Common Illnesses 

Conjunctivitis 

Needs Photo

Most common eye disease, most cases due to bacterial infection. 

This infection can also be caused by viruses and allergy or chemicals. This condition is an inflammation over the posterior surface of the lid and up over the sclera to the cornea. 

Signs and symptoms include: 

• Inflammation, redness and irritation 
• No photophobia 
• Purulent discharge (bacterial) 
• Copious purulent discharge (gonococcal) 

• Bilateral tearing with stringy discharge (allergic 
• Copious watery discharge (viral) 
• Mild discomfort 

Focused History 

• Onset and progression 

• Age 
• Environment 
• Season 
• Daycare 
• Exposures—family & friends with similar signs & symptoms 

• Does the child have juvenile rheumatoid arthritis 
• Neonate 
• Parent history of STD 
• Maternal history of vaginal discharge 

Physical Exam 

• Nature of discharge 
• Clear 
• Watery 
• Mucoid 
• Purulent otitis media often associated with conjunctivitis 

• Head & neck—check for lymphadenopathy 
• Rhinorrhea 
• Congestion 

Differential Diagnosis 

• Trauma 

• Tumors 
• Hordeolum 
• Sinusitis 
• Periorbital cellulitis 
• Preseptal cellulitis 

• Dental abscess 
• Contact dermatitis 

Laboratory/Diagnostics 

• Gram stain and culture 

• It is critical to rule out gonococcal infections because of the destructive nature of this disease 

• Always done for ophthalmia neonatorum 
• Diagnosis is gonococcus if gram-negative intracellular diplococci are observed 

Management 

Type	Discharge	Treatment Considerations
Chemical		Self-limiting  Flushing with normal saline
Bacterial	Purulent	Erythromicin 0.5% ophthalmic ointment  Tetracycline 1%  Polymyxin B ophthalmic solution or ointment
Gonococcal (ophthalmic emergency)	Copious, purulent	IV Pen G or ceftriaxone IM
Chlamydia		Erythromycin ophthalmic ointment  Oral:  Tetracycline, erythromycin, clarithromycin, azithromycin, doxycycline
Allergic	Stringy; increased tearing	Oral antihistamines  Refer to allergist/ophthalmologist  *steroids are not ordered in primary care because of increased intraocular pressure and activation of herpes simplex virus*
Viral	Watery	Symptomatic care  Mild:  Saline drops/artificial tears (cool is best)  Moderate: Decongestants/antihistamines, mast cell stabilizers, NSAIDS  Sulfacetamide 10% ophthalmic solution for bacterial (secondary) prophylaxis
Herpetic	Bright red and irritated	Refer to Ophthalmologist

Table from Barkley & Associates (2016).  Pediatric primary care nurse practitioner: Certification review/clinical update continuing education course.  West Hollywood, CA: Author.  Available from http://www.npcourses.com/    

  

Common HEENT Disorders, continued 

Acute Otitis Media (AOM) 

 NEEDS PHOTO

Bacterial infection of mucosally lined air-containing spaces of temporal bone.   

Causes/Incidence 

• S. pneumonia (gm+ diplococci) 49% 
• H. influenzae (gm- bacillus) 29% 
• M. catarrhalis(gm- cocci) 28% 

• Frequently precipitated by viral URI 
• Also can occur in combination with conjunctivitis 

Signs and Symptoms 

• Mild otalgia for < 48 hours indicates non-severe illness while moderate to severe otalgia indicates severe illness 
• Fever (>102.20F indicates severe illness) 

• Pulling, holding, rubbing at the ears 

Physical Exam 

• Erythematous tympanic membrane (TM) 
• Significantly bulging TM 
• New onset of otorrhea not related to otitis externa 

 NEEDS PHOTO

A, Normal TM. B, TM with mild bulging. C, TM with moderate bulging. D, TM with severe bulging. Courtesy of Alejandro Hoberman, MD. 

