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73 Cards in this Set

  • Front
  • Back

how many upper respiratory infections (URIs) do adults have? children?

- adults have 3-4 URI infections per year


- children average 6-8 URIs but varies according to exposure

common cold

- benign, self-liminted syndrome


- most frequent acute illness in US

common cold: associated viruses

- adenovirus, RSV, coronavirus


- rhinovirus >> 100 serotypes, responsible for 50% of colds


- enteroinfluenza, parainfluenza

common cold: symptoms

- common symptom cluster, all or a few:


- nasal congestion and/or discharge


- sneezing


- sore throat


- cough


- low grade fever


- headache


- malaise

common cold: differentials

- influenza


- bronchitis


- acute bacterial sinusitis


- allergic rhinitis


- pertussis

are antibiotics appropriate for UTIs?

antibiotics are rarely appropriate, often expected


- several studies demonstrate that providers think they need to give antibiotics to satisfy patients but often patients just want provider to listen carefully and spend time with them to give them the tools to feel better



educate why antibiotics do not help

common cold: treatment

- NSAIDS: consider drug interactions, ADE, and co-morbidities


- acetaminophen


pros: less GI side effects


cons: shorter duration, hepatotoxicity if taken at higher doses

common cold: treatment, congestion

- saline nasal rinses


- expectorants >> guaifenesin


mild increase uric acid secretion via urine >> renal stones



decongestants are controversial


- pseudoephedrine vs. phenylephrine


- intrasnasal or oral, few doses max



ipratropium (atrovent) or cromolyn (nasocrom) nasal spray to reduce sneezing


common cold: treatment, cough

- dextromethorphan with guiafenesin -- best support


- codeine agents same as placebo


- honey &/or pectin lozenges, warm humidified air, fluids, saline


- warm vapor inhalation decreases symptoms

what about vitamin c?

- regular ingestion has no effect on incidence of common cold


- regular supplementation has modest effect in reducing symptom duration (39 studies)

ecchinacea


garlic


zinc

- may be beneficial for shortening duration but inconsistent for preventing the common cold


- garlic may shorten duration of cold symptoms if taken every day


- zinc may decrease duration but it's inconclusive

common cold: treatment, general tips

- avoid OTC medication "potpourri" just focus on specific symptom


- sputum color has no relevance r/t etiology


- manage expectations: duration 7-10 days, 3 days longer in smoker


- recommend patient return if symptoms are worsening despite symptomatic treatment or if fever is increasing

influenza

- influenza A or B


- transmission by droplets, incubation 1-4 days


- sudden onset fever & symptoms, often pt is aware exactly when it started


- headache


- myalgia


- feel like they've ben hit by a bus


- usually so ill unable to get out of bed or complete ADLs unlike most URIs

what is a common and serious complication in influenza?

pneumonia

is it the flu or a cold?


high fever


cough and sore throat


body ache, headache, tired


sneezing


stuffy nose


breathing problems

high fever (102 +), cough and sore throat, body ache, headache and tired, stuffy nose, breathing problems >> flu


cough and sore throat, sneezing, stuffy nose >> cold

influenza: diagnosis

- clinical picture and local epidemiological trends


- testing emphasis on high-risk patients or if diagnosis is unsure


- point of care testing with rapid antigen test


via nasalpharyngeal swab


- viral culture, typically via nasalpharyngeal swab. may delay in results, window for prescription will have passed, typically used for epidemiological monitoring

influenza: treatment

- antiviral drugs: usually not required


- best if started within 24-30 hours of symptom onset


- consider in high risk individuals


- can shorten symptoms in duration by 1-3 days


- neuraminidase inhibitors

neuraminidase inhibitors

used to shorten flu symptom duration


- effective against A & B


- oseltamivir (tamiflu)


- zanamivir (relenza)


- resistance is seasonal

rhinosinusitis: viral

up to 98% of rhinosinusitis cases are viral: rhinovirus, parainfluenza, or influenza virus


rhinosinusitis: bacterial

- streptococcus pneumoniae (41%)


