacin otic
- oxafloxacin otic
- polymyxin B + neomycin + hydrocortisone
What is the number one risk factor for the development of COPD?
What are the characteristic symptoms of COPD?
- chronic and progressive dsypnea cough and sputum production
- as disease progresses can develop reduced exercise capacity, fatigue, dyspnea on exertion and cor pulmonale
What are some physical exam findings that are characteristic of COPD?
wheezing, hyperresonance (from air trapping), diminished breath sounds, use of accessory muscles, pursed lip breating, elevated JVP, hepatomegaly, peripheral edema
COPD findings on chest CXR
- hyperinflated lungs
- flattened diaphragms
- hyperlucency in severe emphysema
What is the recommended treatment for all patients with COPD?
SABA prn, influenza and pnumococcal vaccinations, smoking cessation
True or False inhailed corticosteroids don't work ask well for COPD patients as they do for asthmatics
What treatment plan would you choose for mild COPD FEV1 > or =80% predicted?
Short acting bronchodilator
What treatment plan would you choose for a moderate COPD patient FEV1 50% < FEV1 < 80% perdicted with or without symptoms?
Add regular treatment with LABA, add rehab
What treatment plan would you choose for a severe COPD patient 30% < FEV1 < 50% ?
Add ICS to albuterol, LABA and rehab with exacerbations
What treatment plan would you choose for a VERY Severe COPD patient with an FEV1/FVC of less than 30% or chronic respiratory failure?>
Albuterol, ICS, Rehab, LABA, LTOT and possible surgery
What are the general treatment options for COPD?
- Inhailed corticosteroids
- systemic corticosteroids
- oxygen therapy
- rehabilitation therapy
Name a short acting beta 2 agonist ( bronchodilator)
Name a long acting B2 agonist (bronchodilator)
salmeterol, formeterol, arformeterol
What are the side effects of long acting beta 2 agonists?
Muscle tremor, tachycardia, palpitations, hypokalemia
Name an anticholinergic
Ipratropium bromide, tiotropium bromide
In COPD anticholinergics may be (less effective? or more effective?) than beta 2 agonists?
the same as or more effective
What are the side effects of anticholinergics?
bitter taste after ipratropium, caution in prostatic hypertrophy, glaucoma
Name a combination inhaled ICS and LABA
Fluticasone/salmeterol or budesonide/formoterol
Name a combination anticholinergic and SABA
albuterol and ipatropium
Name a methylxanthine
What is the MOA of methyxanthines
What are the side effects/ drawbacks to using methyxanthines?
- Narrow theraputic window
- SE: major cardiac events such as arrythmias and seizures
When would you use systemic steroids for a chronic COPD patient?
With acute exacerbation ONLY
True or False inhailed corticosteroids have a significant effect on the disease process of COPD
Does thophylline work better for an Asthma patient or a COPD patient?
Why do you use an inhaled corticosteroid in a COPD patient?
they upregulate B2 receptors for more effective B2 agonist use, they decrease the number of exacerbations especially in patients with FEV1<50% of predicted
Name 3 smoking cessation medications
Nicotine replacement, Bupropion, Chantix (varenicline)
- gum lozenges, patches, nasal sprays
- efficacy primarily results from preventing withdrawl
- efficacy improved with counseling and motivational therapy
- enhances both noradrenergic and dopaminergic neurotransmission via uptake inhibition
- quit day one week after treatment
- black box warning
- contraindicated in: sz d/o, anorexia, bulimia, MAO inhibitors
- Interacts with the ACh receptors so that when you smoke you dont get any positive chemical enforcement
- start one week before quit day
- Black box warning: mood and behavioral changes and suicide ideation
- caution in cardiovascular disease which remember is VERY common in COPD patients BE CAREFUL!
What are the benifits of Long Term Oxygen Therapy for a COPD patient?
- improves survival, exercise, sleep and cognitive performance
- reverses hypoxemi and prevents hypoxia
- reverses secondary polysythemia, improves cardiac function during rest and exercise
What are some indications for putting a COPD patient on LTOT
hypoxia, HTN, cor pulmonale, edema from right heart failure, impaired mental status
What are 3 types of surgery that can be done for COPD?
Bullectomy, Lung volume reduction surgery, Lung transplantation
What are some symptoms of an acute COPD exacerbation?
- progressive hypoxemia which causes: tachypnea, tachycardia, systemic htn, cyanosis, change in mental status
- pt will be sitting up and forward with pursed lip exhalation, accesory muscle use and diaphoreis
What is the treatment progression for a patient with an acute COPD exacerbation?