Retrieved from http://pediatrics.aappublications.org/content/131/3/e964.figures-only  

Know the Landmarks 

   

Diagnostics 

• Usually clinical diagnosis 
• Pneumatic otoscopy to assess mobility of TM 
• Tympanometry supplements but does not replace pneumatic otoscopy for children older than 6 months of age 
• Tympanocentesis with culture will diagnose organism, if necessary 

Differential diagnosis 

• Otitis externa, otitis media with effusion, sinusitis 
• Mastoiditis, furuncle 
• Eustachian tube dysfunction 
• Dental abscess, impacted teeth, tonsillitis 

 

Management 

 

Pain management is a priority! 

• Acetaminophen and ibuprofen 

• Warm compresses 
• Benzocaine otic drops (limited evidence of effectiveness) 

Watchful waiting for 48-72 hours or prescribe antibiotic therapy 

• Must be able to start antibiotic therapy if child fails to improve or worsens within 48-72 hours 

• 6 months to 2 years 

• Unilateral AOM without otorrhea 

• 2 years or older  

• Bilateral AOM without otorrhea 
• Unilateral AOM without otorrhea 

Antibiotics (oral) first-line treatment 

• Non-severe or severe illness in children less than 6 months, unilateral or bilateral 
• Severe illness in children >6 months, unilateral or bilateral 
• Non-severe illness in children 6-23 months with bilateral AOM   
• Amoxicillin 80-90 mg/kg/day BID for 10 days or 
• Amoxicillin-clavulanate (amoxicillin 90mg/kg/day and clavulanate 6.4 mg/kg/day) BID 

• If PCN allergy:  

• Cefdinir 14mg/kg/day daily or BID 
• Cefuroxime 30mg/kg/day BID 
• Cefpodoxime 10mg/kg/day BID 
• Ceftriaxone 50mg IM or IV daily for 1 or 3 days  

• Failure of initial antibiotics after 48-72 hours: 

• Amoxicillin-clavulanate (amoxicillin 90mg/kg/day and clavulanate 6.4 mg/kg/day) BID 
• Ceftriaxone 50mg IM/IV for 3 days 

• Length of therapy 

• <2 years of age 10 days 

• 2-6 years of age    7 days 
• >6 years of age 5-7 days 

Prevention 

• Vaccinations 

• HIB 

• PCV13 
• Annual influenza 

• Avoid second-hand smoke  

Retrieved from:  

Lieberthal, a. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, Al, Jackson, M. A., Joffe, M. D., Miller, D.,…Tunkel, D. E.  (2013). The diagnosis and management of acute otitis media.  Pediatrics, 131 (3).  Retrieved from http://pediatrics.aappublications.org/content/131/3/e964   

Otitis Media with Effusion (OME) 

OME is defined as fluid in the middle ear without signs or symptoms of ear infection.  Fluid in the middle ear decreases TM and middle ear function, leading to conductive hear loss, fullness in the ear, and occasional pain from the pressure changes.  Occurs frequently in children.   

Managed with watchful waiting; most episodes of OME resolve within 3 months but a small percentage last more than a year.  Over a third of children have recurrence of OME.  It is unclear if OME has long-term effects on speech and language. Current guidelines do not recommend routinely treating children with antibiotics for OME. 

Source: 

Wallace, I. F., Berkman, N. D., Lohr, K. N., Harrison, M. F., Kimple, A. J., & Steiner, M. J. (2014).  Surgical treatments for otitis media with effusion:  A systematic review.  Pediatrics, 133 (2).  Retrieved from http://pediatrics.aappublications.org/content/133/2/296  

Pharyngitis 

NEEDS PHOTO

Causes/Incidence 

 

• Viruses (RSV, influenza A and B, Epstein Barr virus) 
• Group A b-hemolytic streptococci 

• Neisseria gonorrhoeae 
• Mycoplasma 
• Chlamydia trachomatis 
• Corynebacterium sp. 

Signs and Symptoms 

• Sore throat 
• Dysphagia 
• Malaise 
• Rhinorrhea (viral) 
• Fever (more pronounced in bacterial infection) 

Physical Exam 

• Erythematous pharynx 
• Exudate (bacterial) 
• Anterior cervical adenopathy (bacterial) 

Modified Centor Criteria   

Criteria may be used to identify the likelihood of a bacterial infection in a patient complaining of a sore throat.  One point for each positive answer.  2-3 points indicates culture and treat if positive.  4-5 points indicates rapid strep and/or culture and treat if positive.  Recommendation is NOT to treat empirically based on symptomatology alone.    

