Ophthalmology, ENT (ENDOFFCWEIRD?)

retinoblastoma

white pupillary reflex is concerning for

S. pneumoniae (gram pos)

H. flu, M. Catarrhalis (gram neg)

main bugs causing acute otitis medida

Diagnosed clinically through physical exam and pneumatic insufflation (blowing in ear, watch tympanic membrane for change in size

how do you diagnose acute otitis medida

amoxicillin 1st line. If recurrent amox-clav

-if penicillin allergy use cephalosporin

treatment of acute otitis media

-more than 3 cases of AOM in 6 months or 4 in a year

indication for tympanoplasty

inhibition of transpetidase

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_{β-lactam antibiotic that inhibits bacterial cell wall synthesis.}

_MOA:

1. _{Binds penicillin-binding proteins (PBPs)}

2. _{Blocks peptidoglycan cross-linking in the bacterial cell wall}

3. _{Causes cell wall weakening → bacterial lysis (death)}

MOA of amoxicillin

Amoxicillin/Clavulanate

tx for otitis media with concomitant purulent conjunctivitis

C: +1 for absent cough

E: +1 for tonsillar exudate

N: +1 for neck tender anterior lymphadenopathy

T: +1 for temperature (>100.4)

O: -1 over 45 and +1 under 15

R: remember to score

_{<= 1: supportive care}

_{2-3 rapid strep test}

_{>4 treat with abx}

Centor Criteria (Modified/McIsaac Score) ⭐

Purpose: Predicts likelihood of Group A Streptococcus (GAS) pharyngitis and helps determine whether to test/treat.

Centor Criteria

to determine whether need for abx for streptococcal pharyngitis

1) fever (> 100.4)

2) pharyngotonsillar exudate

3) tender ANTERIOR cervical lymphadenopathy

4) absence of cough

if GAS: amox-clav, if viral then supportive care. Avoid aspirin.

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viral causes of pharngitis:

• Rhinovirus — common cold; sore throat + rhinorrhea/cough

• Adenovirus — pharyngitis + conjunctivitis + fever

• Influenza — fever + myalgias + headache + cough

• Parainfluenza — may cause croup with barking cough/stridor

• EBV — infectious mononucleosis

  • Posterior cervical lymphadenopathy

  • Tonsillar exudates

  • Fatigue

  • Splenomegaly

• CMV — mono-like illness, usually less prominent pharyngitis

• Enteroviruses (Coxsackievirus)

  • Herpangina → posterior oral vesicles/ulcers

  • Hand-foot-mouth disease → oral lesions + hand/foot rash

• HSV — painful oral vesicles/ulcers + gingivostomatitis

• COVID-19 (SARS-CoV-2) — sore throat ± cough/fever/congestion

treatment of group A strep / viral causes

-scarlet fever

-acute rheumatic fever

-PSGN (can occur even with treatment)

complications of untreated GAS

scarlet fever

blanching, sandpaper rash, strawberry tongue, treated with abx

-hx of pharyngitis

Major Criteria — J♥NES

• J = Joints → migratory polyarthritis

• ♥ = Carditis → especially mitral valve involvement

• N = Nodules → subcutaneous nodules

• E = Erythema marginatum

• S = Sydenham chorea

Minor Criteria

• Fever

• Arthralgia

• ↑ ESR/CRP

• Prolonged PR interval on ECG

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  2 major
  OR
  1 major + 2 minor

Jones criteria for acute rheumatic fever

rhinovirus » adenovirus

most common viral causes of pharyngitis

Post-Strep Glomerulonephritis (PSGN)

peripheral and periorbital edema, tea/cola colored urine, HTN. Supportive care

hx of strep pharyngitis

concomitant rhinorrhea (runny congested nose), cough, hoarseness, diarrhea, oropharyngeal vesicles, and/or absence of fever

viral etiology of of pharyngitis is usually associated with

tonsillar hypertrophy of:

>7 episodes in 1 year,

>5 episodes per year for 2 years,

>3 episodes per year for 3 years.