- Beta 2 agonists and anticholinergics (nebulizer) often in combination
- corticosteroids sytemically
- antibotics if there are signs of infection
- assisted ventillation if needed
- (EKG with chest pain)
- admission if the signs and symptoms are bad enough
COPD patients in acute exacerbation with respiratory fatigue, worsening of respiratory acidosis, or deteriorating mental status should be treated with ___
What are some contraindications for assisted ventilation for a COPD patient (3)
Obtunded, Facial surgery, morbidly obese
What are some tests you would order if you suspected a patient had an acute exacerbation of COPD?
ABG, CBC, BMP, EKG, CXR, close monitoring
What are the contraindications for noninvasive positive pressure ventilation?
uncooperative or obtunded patient, patients who cannot clear secretions, pts with recent facial or gastroesophageal surgery, burns, hemodynamically not stable
What are some signs and symptoms associated with PE?
shortness of breath, tachypnea, hypoxemia, chest pain, fever (if there is infarction), tachycardia, pertinent history of coagulation or long sitting periods or surgery or OTCs
You suspect your patient has a PE. You decide to touch the chest to see if their chest pain was reproducible and it is, does this change your diagnosis? how?
GOOD! most likely not a PE reproducible chest pain suggests costochondritis
What are the two most common symptoms of PE?
shortness of breath and chest pain
What are the risk factors for PE?
- Hypercoagulability: malignancy, pregnancy, estrogen, coagulopathies
- Venous stasis: bed rest for more than 48 hours, immobility secondary to cast, recent hospitalization, long distance travel
- Venous injury: recent surgery, recent trauma
What is the test of choice for a PE?
What will falsely elevate d-dimer with a patient who you suspect has PE?
pregnancy, malignancy, sepsis etc.
Why would you order a D-dimer?
if you suspect a PE it can rule PE out but not definitivly diagnose a PE
How would you handle a patient who you have a high suspiction of PE?
CT angiogram or treat
How would you handle a patient who you have a low suspicion of PE?
if all the PERC criteria are met no D-dimer is nesissary if they are not perform a D-dimer and if it is positive then do a VQ scan or a CT angio
What lab tests can you order to indicate the presense of a PE?
- Severe distress do an arterial blood gass
What are 3 possible treatments for PE
Unfractionated heparin, low molecular weight heparin, fibrinolytic therapy
- used to treat PE
- binds to antithromin and accelerates its activty thus preventing extension of thromus, short half life if pt has to undergoe surgery, contraindicated in active hemorrhage and/or recent brain hemorrahage
Low molecular weight heparins
- Used to Treat PE
- greater bioavalibility, more predictable response than unfractionated, longer half life
- enoxaparin and dalteparin
- used for PE tx
- contraindications: intracranial neoplasm, previous hemorrhagic stroke, ishemic CVA in past year, active internal bleeding or suspected aortic dissection
__ occurs when air enters the potential space between the visceral and parietal pleura
What are the symptoms of pneumothorax?
chest pain, dyspnea, often tachycardia
what are some physical exam findings that are sugestive of pneumothorax?
decreased breath sounds, decreased tactile fremitus, hyperresonnance
What will you see on CXR in a patient with a pneumothorax?
visualization of the visceral pleural line with an overlying radiolucent area without vascular or lung markings between the visceral pleural line and chest wall
what are 4 causes of pneumothorax?
- Primary spontaneous- absence of underlying lung disease
- Secondary spontaneous- underlying lung disease
What treatment would you choose for a very small pneumothorax?
watchful waiting with oxygen
What would you do for a small to medium sized pneumothorax?
simple needle aspiration
What would you do for a bad pneumothoraxy or one with secondary complications??
What are some symptoms of a tension pneumothorax?
hypotension, tachycardia, diaphoresis, trachial deviation, distended neck veins, cardiovascular collapse
What are the symptoms of Asthma?
Cough, chest tightness, wheezing, quiet chest, acute respiratory distress, noctournal coughing, exercise induced, atopy, couging at night
Mild intermittent Asthma
- 2 or less attacks per week, lung function or PEF 80% or greater than predicted FEV1/FVC normal, Nighttime symptoms 2x or less per month,
- Treatment: SABA
Mild persistent Asthma
- more than 2 attacks per week but less than one per day, FEV or PEF = or less than 80%, nighttime symptoms more than 2x montly
- Treatment: SABA + Low dose ICS or alternative
Moderate persistent Asthma
- Daily symptoms and daily use of SABA, FEV1>60% to <80% predicted, Exacerbations affect activity, night time exacerbations 1x per week, FEV1/FVC reduced 5%,
- Treatment: low dose ICS + LABA or medium dose ICS
Severe persistent Asthma
Continual symptoms that limit physical activity, Frequent exacerbations and frequent nighttime symptoms
When would you use a methacoline challenge to diagnose asthma?
