My Peds EOR Set

simple vs complex febrile seizure

simple:
- generalized seizure
- lasts

What causes acne

increased sebum/oil production
Follicular hyperkeratinization
Proliferation of propionibacterium acnes
inflammation

Describe different types of acne

Comedonal (noninflammatory):
Open comedones (blackheads) and closed comedones (whiteheads)

Mild papulopustular and mixed acne:
Open comedones, closed comedones, pustules

Moderate papulopustular and mixed acne:
Open comedones, closed comdones, pustules, nodules

Severe acne:
Open comedones, closed comedones, pustules, nodules, extreme inflammation"

What is the treatment of mild vs moderate vs severe acne (also medication ADE)

Mild (comedones only):
Topical retinoids (Tretinoin, Tazarotene, Adapalene Gel)
• Every 3rd night, then slowly increase
• Increases cell turnover
• SE: dryness; CI: pregnancy
*alone or in combo
BPO 2.5% *alone or in combo
• SE: skin irritation
Topical abx (clinda) *w/ BPO

Moderate:
Add oral ABX
Doxycycline
• SE: GI, photosensitivity, teeth
• CI: pregnancy, young children
Erythromycin *okay in pregnancy
Bactrim
• SE: SJS/TEN, CI: pregnancy

Severe:
Isotretinoins
• SE: dryness, HA, SI, depression
• CI: tetracyclines, pregnancy
• Labs: LFTs, CBC, lipid monthly
• 2 birth control methods, pregnancy test, no blood donation"

Describe pattern of androgenic alopecia
What labs should be checked

Frontoparietal scalp recession and vertex thinning

check iron, TSH, vit D, testosterone, DHEAS-S

What is the cause of androgenic alopecia

genetics
DHT (dihydrotestosterone)
hormones
age

what is the treatment of androgenic alopecia

Males: rogaine, propecia
Females: rogaine, spironolactone
hair transplants

What is the treatment of eczema

Topical steroids (flares) - mild to moderate potency

Calcineurin inhibitors (maintenance) - nonsteroidal anti-inflammatory immunosuppressant (steroid sparing) Tacrolimus (Protopic) or pimecrolimus (Elidel)

Lubricants like Aquaphor, CeraVe, vanicream

Avoid triggers

Antihistamines - sedating, for sleep disturbances (Benadryl)

Aluminum subacetate solution or Aveeno soaks for acute, weeping lesions

Oral/topical antibiotics PRN infection to cover S. aureus

Dilute bleach bath to decrease bacteria and severity

Difference between moisture trapping and candidal diaper dermatitis

Moisture trapping: red, painful, in buttock but spares folds

Candida: red, beefy, in the folds with satellite lesions

How to treat diaper dermatitis

Moisture trapping: barrier ointment with zinc oxide, low potency corticosteroids, topical mupirocin if infected

candida: nystatin

what rash is 1-2mm grouped erythematous papules and vesicles around the mouth with the vermillion border spared

how do you treat it?

perioral dermatitis

eliminate offending agents
mild: topical pimecrolimus or erythromycin
Moderate: oral tetracycline

Describe the different degree of burns

1st degree: superficial
Depth: epidermis
Dry, blanches w/ pressure, erythematous

2nd degree: superficial partial
Depth: papillary
Moist, blisters, blanches w/ pressure

2nd degree: deep partial
Depth: reticular
Wet or waxy dry, blisters that easily pop, blanches w/ pressure (delayed)


3rd degree: full thickness
Depth: hypodermis
Waxy white/grey/charred, dry, no blanching w/ pressure

Describe how to estimate BSA of burns

Rule of 9s: Estimates percentage of body burned:
- Entire head and neck = 9%
- Right arm = 9%
- Left arm = 9%
- Anterior torso = 18%
- Posterior torso = 18%
- Right leg = 18%
- Left leg = 18%
- Groin = 1%

Infants:
- Head = 18%
- Each arm = 9%
- Anterior torso = 18%
- Posterior torso = 18%
- Each leg = 14%