_{If pt has sleep disordered breathing it should also be strongly considered.}

indications for tonsillectomy

the Mallampati score is a scoring system of

abx (oral or drops)

artificial tears, NSAIDs, cool compress

First-line	Antibiotic
⭐ First-line	Erythromycin ophthalmic ointment
Alternative	Trimethoprim-polymyxin B ophthalmic drops
Contact lens wearers / concern for Pseudomonas	Fluoroquinolone drops (e.g., ciprofloxacin, ofloxacin, moxifloxacin)

treatment of bacterial conjunctivitis

NSAIDs

steroid eye drops

artificial tears, cool compress, antiviral med

treatment of viral conjunctivitis

Bacterial conjunctivitis

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Most common bacteria in children:

• Haemophilus influenzae

• Streptococcus pneumoniae

• Moraxella catarrhalis

• Staphylococcus aureus — more common in older children/adults

High-yield special cases

• Neisseria gonorrhoeae → severe purulent conjunctivitis, especially neonates; can damage the cornea

• Chlamydia trachomatis → neonatal conjunctivitis, classically 5–14 days after birth

+purulent eye discharge

+ redness

+/- light sensitivity

Viral conjunctivitis

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• Adenovirus — most common

• Enterovirus

• Coxsackievirus

• HSV

• VZV

+ eye redness

+ swollen lymph hnondes near the ear

Epistaxis, pain, irritation, new onset snoring, unilateral nare obstruction, chronic sinusitis, etc

presentation of nasal foregn body

bronchiolitis (RSV).

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Finding	Description
⭐ Hyperinflation	Increased lung volumes from air trapping
⭐ Flattened diaphragms	Due to lung overexpansion
Peribronchial thickening/cuffing	Thickened bronchial walls from inflammation
Increased interstitial markings	Prominent perihilar markings
Atelectasis	Patchy areas of collapse (common)
Normal CXR	Can occur

Infant + wheezing + URI symptoms + CXR showing hyperinflation →

CXR of community acquired pneumonia

dx?

doxycycline or azithromycin or levofloxacin

empiric treatment of uncomplicated CAP

Levofloxacin, Moxifloxacin OR ceft + azithromycin

empiric treatment of hospitalized CAP

zosyn with levofloxacin

treatment for pseudomonas suspected pneumonia

S. pneumoniae

most common cause of CAP

S. pneumoniae

pneumonia associated with rust colored sputum

H. influenzae

-aerobic gram - coccobacillus

-pneumonia with this bacteria is more common pts with COPD

ceftriaxone or levofloxacin (they can produce beta lactamase)

treatment of H. flu pneumonia

Moraxella pneumonia CAP

-gram negative diplococci

-CXR: patcy infiltrate

S. pneumo, H. influenzae, M. catarrhalis

main bacteria associated with typical lobar pneumonia

mycoplasma, chlamydia, legionella

main bacteria associated with atypical pneumonia

Mycoplasma pneumoniae

-walking pneumonia type most common in pts under 40

-may be associatedd with earache, erythema multiforme

-gram stain is usueless (no cell wall)

Chlamydia pneumoniae

-more common cause of walkin pneumonia in those over 65

Legionnaire's disease

-cause of walking pneumonina that can alsso reesult in diarrhea, hyponatremia, hematuria

-urinary antigen

S. aureus

-produces proteases that can cause bronchopneumonia--> necrotizing pneumonia---> lung abscess or empyema

CURB-65

confusion, urea, high RR, low BP< age over 65

Point scoring system used for evaluating the risk of mortality with pneumonia

Staph aureus, gram negative rods, mycoplasma, chlamydia, viral

most common organisms of bronchopneumonia

bronchopneumonia

infiltrates are patchy and involves multiple areas of the lung

influenza, CMV, pneumococcal pneumonia, miliary TB

main pathogens of interstitial pneumonia

interstitial pneumonia

abnormal lung condition with increased fluid between the alveoli and a decrease in lung function

chemical pneumonitis

bronchial obstrucction secondary to aspiration

bacterial aspiratin pneumonia

main syndromes of consequence of aspiration

superior segment of lower lobbe

with patient lying on back, aspiration occurs where?

dysphagia and an infiltrate

aspiration pneumonia should be considered in the ddx for any pt with

-catarrhal: non-specific low grade fever and nasal secretions for 1-2 weeks

-paroxysmal: lasts 2-4 wks, cyanosis, apnea and choking; between fits children appear well and are afebrile

-convalescent stage: gradual resolution of symptoms in 1-2 wks

what are the 3 stages of pertussis?