In patients with exercised induced asthma and someone who cannot perform spirometry
what two tests can you do to confirm a diagnosis of asthma?
Methacholine challenge, and Bronchodialator response to short acting bronchodialator
What percentages of change would you suspect in an asthmatic for spirometry (bronchodialator)/bronchial provocation testing ?
Improvement of >12% or a decrease >20%
What are the side effects of a SABA?
nervousness tremor tachycarida palpatations and headache
what are some side effects of inhailed corticosteroids for asthma?
hoarsness and candidiasis
When do you use systemic corticosteroids for an asthma patients?
in acute exacerbations, use the lowest dose possible
what are some side effects of systemic corticosteroids?
hypertension diabetes mellitus, osteoporosis, HPA supression, caution tachyphylaxis
When do you use an Antileukotriene for asthma?
when you are trying to cut down on steroid use
How do antileukotrienes modify the course of disease in asthma?
work on leukotriene receptors in the respiratory tract producing: bronchodialation, decrease microvascular leakage, increase eosinophilc inflammation
Name an antileukotriene
- montelukast singulair
- zariflukast accolate
Name an immunomodulator druge used to treat asthma
- immunomodulator used to treat asthma
- block antibody that neutralizes circulating IgE and inhibits IgE mediated reactions
- decreases number of exacerbations in those patients with severe asthma
- treatment is suitable for highly selective patiens who are not controlled with maximal doses of inhailer therapy, very expensive
- have an IgE within a specified range
Pt has been on SABA prn however she has been using her inhailer several times per week what would you do first?
- A: Check environment
- B: Put her on high dose ICS
- C: put her on LABA
- D: start her on theophylline
- A: Check environment
Your patient with mild asthma has been using her SABA multiple time per week and denies any environmental changes recently or any new exacerbating factors, you decide that she is poorly controlled what do you do next?
- A: add low dose ICS
- B. Add high dose ICS
- C. add LABA
- D. Add albuterol
- A. Add low dose ICS
Pt is on albuterol prn and low dose ICS having night time symptoms greater than one time per week, using inhailer daily what would your next step after checking environment, adherence and co-morbidities?
- A: Add a LABA
- B: Increase ICS to medium dose
- C. add oral steroids
- D. A or B
- D. A or B
Your patient is having an acute asthma exacerbation, they come into the ER with wheezing and shortness of breath. You do a PEF, pulse ox and CXR, What will you give them via nebulizer?
Albuterol and possibly oxygen
What are the steps for treating mild, moderate and severe asthma exacerbations?
- Mild- albuterol, PEF before and after treatment, pulse ox and possibly CXR
- Moderate- all of the above plus albuterol or combivent via nebulizer, and prednisone d/c home after normal pulse ox with walk tests
- Severe- albuterol or combivent nebulizer, magnesium, solumedrol, reevaluate, and/or admit (usually admit with severe wheezing, inability to talk in full sentances, inability to walk)
- Very severe- Respiratory distress- intubate
Symptoms of pneumonia
productive/nonproductive cough, dyspnea, fever, pleuritic chest pain, tachycardia, tachypnea
Physical exam findings of pneumonia
- alveolar fluid (inspiratory rales, consolidation)
- Bronchial breath sounds
- Pleural effusion (dullness)
- bronchial congestion (rhonchi and wheezing)
What are the 4 types of pneumonia (classified by setting)?
CAP, HAP, VAP, HCAP
You have a patient with pneumonia who you are treating outpatient who is mildly ill, has no cardiopulmonary disese or other modifying factors what do you choose to treat with?
Azithromycin or clarithromycin
You have an patient with pneumonia who you are treating outpatietn who is stable with comorbidities what would you treat with?
Floroquinolone (moxifloxacin, levofloxacin) or a beta lactam (amoxicillin clavulanate with a macrolide)
Floroquinolones (moxifloxacin and levovloxacin) are contraindicated with what?
You have a patient with pneumonia who you are treating as an outpatient who has had a course of antibiotics in the past three months how do you treat this person?
Floroquinolones (moxifloxacin, levofloxacin) or a beta lactam (amoxicillin clavulanate with a macrolide)
What are the criteria for curb 65?
- Confusion, BUN > 19 mg/dL, Systolic pressure of <90 or diastolic <60, Respiratory rate 30 or greater, age 65 or older
- each of these factors earns you one point
1 or 2 points on a CURB 65 how would you manage?
