NR 602 MIDTERM STUDY GUIDE EXAM

NR 602 MIDTERM STUDY GUIDE TOPICS Covered o Chalazions o Blepharitis o Conjunctivitis o Hand-foot-mouth syndrome o Strep pharyngitis o Kawasaki disease o Rheumatic fever o Milia o Port-wine stain/Nevus flammeus o Salmon patch o Café-au lait spot o Impetigo o Molluscum Contagiosum o Verruca Vulgaris o Herpetic Whitlow CHALAZIONS – Benign, chronic lipogranulomatous inflammation of the eyelid Causes – blockage of the meibomian cyst Risk – hordeolum or any condition which may impede flow through the meibomian gland. Also mite species that reside in lash follicles Assessment – PAINLESS, NOT INVOLVING LASHES Lid edema, or palpable mass Red or grey mass on the inner aspect of lid margin Prevention – good eye hygiene Treatment – warm, moist compresses 3x per day Antibiotics not indicated because chalazion is granulomatous condition, if secondarily infected consider SULFACETAMIDE, ERYTHROMYCIN Follow up – 2-4 weeks, if still present after 6 weeks follow up with ophthalmologist BLEPHARITIS – Inflamation/infection of the lid margins (chronic problem) 2 types – seborrheic (non ulcerative) : irritants (smoke, make up, chemicals) s&s – chronic inflammation of the eyelid, erythema, greasy scaling of anterior eyelid, loss of eyelashes, seborrhea dermatitis of eyebrows and scalp Ulcerative- infection with staphylococcus or streptococcus s&s – itching, tearing, recurrent styes, chalazia, photophobia, small ulceration at eyelid margin, broken or absent eyelashes • the most frequent complaint is ongoing eye irritation and conjunctiva redness Treatment – clean with baby shampoo 2-4 times a day, warm compresses, lid massage (right after warm compress) For infected eyelids – antistaphyloccocal antibiotics BACITRACIN, ERYTHROMYCIN 0.05% for 1 week AND QUIONOLONE OINTMENTS For infection resistant to topical – TETRACYCLINE 250 MG PO X4 DOXYCYCLINE 100 MG PO X2 CONJUCTIVITIS – inflammation or irritation of conjuctiva Bacterial (PINK EYE) – in peds bacteria is the mosts common cause, contact lens, rubbing eyes, trauma, S&S – purulent exudate, initially unilateral, then bilateral Sensation of having foreign body in the eye is common Key findings – redness, yellow green, puru,ent discharge, crust and matted eyelids in am Self limiting 5-7 days. Eye drops – polytrim, erythromycin, tobramycin or cipro Improvement 2-4 days Most common organism H. influenza <7 Viral – adenovirus, coxsackie virus, herpes, molluscum S&S – profuse tearing, mucous discharge, burning, concurrent URI, enlarged or tender preauricular nose Antihistamines/decongestant Improvement, self limiting, 7-14 days Chlamydial – chlamydia trachomatis S&S – profuse exudate, associated with genitourinary symptoms, 1-2 weeks after birth Gonococcal – 2-4 days after birth, most concern can cause blidness PO azithromycin, doxycycline (tetracyclines increase photosensitivity, don’t use in pregnancy) Improvement 2-3 weeks Allergic – IgE mast cell reaction, environmental, cosmetics S&S – marked conjuctival edema, severe itching, tearing, sneezing Topical antihistamine or topical steroids Improvement 2-3 days Chemical –thimerosal, erythromycin, silver nitrate S&S conjuctival erythema, 30 minutes afer prophylactic antibiotics drops Avoid contact Can consider steroids Conjunctivitis never accompany vision changes Diagnostic studies: swap and scraping must be done, gram and Giemsa staining, ELISA, PCR testing, newborn < 2 weeks needs to be tested for gonorrhea Non –pharm – clean towels, change pillows, warm compress, no contacts, no eye make up – mascara Gonococcal conjunctivitis: newborn – give Ceftriaaxone IM once (don’t give if hyperbilirubinemia, Non-gonococcal – erythromycin 0.5% ointment Consider fluorescein staining if abrasion suspected CDC recommends prophylactic administration of antibiotic eye ointment (ERYTHROMYCIN) 1 hour after delivery Refer to ophthalmologist if herpes, hemorrhagic conjunctivitis or ulcerations present May return to work/school 24 hours after topical HAND-FOOT-AND-MOUTH DISEASE – HIGHLY CONTAGIOUS, viral illness clinical entity evidenced by fever, vesicular eruptions in the oropharynx that may ulcerate and a maculopapular rash involving hands and feet, the rash evolves to vesicles, especially on the dorsa of the hands and feet. Last 1 to 2 weeks. lesions appear on the buccal mucosa, palate, palms of hands, soles of feet and buttocs most common cause – COXSACKIE A 16 common in children <5 S&S – low grade fever, malaise, abdominal pain, enlarged anterior cervical nodes or submandibular Oral – small red papules on the tongue and buccal mucosa, which will progress to ulcerative vesicles EXANTHEM (papulovesicular) – occurs 1-2 days after oral lesions Differential – herpangina, Stevens- Johnson syndrome Treatment – maintain hydration, cool liquids, avoid spicy food, rest Topical aluminum hydroxide/ magnesium hydroxide gel with diphenhydramine applied to painful lesions Topical anesthetics – Kank A, Orabase Resolution with 7 days STREP PHARYNGITIS – An acute inflammation of pharynx/tonsils, associated with crowding (school) rare in children <3 Viral – rhinovirus, adenovirus, parainfluenza, Epstein-barr virus