- Haemophilius influenzae (35%)

sinusitis: making the diagnosis

- facial pressure or pain, typically maxillary or frontal


- postnasal drainage (PND), sometimes worse when supine


- fatigue


- cough, can be triggered by postnasal drainage


- nasal congestion


- dental pain, on affected sinus side


- headache


- fever, low grade if present



sinus xray vs CT vs culture (swab or puncture)

sinusitis: treatment

manage expectations: 50% will be well and 75% will feel substantially between within the next 10 days



antibiotics little or no impact the first 7-10 days of symptoms


- nasal steroids: modest improvement


- decongestants & antihistamines


- mucolytics/ expectorants


- hydration


-analgesics PRN


- saline irrigation

sinusitis and antibiotics: who will benefit?

most to least


- purulent discharge via exam, do a nasal exam


- symptom > 7 days


- 10 days


- facial/ sinus tenderness including headache, maxillary/ tooth pain


- fever


- feeling ill/ unable to work

sinusitis: treatment

- amoxicillin- clavulanate (first line) 500/125 mg TID or 875/125 BID for 5-7 days


- doxycylcine, quinolone for PCN allergic patients


- macrolides or TMP- SMX


- cephalosporins

allergic rhinitis

- affects about 20% of US citizens


- 6th most preventable chronic illness


- the history is the diagnostic tool


- symptoms associated with exposure to substance r/t exposure to allergen, first or repeated (antigen- antibody response)


- seasonal: occurs various times of year


- perennial: symptoms year round

allergic rhinitis: diagnosis & symptoms

- typically: clear rhinorrhea, sneezing, nasal obstruction. itching of eyes, nose and palate



- sometimes: postnasal drip, cough, irritability and fatigue



physical exam:


- allergic salute and/ or allergic shiners


- boggy, edematous, pale, bluish turbinates


- often associated with bleeding, crusting, mucus esp with children

allergic rhinitis: treatment, second generation antihistamines

second generation antihistamines & intranasal steroids too


- loratadine (claritin), fexofenadine (allegra), cetirzine* (zyrtec), intransal azelastine* (astelin)



may have more sedation than other second generation antihistamines

allergic rhinitis: treatment, intranasal steroids

remember: intranasal steroids and second generation antihistamines too


- flutocasone (flonase), mometasone (nasonex), triamcinolone (casacort)


- best efficacy, okay to combine with antihistamine


- nasal irritation, epitaxis (nose bleed)


- few days delay in full effect, make sure to manage pt's expectations

allergic rhinitis: treatment, antileukotriene agents, allergic conjunctivitis

antileukotriene agents


- montelukast (singulair)


- alone or in combination with antihistmaines


- consider if coexisiting asthma



allergic conjunctivitis


- ocular decongestants: naphcon- A (OTC)


- ocular mast cell stabilizers: patanol, zaditor ($$)

pharyngitis: viral

does not look like much but it's very painful


symptomatic treatment


- can present with strawberry patches (palatine petechia)


- adequate analgesics, if no relief get detailed history of use


- salt or warm water, gargles


- hydrate, lozenges, sprays


- voice rest pm

group A beta- hemolytic streptococcus (GABHS)

transmitted via respiratory secretions


- incubation 24-72 hours


- no longer contagious after 16 hours of starting antibiotics; OK to return to school/work 24 hours



- if untreated, continues to be contagious for up to 10 days after symptom resolution


- long period of asymptomatic transmission, a lot of people infected

centor criteria

to determine risk of strep



- history of fever


- tonsillar exudates


- tender anterior cervical adenopathy


- absence of cough


- modified criteria ( < 15 add 1 point; > 44 subtract 1 point



points 0-1 risk of strep is < 10 %


2-3 risk 32% if 3 criteria, 15% if 2


4-5 risk 56%

diagnosis: GABHS pharyngitis

testing is not needed in everyone


- RADT: "quick strep", rapid antigen detection testing


immediate, in office detection that allows for earlier treatment


sensitivity depends on kit, older is 70% and newer is 90%


specificity is 90- 99%


$ can be more than the cost of culture



throat culture is the gold standard


90 - 95% sensitive if done right


- takes a few days to get results

GABGS pharyngitis: treatment, goals

- reduce severity of symptoms


- reduce complications


- reduce infectivity

pharyngitis management

symptomatic: saline gargles, analgesics, cool mist, humidification, throat lozenges



antibiotics:


- penicillin VK 500 mg TID x 10 days


- benzathine Pn-G 1.2 million units IM x 1


- amoxicillin 500 mg BID x 10 days


if allergic to PCN:


- erythromycin 500 mg QID x 10 days


- azithromycin 500 mg daily x 3 days

agents not effective against GABHS

- tetracyclines


- fluroquinolones


- sulfonamides


- trimethoprim


- chloramphenicol

what about steroids treating GABHS?