Short in patient hospitalization or closely supervised outpatient care
0 points on CURB 65 how would you manage?
Low risk consider outpatient treatment
3 or 4 or 5 on Curb65 how would you manage?
hospitalization and consider ICU admission
A 62 year old male presents with fever, cough, chillls x3 days. He has well controlled DM and HTN but otherwise healthy. RR 24 BP 130/70, HR76 no signs of confusion WBC 23,000 BUN 14 where should the patient be treated? Bonus what should the patient be treated with?
Out patient therapy (according to CURB65) and with Levofloxacin or moxifloxacin because he has comorbidities
First line treatment of a patient that has no comorbidities that has CAP and is going to be treated outpatient is ?
- Note: you can also use erythromycin but it has a worse side effect profile and can cause C.diff
16 year old male presents with fever, cough, and 15 pounds of weight loss in 3 months. He recently returned from Ghanna doing missionary work. On chest X-ray he has a consolidated apical mass in his right upper lung apical region what is the most likely Dx?
A PPD test induration of 5 or more millimeters is considered positive in...
- HIV in fected persons
- a recent contact of a person with TB disease
- persons with fibrotic changes on chest radiograph consistent with prior TB
- Pts with organ transplants
- persons who are immunosurppressed
A PPD test induration of 10 or more millimeters is considered positive in
- recent immigrants
- Injection drug users
- Residents and employees of high-risk congregate settings
- mycobacteiology laboratory personel
- persons with clinical conditions that place them at high risk
- children under 4yo
- infants, children, and adolescents exposed to adults in high risk categories
A PPD test with induration of 15 or more mm is considered positive in
any person, including people with no known risk factors for TB, however targeted skin testing programs should only be conducted among high-risk groups
What are some symptoms of TB?
- many cases are asymptomatic, fever, shortness of breath, cough,
- post primary TB- productive cough, night sweats, anorexia
- Other signs and symptoms of disese depend on location such as abdominal pain
What is the preferred Tx for treatment of latent TB (for both HIV positive and HIV negative)?
Isoniazide for 9 months taken either daily or twice weekly
What should all suspected latent TB patients get before starting treatment?
For patients who in whom active TB is proved or strongly suspected what is your choice for initial treatment?
Isoniazid, rifampin, pyazinamide and ethambutol (initial phase) Then a continuation phase of 4 months on just two
What must all patients baseline tests should you get on all patients before starting initial TB therapy?
LFTs, CBCs, HIV, etc
After initial TB treatment what are subsequent treatments based on?
initial chest x ray, smear results, CD4 count
Adverse effects of Isoniazide (INH)
- asymptomatic elevation of aminotransferases discontinue if they become 5x the upper limit or symptomatic
- Clinical hepatitis
- Peripheral neuropathy- recommend pyridoxine supplementation in pts that have increased for this secondary to other conditions
What monitoring do you need if you have a patient on Isoniazide?
routine monitoring not necessary. however pts who have preexisting liver disesae or had abnormal liver function baseline lfts should be monitored monthly monitor serum concentratiosn of drugs that have interactions (phenytoin)
- first line treatment for all forms of TB caused by organisms known or presurmed to be susceptible to the drug. inhibits cytrochrome p450 system therefore significant drug interations
- First line agent for treatmetn of all forms of TB caused by organisms with known or presumed sensitivity to the drug
- Inducer of cytochrome P450 system; interferes with NRT and PI (rifambutin is used as a substitute for RIF patietns recieveing any drug having unacceptable interactions with RIF)
If a patient is on a drug that is not compatable with Rifampin what do you use instead?
What are the adverse effects of Rifampin?
- Cutaneous reactions with or without rash
- Orange discolorations of bodily fluids
Which TB drug causes Red urine?
first line agent for the treatment of all forms of TB caused by organisms with known or presumed susceptibility to the drug
What do you have to monitor on a patient who is on pyrazinamide and rifampin for the treatment of latent TB?
What are the adverse effects of Pyrazinamide?
Hepatotoxicity, GI symptoms, polyarthralgias, asymptomatic hyperuricemia, photodermatitis
- first line agent for the treatment of all forms of TB caused by organisms with known or presumed susceptibility to the drug
- Not recommended in children whose visual actuity can not be monitored
Which TB drug is contraindicated for children whose visual acuity cannot be monitored?
What are the side effects of Ethambutol?