Bacterial- group A beta hemolytic streptococcus Risk – family hx of rheumatic fever, day care S&S – sore throat, tonsillar exidate, malaise Strep: cervical adenopathy, fever >102F, no cough or nasal congestion, petechiae on soft palate, “Beefy Red” tonsils, “sandpaper” rash (nose, neck and torso), abdominal pain, headache Suggestive of viral : conjunctivitis, nasal congestion, cough, diarrhea When cough - almost always exclude Streptococcus Tests – rapid strep test CBC: WBC shift to left Monospot if mono suspected Treatment: gargling with salt water, change toothbrush, incubation period 2-5 days PCN – one IM or 10 days treatment PO First generation cephalosporins – 10 days treatment Azithromycin (if PCN allergy) Consult/referral – evidence of acute renal failure and reddish, tea collared urine (2- 3 weeks post infection) No longer contagious after 24 hours on antibiotics, peak fever on days 2and 3, last 4-10 days KAWASAKI DISEASE (also known as mucocutaneous lymph nodesyndrome or infantile polyarteritis– an acute, febrile, immune-medicated, self-limited disease characterized by vasculitis. Leading cause of acquired heart disease in children 85% <5 years old most prevalent in Japan S&S Stage 1 -Acute (1-2 weeks) – high fever 103-105 for at least 5 days unresponsive to antibiotics, oral mucosa lesions may last 1-2 weeks, perineal rash, non-tender cervical adenopathy, painful rash and edema on feet Diagnosis requires fever for 5 days and 4 of these criteria: Edema or erythema of hands and feet, conjuctival injection (bilat), cervical adenopathy, rash (non-vesicular and polymorphous), exudative pharyngitis, diffuse oral arythema, STRAWBERRY TONGUE, crusting of lips and mouth Stage 2 - Subacute (2-8 weeks after onset) – without treatment: desquamation of palms, feet, periungual area, coronary artery aneurysm, joint aches and pains, acute MI may be seen, Pancardidis, diarrhea, jaundice, hepatosplenomagaly, platelet couns >10, 000 000 per mm Stage 3 – Convalescent – clinical signs have resolved, completed when all lab values are normal, however nail changes include Beau lines (deep transverse grooves across the nails) It is a fatal disease in small % of children who develop coronary artery problems despite treatment Differentials: Group A strep: scarlet fever Measles Epstein barr Toxic shock Rocky mountain spotted fever Steven-johnson syndrome Juvenile RA Tests: based on S&S and diff CBC, anemia, platelets 50% > 450 000 ESR >100 C-reactive protein EKG – prolonged PR intervals, decrease QRS Chest Xray – dilated heart, pleural effusion Pyuria/mild proteinuria Pharmacology IVIG single dose of 2g/kg for over 12 hours in the first 10 days Aspirin 80-100 mg/kg/d in 4 doses (Reye’s syndrome) Complications MI Development and rupture of coronary artery aneurysm may lead to emboli, HF, heart valve problems, dysrhythmias, myocarditis RHEUMATIC FEVER – An inflammatory disease that develops in 1-3% of children who have untreated infection with group A strep (GAS). This can affect the heart, blood vessels, joints , skin, CNS, connective tissues S&S – hx of pharyngitis 2-4 weeks prior onset of symptoms. Modified Jones criteria used to diagnose patient: 2 major, or 1 major and 2 minor criteria must be presented as evidence Major – carditis: 65% have with murmurs Polyarthritis:75% Chorea: 15% Erythema marginatum (macular rash with erythematous border Subcutaneous nodules Minor Fever 101-104F Artharlgias Elevated ESR, C-reactive protein Prolonged PR intervals on EKG Tests: throat cultures, negative antigen test ESR, C-reactive protein ASO tites EKG Chest xray CBC Treatment: first line PCN, if allergic Azithromycin Prednisone Aspirin AHA 2010 no longer recommends prophylaxis treatment for endocarditis in those with rheumatic fever PEDIATRIC BENIGN SKIN LESIONS MILIA (superficials cysts filled with keratin) – white papules found on the forehead, face, chin, and cheeks of infants, 1-2 mm in size, disappear few weeks after birth, may appear on palate – EPSTEIN’S PEARLS’S PORT-WINE STAIN (Nevus flammeus) – permanent defect that grows with child, if forehead and eyelids are involved, there is potential for multiple symptoms, includidng Sturge-Weber, Klippel-Trenaunay-Weber and Parkes Weber. Flat port wine stain- dark red to deep purple lesions present at birth, frequently found on face, do not fade with time SALMON PATCH – fade with time, usually by 5 or 6 years old, no treatment needed. Salmon patches (called a "stork bite" at the back of the neck or an "angel's kiss" between the eyes) are simple nests of blood vessels (probably caused by maternal hormones) that fade on their own after a few weeks or months. Occasionally stork bites never go away. CAFÉ AU LAIT SPOT – smooth, regular borders, Child > 5, 6 or more , >1.5 cm - possible Von Recklinghausen’s disease (90 -100%) *LEOPARD syndrome (Lentigines, Electrographic abnormalities, Ocular hypertelorism, Pulmonary stenosis, Abnormalities of genitalia, Retardation of growth, Deafness In child <5 years, 5 or more , 0.5 cm suggests neurofibromatosis Smaller 1-4 cm in diameter I axillae ( axillary freckling or Crow’s sign) rare but diagnostic sign of neurofibromatosis