C  absent cough 

E – exudate 

N – nodes 

T – elevated temperature (fever) 

OR – young or old (under 15 years adds point) 

Diagnostics 

 

• Throat culture if suspicious of strep 

Differential Diagnosis 

• Epiglottitis 
• Abscess 

Management 

• Viral 

• OTC analgesics 

• Warm salt-water gargle 
• Hydration 

• GABHS (Strep Throat). A rare complication of untreated strep infection is rheumatic fever which can affect several organs in the body. 

• Penicillin VK 250 mg TID for 10 days 
• If PCN allergic then Erythromycin 250 mg QID for 10 days  

Watch an overview of strep infections: 

Direct link: https://youtu.be/ddkhUbd37RQ  

Common Adolescent Conditions 

Acne Vulgaris 

NEEDS PHOTO

• Polymorphic skin disorder characterized by 

• Comedones (noninflammatory acne) 

• Open: blackheads 
• Closed: whiteheads 

• Papules (inflammatory acne) 

• Pustules (inflammatory acne) 
• Cysts (inflammatory acne) 

• Cause unknown 
• Exacerbated by steroids and anticonvulsants 
• Food is not proven to be contributory 

• More common & severe in males 

Severity	Definition
Mild	<20 comedones  or  <15 inflammatory lesions  or  <30 total lesions
Moderate	20-100 comedones  or  15-50 inflammatory lesions  or  30-125 total lesions

Table retrieved from https://www.merckmanuals.com/professional/dermatologic-disorders/acne-and-related-disorders/acne-vulgaris  

Signs and Symptoms 

• Occurs primarily on the face, back, chest and shoulders 
• Depressed or hypertrophic scars 
• May exacerbate just before menses in females 

NEEDS PHOTO

Example of open comedones (or blackheads)	Example of a combination of blackheads and pustules
Example of inflamed lesions (the lesion sits on an erythematous base)	Example of cystic acne and scarring

Diagnostics 

None, unless need to identify causative organism in atypical folliculitis. 

Differential Diagnosis 

• Acne rosacea 
• Folliculitis 

• Tinea 

   Goals of Treatment 

 

• Alter keratinization 
• Decrease excess production of sebum 

• Reduce production of P. acnes 
• Minimize scarring & hyperpigmentation 

Principles of Management 

• Medications should be administered at the lowest dose and/or frequency to produce & maintain improvement 
• Initial treatment is based on the patient’s acne classification 

• Follow-up visits should occur in 8 weeks 
• Improvement of 25% to 50% confirms therapy is appropriate 
• Tips to boost adherence to acne treatment 

• Simplify treatment regimen with fewest number 
• Minimize adverse effects 

• Set realistic expectations 
• Your clinical assessment of severity may not match the patient’s assessment 
• Peer opinion is more important than scientific data 
• Warn about behaviors that worsen acne (e.g., picking, squeezing, etc.) 

Patient Education 

• Avoid triggers 

• Occlusive cosmetics and clothing 
• topical oil-based products 
• Harsh soaps, grainy washes, picking lesions 
• High humidity 

• Some drugs and chemicals 

• Use oil-free, mild soaps, cleansers and moisturizers 
• Moisturizers & makeup should be water based 
• Discuss importance of consistent self-care 
• Discuss time frame necessary for improvement (several months) 

• Discuss need for sunscreen 

Treatment 

• Mild Acne 

• Can be adequately managed with topical therapy, such as benzoyl peroxide 2.5 to 10% (2.5% is as effective as 10% but less irritating) 

• Benzoyl peroxide: inexpensive & available over the counter in many formulations. Essentially an antimicrobial, it causes desquamation, decreasing follicular plugging. Also reduces numbers of P. acnes in the follicles, including strains that have become resistant to other antibiotics.  