- some data suggests reduction in pain severity but only modest change compared to no steroid (4 hours 1 day)


- consider risk and benefits

non- group A strep: group C & G

non- group A streptococcal infections


- group C & G, some throat culture will report


- some are colonized but without symptoms


- no definitive treatment recommendations, case by case


- if culture positive group C or G in symptomatic patient


- treatment will reduce symptom duration

treatment of n. gonorrheae

- ceftriaxone 250 mg IM x 1 dose +



doxycylcine 100 mg twice daily x 7 days


OR


zithromax 1 GM x 1 dose

infectious mononucleosis

- espstein-barr virus (majority), cytomegalovirus


- spread via saliva


- most common incidence between 15 to 30 years


- long incubation 4-7 weeks


- presentation is similar to GABHS: fever, erythematous tonsils w/ exudate, often very toxic with malaise


- posterior cervical lymphadenopathy


- splenomegaly, avoid contact activities

infectious mononucleosis: how can you distinguish from other pharyngitis

significant cervical lymphadenopathy may help distinguish from other pharyngitis at early stages

infectious mononucleosis

90% of people given a penicillin will develop a maculopapular rash if given penicillin with mononucleosis

infectious mononucleosis: diagnostics

diagnostics


- monospot/heterophile


- CBC (lymphocytosis)


- LFTs (transaminitis)



treatment: symptomatic

peritonsillar abscess

- continuum: exudative tonsillitis to cellulitis to abscess


- toxic/ ill appearing


- hot potato voice, muffled, godfather voice


- flucuant peritonsilar mass


- asymmetric deviation of the uvula


- severe: trismus, difficulty swallowing, drooling


- any age but most common 20-40 years old


- associated with GABHS, staph aureus, H influenza

peritonsillar abscess: management

- drainage is definitive treatment for all abscesses- refer to ED or ENT if can get someone immediately


- also antibiotics, pain control, hydration


- hospitalize PRN, can affect airway


- if pre-abscess, treat with antibiotics and watch closely


peritonsillar abscess: antibiotic options

- amox- clav 875 mg BID


- clindamycin 300- 450 mg QID


- oral or IV steroids can reduce symptoms and speed recovery

acute HIV infection: symptoms

- typically occurs 2-4 weeks after infection


- characterized by constellation of non-specific flu like symptoms



fever, myalgias


pharyngitis


rash


headache

acute HIV infection: differential diagnosis (broad)

- influenza


- step pharyngitis


- GC pharyngitis


- mononucleosis


- acute HCV


- syphilis

acute HIV infection: diagnosis

key is to assess history and risk


laboratory testing:


HIV plasma RNA


HIV Ag/Ab testing



ALWAYS DO THE COMBINED TEST



if you are going to order testing for mononucleosis think acute HIV

common oral lesions, treatment

- many conditions can be assess via findings on oral exam


- topical therapy


clotrimazole troches 5 x daily


nystatin 400,00 - 600,000 units QID



- systemic therapy


fluconazole 200 mg x 1, 100 mg x 7 - 14 days



consider -- azaole resistance if no response

canker sores: treatment

- orabase with triamcinolone or fluocinoide


- amlexanox 5% paste


- intralesional paste for severe disease


- thalidomide- need special access

oral cancer

always look under tongue


HPV looks like a wart in the mouth and can lead to head and neck cancer

Acute otitis media (AOM)

- viral or bacterial


- most common in children


- onset often several days to weeks after URI

actue otitis media: etiology

- streptococcus pneumoniae (40-50%)


- haemophilus influenzae (30 - 40%) nearly one half produce B lactamase


- moraxella catarrhalis: most preduce b- lactamse


- viral 10%: foten co-infected with bacteria (40 %)

acute otitis media: diagnosis

- acute onset


- middle ear effusion, limited or absent mobility of membrane, air- fluid level behind membrane


- erythema of tympanic membrane or otalgia

acute otitis media: treatment

- need to be discerning because:


70-90% spontaneously resolve in 7-10 days


- less antibiotic use means less microbial resistance and some evidence suggests less otitis media recurrence


- discuss with patients


- Any child or adult with severe disease needs antibiotic tx and close monitoring

adult acute otitis media: treatment



normal rx?


severe rx?


severe with PCN allergy?