Describe the parkland formula and what it is used for

For calculating volume of LR for burn patients

3mL x total body surface area of burn (%) x body weight (kg)
- First half over first 8 hours
- Second half over next 16 hours

Same formula but 4mL instead of 3mL in teenagers/adults

What rash can be immediate (urticaria) or delayed (vasculitis, rash eruption) that is morbiliform, generalized small red macules and/or papules resembling measles rash

drug eruption

can be fixed: rash shows up in same spot every time that drug is taken

What is the treatment of a drug eruption

stop offending agent
antihistamines

what rash is an acute, self limiting hypersensitivity reaction triggered by various bacteria, viruses, or meds.

erythema multiforme

describe erythema multiforme rash

sudden onset symmetrical erythematous macules, papules, and target lesions that favor extremities like palms and soles and extensor surfaces
puritic

erythematous/purpuric center w/ or w/o bullae, surrounding halo of lighter erythma and edema and 3rd red ring

what causes erythema multiforme

type 4 sensitivity reaction
HSV usually

What is the treatment of erythema multiforme

treat underlying cause- stop offending med, acyclovir for herpes

treat symptoms: antihistamines, topical steroids, prednisone for oral lesions

derm referral if uncertain if SJS/TEN

What rash has different stages of lesions with small red lesions that progress from macules to papules to vesicles to pustules that crust over

all over body and very itchy, fever, malaise, low fever

varicella/chicken pox

what causes varicella

herpes zoster

what is the treatment of chicken pox/varicella

supportive care: ibuprofen, tylenol, cool compress, oatmeal bath

acyclovir in teens and adults at risk of complications

NO ASPIRIN: reyes syndrome causing swelling of liver and brain

prevent with varivax

what rash is a maculopapular rash that begins on the head and face and progresses down. symmetric and diffuse. cough, stuffy nose, conjunctivitis, fever

koplik spots (little white spots in the mouth)

measles/Rubeola

What rash is maculopapular beginning on the head and face and progressing down and is diffuse and symmetric. Not as much fever, cough, etc.

lymphadenopathy postauricular and suboccipital

rubella (rubella virus)

What rash is generalized and subtle pink that begins several days after a fever resolves. rash begins on trunk and spreads to face.

Roseola

What causes roseola

HHV-6

what causes erythema infectiosum/Fifth disease

parvovirus B19

What rash has a mild viral prodrome with fever then slapped cheek rash with generalized lacy reticular erythematous rash all over body

erythema infectiosum/fifth disease

describe molluscum and how its treated

firm skin colored round 3-5mm, central umbilication with central curd like core. painless

treatment: benign neglect, direct lesion trauma with cryotherapy, cantharidin, salacylic acid, tretinoin, curettage, imiquimod

What causes molluscum

pox virus

describe impetigo

begins with single red papulovesicle progressing to one or many honey-crusted lesions weeping serous drainage around nose and mouth.

bullous impetigo: larger bullae or vesicle with yellow crust

What is MCO of impetigo

strep and staph (MRSA included)

Consider culture if known MRSA colonized, systemic sx, severe local sx, immunosuppression, lack of improvement with tx

what is the treatment of impetigo

topical mupirocin ointment

oral keflex if widespread of bullous

if MRSA: bactrim

what is the treatment of lice

permithrin- leave in hair for 10 min then rinse and repeat in 7 to 14d

suffocation with alcohol

place things that cant be washed in plastic bags for 2 weeks. wash clothes and linens in hot water

signs of lice

head lice: nits on base of hair, intensely pruritic

body lice: found on seams of clothing, itchy, maculae ceruleae (blue/gray macules)

pubic lice: itchy pubic area with visible nits

how to treat body and pubic lice

body: good hygiene, wash clothes

pubic: permethrin cream, treat sexual contacts, wash clothes

describe scabies rash

intensely pruritic, excoriated papules, pustules, curvilinear burrows on intertrigenous zones