• If not responsive, try topical retinoid (cream or gel) 

• Apply sunscreen, regardless of skin tone 
• Mild to moderate skin irritation, improves over time 

• Salicylic acid preps, such as Neutrogena 2% wash 
• Topical antibiotics: available in several formulations to accommodate patient preferences and dry/oily skin types 

• Topical clindamycin & erythromycin lotions or pads 
• Most effective for mild acne 
• Not as effective as oral antibiotics for moderate-severe acne 
• Can be used with benzoyl peroxide and/or retinoid 

• Moderate Inflammatory Acne 

• Reasonable to add an oral antibiotic if topical antibiotics are inadequate 

• Doxycycline 100mg BID 
• Erythromycin 1gm BID or TID 
• Minocycline 50-100 mg BID 
• Azithromycin 

• TMP/SMX 

• Takes about 3 months of continuous therapy for the skin to clear 
• Slowly taper over a few months while adding topical antibiotics 
• Long-term / repeat treatment often necessary 
• Contraceptives – combined estrogen-progestin  

• Good for moderate to severe acne 
• Takes about 3 months for improvement 
• When contraceptive discontinued, acne gradually returns 

• Severe cystic acne that does not respond to oral antibiotics and topical retinoids 

• Isotretinoin – capsules of varying strengths  

• Treat for 4-6 months 
• Must be off drug for 2 months before repeat, if repeat is necessary 
• Monitor for mood destabilization and suicidal thoughts 
• Educate on use of drugs and adverse effects 
• Cheilitis 

• Conjunctivitis 
• Hypertriglyceridemia 
• Xerosis 
• Photosensitivity 
• Potent teratogenicity 

• Females of childbearing age must use 2 types of highly-effective contraception beginning 1 month before starting isotretinoin and continue contraception through the treatment and one month after completing the treatment. 
• iPLEDGE Program  https://www.ipledgeprogram.com/iPledgeUI/home.u 

Resource: 

Zaenglein, A., Pathy, A. L., Schlosser, B. J., Alikhan, Al, Baldwin, H. E., Berson, D. S…..Bhushan, R.  (2016).  Guidelines of care for the management of acne vulgaris. American Academy of Dermatology.   http://dx.doi.org/10.1016/j.jaad.2015.12.037   

Infectious Mononucleosis 

NEEDS PHOTO

Infectious mononucleosis is usually seen in older children usually after the age of 10, so it’s a real common occurrence in adolescence and young adulthood. It’s caused by an acute infection due to the Epstein-Barr virus and we call this the “kissing disease” because the motor transmission is usually swapping spit, hence, the term, kissing disease. Sometimes it is caused because people share cups and straws and drinks and so this is another way of transmission. 

They are exquisitely ill looking for what you find in terms of physical findings. The differential diagnosis would be sore throat and when you look into their throat or their mouth you’ll see that the throat is somewhat erythematous, the tonsils are inflamed, and you might see white exudate on the tonsils, but the key is how ill they look. They are miserable. They feel really sluggish, they are not hungry, and they have aches and pains. When obtaining a monospot for the Epstein-Barr virus, it needs to be present for a window of time.  If it is obtained too early the results will be negative. Often providers will then complete a throat culture for strep and it will result negative.  Providers frequently want to treat the child for strep throat. If the child is treated with amoxicillin, he/she will break out in a rash. 

• Acute infectious disease due to Epstein-Barr virus 
• Usually occurs over the age of 10 
• Mode of transmission is saliva 

• Incubation is 1 – 2 months 
• Usually self-limiting, but malaise and fatigue may last for months 

Signs and Symptoms 

• Fever 
• Sore throat 

• Malaise, anorexia, myalgia 

Physical Exam Findings 

• Cervical lymphadenopathy 
• White exudate on tonsils may be present 
• Splenomegaly 

• Maculopapular or petechial rash 

Laboratory/Diagnostics 

• Lymphocytic leukocytosis 
• Positive heterophil and monospot 
• Early rise in IgM 

• Permanent rise in IgG 

Management 

• Supportive (non-steroidals, saline gargles) 
• Corticosteroids when enlarged lymph nodes block airway