PCN (non- type 1)?

- amoxicillin 500 mg q 12 hours; 250 mg q 8 for 5-7



severe disease: amox- clav 875 mg q12 or 500 mg q8 hours x 10 days



severe with PCN allergy: azithromycin, trimethoprim-sulfamethoxazole BID



PCN (non- type 1): cefuroxime (Ceftin) 500 mg BID

what should you not forget when treating adult acute otitis media?

- don't forget the analgesics, regardless whether treat with antibiotics



if no improvement and analgesics are not helping within 2-3 days then review with the patient if they're using the correct dosing and frequency



potentially add an antibiotic



If no response to antibiotic in 2- 3 days then change the antibiotic

Otitis media with effusion (OME)

- middle ear effusion (non- purulent fluid build up) without an acute infection



- effusion or fluid in the middle ear persists after AOM or allergic rhinitis



associated with eustachian tube dysfunction


also known as "glue ear" when chronic

otitis media with effusion symptoms

- may have no symptoms, incidental finding on exam


- middle, intermittent ear pain, fullness or "popping"


- balance problems, unexplained clumsiness


- recurrent episodes of AOM with persistent OME between episodes


otitis media with effusion: treatment

- self- limited process: 75-90% resolve within 3 months, manage patient/ parent expectations


- autoinflation


- nasal/ oral steroids with or without antibiotics: may help short term but no difference long term with hearing or recurrence


- decongestant and/or antihistamines are no help

Ceruminosis

- usually extruded automatically from canal


- may block canal resulting full sensation, decreased hearing, pain or infection (otitis externa)


- often, hearing loss is so gradual patient is not aware of how much has lost until removed

cerumen removal

- do not attempt if known or suspected perforation or tympanostomy tubes


- irrigation: safe, gentle, messy


important water is body temperature, not hot or cold


it's rarely painful but if so then stop


- curette- need experience/guidance to use

cerumen prevention or treatment

ceruminolytics


- helps prevent build up by keeping cerumen soft


- improves irrigation success



some options with about the same in efficacy, just depends on preference


- OTC formulations (Debrox, Audax)


- Docusate (stool softener)


- water or saline



pre- irrigation: use 30" before or 3-4 days before irrigation

otitis externa: acute

pruritus, mild to moderate discomfort, and erythema


- as progresses: edema, otorrhea, and conductive hearing loss


- bacterial (90%) vs. fungal (10%) staphylococcus & pseudomonas most common bacterial


- 40% of fungal also have underlying bacterial etiology

otitis externa: chronic

- fungal


- allergic


- dermatitdes

otitis externa: treatment (if bacterial suspected)



medication list

- neomycin sulfate/ polymyxin B/hydrocortisone (Cortisporin Otic)


- ciprofloxacin/ dexamethosone (ciprodex)


- olfoxacin otic (floxin otic)


- fungal


otitis externa: treatment (if bacterial suspected)neomycin sulfate/ polymyxin B/hydrocortisone (Cortisporin Otic)

pros: cheap, efficacious


cons: resistance and hypersensitivity increasing; potentially ototoxic (neomycin); frequently discourages compliance 4 times daily

otitis externa: treatment (if bacterial suspected)


ciproflaxacin/ dexamethasone (ciprodex)

pros: efficacious, no ototoxicity, 2x per day which favors compliance


cons: expensive, resistance is increasing

otitis externa: treatment (if bacterial suspected)


ofloxacin otic (floxin otic)


- pros: efficacious, no ototoxicity, no hypersensitivity, 1 or 2 x daily which favors compliance


- cons: expensive, increasing resistance

otitis externa: treatment (if bacterial suspected)


fungal

- tolnaflate (tinactin) or clotimazole (lotrimin)


- if mild case with or without possible co- infection (both fungal and bacterial)


- 2.75% boric acid or 90% to 95% isopropyl alcohol


- 2.0% acetic acid (vosol) with or without steroid


- both appropriate for prevention



when do you refer for otitis externa treatment?

when the patient has severe pain, edema and/or fever

ear wick

do not use