commonly seen in finger webs, wrists, axilla, breasts, buttock, penis

confirm with skin scrapings under microscope

how do you treat scabies

permethrin 5% cream from neck down 8-12hrs then wash off, repeat in 1 week

antihistamines, topical corticosteroids for pruritis

describe pityriasis rosea

acute, self-limiting, red and scaly exanthem

starts with herald patch (one big scaly pink patch) then 1-2 weeks later gets truncal rash in christmas tree pattern along langer lines. spares palms and soles

lasts 2-12 weeks

what is the treatment of pityriasis rosea

self limiting

topical steroids, camphor, menthol, antihistamines for itch

acyclovir if severe

what rash is due to chronic inflammatory autoimmune disease affecting skin and mucus membranes

lichen planus

what rash has increased incidence with hepatitis C

lichen planus

describe lichen planus

planar, purple, polygonal, pruritic, papules, plaques

flexor surfaces of wrists, forearms, legs, inside mouth

what is wickham striae

lesions often covered by lacy, reticular white lines associated with koebner's phenomena

what is the treatment of lichen planus

high potency topical steroids
antihistamines
systemic steroids in severe cases

What causes tinea infections

trichophyton
Microsporum fungi

cruris: heat and humidity with poor hygiene

Pedis: heat and humidity, contact with contaminated floor

Describe different tinea infections

Capitus: scalp, scaly patches with black dots, kerion (inflammatory plaque with pustules and thick crusting, rxn to fungal infection)

Corporis: annular, scaly lesions with raised borders with central clearing

cruris: groin and inner thighs, well marginated, erythematous plaques in folds, pruritis

pedis: Erythema, scale, pruritis, may have vesicular or pustular lesions, or fissures on feet and between toes

unguium: thickened nails with debris, discoloration

Describe treatment of tinea infections

unguium and Capetis: oral griseofulvin

pedis, cruris, corporis: topical antifungals (clotrimazole, terbinafine), systemic only if severe, powders, good hygiene

Describe tinea versicolor and its cause

cause overgrowth of malassezia yeast

hyop/hyperpigmentated round lesions that do not tan, fine scale. usually on chest and back

how to treat tinea versicolor

topical antifungals: pyrithione zinc shampoo (head and shoulders), selenum sulfide (selsun) ketoconazole 2%, clotrimazole

oral antifungals if severe/widespread: itraconazole, ketoconazole

how to diagnose tinea versicolor

clinical

woods lamp: fluoresce yellow-orange or blue-green

KOH prep: spaghetti and meatballs- hyphae and spores

differentiate erythrasma and intertrigo

Erythrasma: chronic bacterial, in skin folds, coral red fluorescence (Wood's lamp), hyperpigmentation


Intertrigo: W/ Candidal infection if: satellite papules/pustules; in skin folds

tinea crurus: well marginated erythematous plaques, spaghetti and meatballs on KOH

Diagnostics of tinea capitus

KOH: slender filaments that look like tree branches or streaks

Woods lamp: green tint if microsporum, trichophyton does not fluoresce

differentiate SJS vs TEN

SJS: desquamation/sloughing

what causes SJS/TEN

medications: antibiotics, NSAIDs, anticonvulsants, infection, idiopathic

describe SJS/TEN

erythematous macules, bullae, erosions, desquamation

prodrome of fever, malaise, cough, HA, conjunctivitis 1-3 weeks after exposure, followed by skin lesions 1-3 days

may demonstrate Nikolsky sign: skin sloughing at gentle touch

what is the treatment of SJS/TEN

STAT derm referral and skin bx
d/c offending medication
ICU, wound care, pain meds

what rash is a rapid eruption of erythmatous, edematous, raised, pruritic, blanching wheals of various shapes, sizes, and evanescence. dermatographism

ranging from itchy to anaphylaxis

urticaria

what is the treatment of urticaria

antihistamines
epinepherine IM if anaphylaxis
avoid known triggers

describe a verruca vulgaris and what causes them

cause: HPV

filiform, flat, cauliform hyperkeratotic, black dots when shaved

how are warts treated

self resolve without treatment
destruction with salicylic acid, cryotherapy, cantharidin, TCA, duct tape occlusion, imiquimod

