My Peds EOR Set

simple:

• generalized seizure

• lasts <15 min

• do not recur in 24hr period

• quickly return to baseline

complex:

• focal onset

• 15min seizure

• recurrent within 24hr

• hemiparesis following seizure (Todd's paralysis)

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

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"

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"

Frontoparietal scalp recession and vertex thinning

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

genetics DHT (dihydrotestosterone) hormones age

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

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

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

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

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

candida: nystatin

perioral dermatitis

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

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

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%

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

drug eruption

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

stop offending agent antihistamines

erythema multiforme

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

type 4 sensitivity reaction HSV usually

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

varicella/chicken pox

herpes zoster

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

measles/Rubeola

rubella (rubella virus)

Roseola

HHV-6

parvovirus B19

erythema infectiosum/fifth disease

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

pox virus

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

strep and staph (MRSA included)

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

topical mupirocin ointment

oral keflex if widespread of bullous

if MRSA: bactrim

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

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

body: good hygiene, wash clothes

pubic: permethrin cream, treat sexual contacts, wash clothes

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

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

antihistamines, topical corticosteroids for pruritis

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

self limiting

topical steroids, camphor, menthol, antihistamines for itch

acyclovir if severe

lichen planus

lichen planus

planar, purple, polygonal, pruritic, papules, plaques

flexor surfaces of wrists, forearms, legs, inside mouth

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

high potency topical steroids antihistamines systemic steroids in severe cases

trichophyton Microsporum fungi

cruris: heat and humidity with poor hygiene

Pedis: heat and humidity, contact with contaminated floor

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

unguium and Capetis: oral griseofulvin

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

cause overgrowth of malassezia yeast

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

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

oral antifungals if severe/widespread: itraconazole, ketoconazole

clinical

woods lamp: fluoresce yellow-orange or blue-green

KOH prep: spaghetti and meatballs- hyphae and spores

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

KOH: slender filaments that look like tree branches or streaks

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

medications: antibiotics, NSAIDs, anticonvulsants, infection, idiopathic

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

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

urticaria

antihistamines epinepherine IM if anaphylaxis avoid known triggers

cause: HPV

filiform, flat, cauliform hyperkeratotic, black dots when shaved

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

H flu Strep pneumo Morexella cararrhalis

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

Acute mastoiditis: mastoid inflammation or infection

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

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

testing for bacterial pharyngitis (strep throat)

• fever >38C/100.4F

• Tonsillar exudates

• Lymphadenopathy

• No cough

• <15yo +1

• 44yo -1 16-44 0

2 points swab them

if negative and still suspect, get throat culture

Viral: supportive care

bacterial: amoxicillin, supportive care

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

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

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)

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

oral antihistamines, nasal antihistamines, nasal corticosteroids

almost always viral- rhinovirus, influenza, parainfluenza

If bacterial: strep pneumoniae

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"

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

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

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

viral: adenovirus

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

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

fluorescein stain to r/o corneal abrasion

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

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

copious discharge, conjunctival erythema with no ciliary injection

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

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

clinical dx culture with gram stain and PCT

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

H flu B (vaccine mostly prevents it)

children 2-4 but now seeing in older kids

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

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

Ceftriaxone

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

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

fever postauricular tenderness erythema bulging tympanic membrane protrusion of auricle

CT with contrast showing fluid in mastoid air cell

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

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

CT

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

orbital: complication of rhinosinusitis- strep

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