-azithromycin, clarithromycin, erythromycin

-post-exposure propphylaxis

-under 7 years give macrolide and booster DTap if last dose was more than 3 yrs ago; greater than 7 y/o give macrolide andd TDap

tx of pertussis

2, 4, 6, 15 months and between 4-6 yrs

when is DTaP vaccine given

at 11 years and every 10 years after that

when is Tdap iven

-given in 27-36 wk gestation age

-indicated in each pregnancy even if the woman has a previous hx of vaccination, and even if consecutive pregnancies occur within 12 months

when to give Tdap in pregnancy

Kawasaki disease

-wide spread inflammation of medium and small blood vessels

-most common vascuulitis in children, usuallly under 5

-fever unresponsive to antipyretics

-bilateral conjunctival injection

-strawberry tongue

-erythema of palms or soles

-polymorphous rash

-cervical lymphaddenopathy

main featuress of Kawasaki's

-aspirin and IV Ig reduces risk of aneurysm formation

-steroids used in pts who fafil to respond

treatment of kawasaki's

coronary artery aneuryssm

primary complication associated with kawasaki's

ceftriaxone

treatment of N. meningitis

group B strep

gram negative bacilli

strep pneumo

N. meningitidis

most common agents of meningitis in thosse undr 3 months

S pneumo

N meningitis

Group B strep

gram negative bacilli

most common agents of meningitis in ages 3 months to 3 years

S pneumo and N meningitidis

most common cause of meningitis ffrom ages 3-10

-virus infects epithelial cells, retrogradde transports to sensory ganglia

-latent infection

-reactivation leadds to anterograde axonal transport to epithelial cells

describe the pathogenesis of herpes simplex virus

gingiviostomatitis with local lymphaenopathy

-systemic symptoms

signs of primary HSV infection

Herpes gingivostomatitis

-cold sores in the mouth, usually in children (HSV-1)

-represents initial infection that recurs as fever blisters

Herpes gladiatorum

A skin infection caused by the herpes simplex type 1 virus and seen among athletes participating in contact sports

-initiate antiviral treatment within 48-72 hours of symptom onset (acyclovir)

treatment of HSV

paramyxovirus

etiology of measles (rubeola)

-incubation 8-12 days

-prodrome: cough, fever, koplik spots, coryza, conjunctivitis

-exanthematous phase: maculopapular rash starting on face down

-recovery over 7-10 days

describe the 4 phases of measles

pneumonia

most common cause of measles associated death

-encephalitis

-acute disseminated encephalomyelitiss

-subacute sclerosing panencephalitis

neurologic complications of measle

matonviridae family

etiology of rubella

rubella

a viral infection characterized by a low-grade fever, swollen glands, inflamed eyes, and a fine, pink rash

prodrome: malaise, low grade fever

exanthem: maculopapular rash that begins on head and trunk and spreads to extremities, lasts 3-7 days

enanthem

presentation of varicella

24-48 hrs before rash appears and until all lesions have crusted over

when is varicella contagious

must have lesions in all 3 stages: erythematous macule/papule, vesicle, andd crusted lesion

how do you make a clinical diagnosis of varicella

coxsackie A virus (enterovirus)

etiology off hand-foot mouth dx

Hand-foot-mouth disease

fever, mouth pain, ulcerations on tongue and sofftpalate, +/- vesicular rashh on hands and feet

Herpesvirus 6 and 7

etiology of Roseola infantum

Roseola

-abrupt onset of high fever

-appearance of rash when fever resolves: generalized blanchable, maculopapular rash

1) slapped cheek appearance

2) macular erythema on trunk

3) lacy appearance to rash

spares hands/feet

what are the 3 stages of the exanthem in Erythema infectiosum (fifths disease)