MCO of acute otitis media

H flu
Strep pneumo
Morexella cararrhalis

what is the presentation of acute otitis media

rapid onset ear pain commonly preceded by viral URI (fever, HA, rhinorrhea, postnasal drip, cough), ear tugging, N/V

red bulging TM, purulent effusion, dull light reflex, absent or decreased mobility on pneumatic otoscopy

lymphadenopathy, conjunctivitis is H flu

what is the treatment of acute otitis media

immediate treatment for children

what are complications of acute otitis media

Acute mastoiditis: mastoid inflammation or infection

Choleasteatoma: overgrowth of squamous epithelium in middle ear and mastoid air cells destroying ossicles

describe presentation of viral vs bacterial pharyngitis

Viral: slower onset sore thorat, cough, hoarseness, rhinorrhea, sinus congestion, ear pain, fever, conjunctivitis, pharyngeal edema, tonsillar exudate, cervical adenopathy, fever

bacterial: rapid onset sore throat with dysphagia, fever, lack cough and URI sx, bilateral tonsillar erythema and edema, tender cervical adenopathy, sandpaper rash, palatal petechia

Describe the centor criteria

testing for bacterial pharyngitis (strep throat)

- fever >38C/100.4F
- Tonsillar exudates
- Lymphadenopathy
- No cough
-

Treatment of viral vs bacterial pharyngitis

Viral: supportive care

bacterial: amoxicillin, supportive care

when to get tonsillectomy?

consider in kids >3 episodes in each 3 years, >5 episodes in each of 2 years, and >7 episodes in one year

what are complications of acute bacterial pharyngitis

rheumatic fever: autoimmune response to strep, inflammation- myocarditis, endocardiits, valvulitis, joint pain, muscle pain, movement disorders, tissue changes

PANDAS: pediatric autoimmune neuropsychiatric disorders. seen in kids with OCD or tic disorders

peritonsillar abscess, poststreptotoccal glomerulonephritis

describe types of sinusitis

Allergic: most common, IgE-mediated
+/- allergy testing

Non-allergic rhinits: malignancy, pregnancy, vasomotor, mediation-induced, atrophic
Usually seen later in age

Vasomotor rhinitis: non-allergic & non-infectious dilation of blood vessels (ex. temperature change, strong smells, humidity)

**Rhinits medicamentosa: caused by overusing nasal decongestants, leading to a rebound affect
""addicted to nasal sprays"" (ex. Affrin)

Symptoms of allergic vs non-allergic sinusitis

Allergic: pale nasal mucosa due to infiltration of area with eosinophils
May have ""allergic shiner"" (purple discoloration around eyes or nasal bridge)
May have nasal polyps with cobblestone mucosa of conjunctiva
Swollen/red turbinates

Non-allergic: absence of nasal or ocular itching & prominent sneezing
Red turbinates
Nasal congestion & post nasal drainage are prominent
May have year-round symptoms

treatment of acute sinusitis

oral antihistamines, nasal antihistamines, nasal corticosteroids

MCO of rhinitis

almost always viral- rhinovirus, influenza, parainfluenza

If bacterial: strep pneumoniae

What are signs of bacterial rhinitis and not viral

onset of persistent sx >10 days
severe symptoms or high fever >102F
purulent drainage lasting 3-4 days

worsening symptoms or signs characterized by new onset of fever, headache, increased nasal drainage following URI that lasted 5-6 days and were initially improving "double sickening"

what are symptoms of rhinitis

nasal inflammation and obstruction
discolored nasal drainage
absent transillumination of sinuses
tenderness over sinuses

what is the treatment of viral vs bacterial rhinitis

viral: supportive care

bacterial: augmentin 10-14d if sx present 10-14d and worsening

switch to quinolones if no improvement after 3-5 days
CT if still no improvement

what are possible complications of rhinitis

orbital cellulitis, abscess formation, mucocele formation, cavernous sinus thrombosis, osteomyelitis, otitis media