Retrobulbar neuritis- manifested as decreased visual acuity or decreased red-green color discrimination
What monitoring do you have to have with the use of Ethambutol?
baseline visual acuity test and testing of color discrimination. Pts asked montly about vision and instructed to contact a physician if they experience any change in their vision. Montly testing of vision and color vision discrimination for patients taking doses of 15-25mg/kg or recieving the drug more than twice a month or a patient with renal insufficency
An induration of 10 or more mm on TST would be positive for
- A. pts with no risk factors
- B. IVDU
- C. children under 4
- D. male over 65
- B. IVDU
Pt is on a TB treatment regimin, you did a color discrimination test before treatment what drug is he on?
- A. Streptomycin
- B. pyrazinamide
- C. Ethambutol
- D. Rifambutin
- C. Ethambutol
You are going to start a patient on Rifampin in addition to telling them about skin rx, GI upset you would tell them about what?
- A. Possible visual changes
- B. Productive cough
- C. Orange discoloration of body fluids
- D. Insomnia
- C. Orange discoloration of body fluids
What is the preferred drug for LTBI?
What are the symptoms of Influenza?
Fever, chills, malaise, headache, myalgias
What is the treatment for influenza?
- Supportive treatment, Zanamivir (shortens by 2 days and can be taken prophylactically), Oseltamivir
You have a patient with flu like symptoms fever, chills malaise, headache and myalgias, as a good PA you ask them if they have nuchal ridgidity. what are you ruling out by asking them this?
What are the most common pathogens of Epiglottitis?
Haemophillis influenza, group A strep, S. pneumo
Who presents more acutely with epiglottitis kids or adults?
What are the symptoms of Epiglottitis?
Abrupt onset of fever, drooling, muffled voice, inspiratory retractions, stridor, pts present sitting up and leaning forward
How do adult patients with epiglottitis present?>
1-2 day history of worsening dysphagia, odynophagia and dyspnea especially in the supine position
You inspect the larynx of a patient with worsening dysphagia and see a cherry red swolen eppiglottis what do you Dx
True or false the incidence of epiglottitis is increasing
False the incidence of epiglottitis is actually decreasing secondary to immunizations
What is the primary clinical concern in Epiglottitis?
protection of the airway
what would you perscribe a patient with Epiglottitis?
- Cefuroxime, cefotaxime, ceftriaxone
- Rifampin to PCN allergic patients
Epiglottitis will show what important sign on X-ray
"Thumb Sign" on X ray
Infectious process that is characterized by a bark like or brassy like cough
In addition to cough croup may be associated with what other respiratory symptoms?
Hoarsness, inspiratory stridor, respiratory distress
What is the most common cause of stridor after neonatal period? (6mo to 3yr)
Viral croup (laryngotracheobronchitis)
What is the most common cause of viral croup?
1-5 day prodrome consisting of cough coryza and rhinorrhea followed by a 3-4 day barking type cough that is worse at night
Is stridor from croup greater on inspiration or expiration?
Inspiration (it is also not affected by position or with increased crying or agitation)
True or false increased costal retractions and tachypnea are some symptoms of Croup
How would you treat moderate to severe croup?
Nebulized racemic epinephrine and dexamethasone
How would you treat severe croup for whom intubation is being considered?
What is the most common respiratory infection in children under 2 y.o.?
What is the most common pathogen of Bronchiolitis
Inflammation, edema and necrosis of epithelial cells lining small airways increased mucous production and bronchospasm with a nasal wash positive for RSV would indicate what?
What are some symptoms of bronchiolitis?
- presentation can be minimal to respiratory distress, usually begins with a prodrome of upper respiratory infection first sign is rhinorrhea, followed by increaseing respiratory effort and wheezing, fever inconsistent
- rhinitis, tachypnea, wheezing, cough, crackles, uses of accessory muscles and/or nasal flaring
You 1 year old patient with a respiratory infection and a mild fever. Upon chest auscultaion you note wheezing and some crackles. you also note the child is breathing quickly. What do you diagnose?
What are three important signs of SEVERE bronchiolitis?
Tachypnea >70bpm, listlessness, apneic spells
What are the treatments for Bronchiolitis?
- use of bronchodialators- is controversial
- Use of racemic epinephrine- controversial as well
- IV fluids and supplemental oxygen are indicated
What is the most important step in preventing nosocomial spred of RSV?
hand washing! especially with alcohol based rubs
What prophylaxis is recommended of bronchiolitis?
Who should get prophylaxis for bronchiolitis?
- children under 2 years old with chronic lung disease who have required medical treatment in the preceeding 6 months before the start of RSB season
- Children younger than 2 years old who have cyanotic or complicated congenital heart disease
- infants younger than 6 months that were born at 29-32 weeks gestation
- Infants younger than 6 months born between 32 and 35 weeks gestation and have two or more risk factors (siblings, daycare, neuromuscular disease, congenital abnormality of the airways)