MCO of viral vs bacterial conjunctivitis

viral: adenovirus

bacterial: strep pneumo, H. flu, Moraxella catarrhalis, staph aureus

symptoms of viral conjunctivitis

red conjunctiva, watery or mucoserous discharge, gritty pain, burning, or irritation. assoc. with pharyngitis, fever, cough, body aches

cobblestoning of conjunctiva

absence of purulent discharge, pain with EOM, swelling around eye, foreign body sensation

what diagnostics are done for conjunctivitis

fluorescein stain to r/o corneal abrasion

what is the treatment of viral vs bacterial vs allergic conjunctivitis

viral: self limiting, wash hands, antihistamine drops

bacterial: abx drops- erythromycin, trimethoprim-polymyxin B, cipro if contact wearer, return to school after drainage resolves or 24hrs after abx

allergic: antihistamine eyedrops

what are symptoms of bacterial conjunctivitis

purulent discharge- green, white, yellow, thick and globby

copious discharge, conjunctival erythema with no ciliary injection

what are symptoms of allergic conjunctivitis

itching, bilateral erythema and watery discharge, chemosis, allergic shinners

Describe opthalmia neonatorum (neonatal conjunctivitis)

discharge, redness, swelling
chemical: day 1 after birth from silver nitrate
gonococcal: purulent conjunctivitis with exudate and swelling of lids around 2-5 days after birth
chlamydia seen around days 5-7 after birth

how is opthalmia neonatorum diagnosed

clinical dx
culture with gram stain and PCT

how is opthalmia neonatorum treated

erythromycin eye ointment
HSV: ganciclovir gel
severe and dont suspect HSV- topical corticosteroids (lotepredenol)

MCO of epiglottitis

who is it typically seen in

H flu B (vaccine mostly prevents it)

children 2-4 but now seeing in older kids

symptoms of epiglotitis

rapid onset stridor, difficulty swallowing, muffled voice, sore throat, pain with neck palpation
drooling, dysphagia, distress, tripoding

Dx: laryngoscopy showing red and swollen epiglottis, lateral neck xray with thumbprint sign

how is epiglotitis treated

immediate referral to ED
ICU admit needed to manage airway, intubate and antibiotics

Ceftriaxone

describe anterior vs posterior epistaxis

anterior: kiesselbach plexus, from one nostril when sitting/standing, nose picking, drug use, dry air, allergic rhinitis

posterior: blood flows down back of throat, due to malignancy, anticoagulation, aneurysm, bleeding disorder

what is the treatment of epistaxis

vasoconstrictor: alpha-1 adrenergic receptor agonsit

pressure on bridge of nose with icepack

elevate head

nasal packing- rhinorocket removed by ENT

chemical/electrical cautery only if source can be visualized

symptoms of mastoiditis

fever
postauricular tenderness
erythema
bulging tympanic membrane
protrusion of auricle

how is mastoiditis diagnosed

CT with contrast showing fluid in mastoid air cell

how is mastoiditis treated

middle ear drainage via myrinotomy
IV abx: vancomycin and ceftriaxone
if suspect pseudomonas: cefepime or zosyn
if complicated: surgical removal of mastoid bone

difference between periorbital and orbital cellulitis symptoms

periorbital: unilateral ocular pain, red and swollen eyelid, mild fever, inability to open eye, no changes in EOM or visual acuity, no proptosis, no chemosis

orbital: ocular pain, eyelid swelling, systemically ill with fever, pain with EOM, proptosis, chemosis, vision loss, nasal drainage, tenderness

diagnosis of periorbital vs orbital cellulitis

CT

cause of periorbital vs orbital cellulitis

periorbital: secondary to another infection, sinus infection MC with staph or S. pyogenes, insect or animal bite

orbital: complication of rhinosinusitis- strep

treatment of periorbital vs orbital cellulitis

periorbital: oral abx, close follow up in 24hrs, if no improvement consider orbital cellulitis

orbital cellulitis: immediate referral to ED, need IV abx, consider surgery