Download L1 L2 Examining of respiratory system. Upper respiratory tract

2012-10-10
Examining of respiratory system
Prof. dr hab. n. med. Anna Wasilewska
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Respiratory system examination
• Inspection
• Palpation
• Percussion
• Auscultation
• Accessory invastigations
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Characteristics of Normal Breathing
•
•
•
•
•
Normal rate and depth
Regular inhalation and exhalation pattern
Audible on each side of chest
Equal rise and fall of each side
Movement of the abdomen
Sign of Abnormal Breathing
• Rate slower than 8 per minute or faster than 24 per
minute
• Muscle retractions above clavicles, between ribs
and below rib cage (especially in children)
• Pale or cyanotic skin
• Shallow or irregular
• Pursed lips
• Nasal flaring
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Inspection of respiratory system
1. chest
– shape
– symmetry
– mobility
2. respiratory rate
3. dyspnoea
4. respiratory type
5. respiratory path
6. Hypoxia symptoms
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1. Chest shape (1)
• Physiology:
• infant – round on the cross-section, ribs at a
right angle from the spine
• elderly children – flattened, anteroposterior
dimension smaller than transverse
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Chest shape (2)
• Deviations:
• Barrel chest (bronchial asthma, emphysema)
• Funnel chest – developmental disorders,
depression in the center of the chest over the
sternum
• Rachitic chest
- pigeon breast (the chest wall held in an outward
position)
- cobbler’s chest (depression of the sternum)
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Chest shape (3)
• Conical chest - abdominal tumours, ascites dilated at the base
• Asymmetrical chest
- one -side dilated (exudative pleuritis,
mediastinalis tumors, heart, liver, spleen
enlargement)
- one - side hollowed (pulmonary fibrosis or
hypoplasia)
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Bronchial asthma
Severe dysponoea,
characteristic posture
of child with
bronchial asthma
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(Hertl, 1999)
Breathing Considerations
Age
Pediatric Respiratory Rates
Rate (breaths per minute)
Preterm:
Term
Preschooler (5 years)
School-age (10 years)
Adolescent (12–18 years)
Adult
50-60
30-40
25
20
16
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A silent chest is an ominous sign of low blood oxygen
in the pediatric patient.
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2. Respiratory rates
Tachypnoe
–
–
–
–
–
–
–
pneumonia
bronchitis
foreign body in the airway
bronchial asthma
mediastinal tumors
fever, anaemia, metabolic acidosis
circulatory failure
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3. Dyspnoea - difficulty breathing (1)
1. Inspiratory dyspnoea (difficulty breathing)
• obstruction of the upper respiratory tract including
larynx
• use of accessory respiratory muscles (alae nasi,
sternocleidomastoid muscle, intercostal muscles,
diaphragm)
• causes: inflammation, foreign body, spasm
(tetany, Quincke’s oedema), outside pressure
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Dyspnoea - difficulty breathing (2)
2. Expiratory dyspnoea (laboured expiratory
phase)
• larynx and bronchi obstruction
• use of accessory respiratory muscles (diaphragm,
abdominal muscles)
• causes: bronchial spasm, swelling of mucous
membrane, excretion, outside pressure, foreign body
(bronchial asthma, bronchitis, tumors, foreign body)
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Dyspnoea - difficulty breathing (3)
3. Inspiratory and expiratory dyspnea
• upper and lower airways obstruction
• pneumonia
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4. Respiratory type (1)
1. Physiological - regular
• irregular during falling asleep only in
premature infants and small childrens
2. Pathological • Kussmaul’s breath - acidotic (deep and
rapid)
• Cheyne - Stockes breath - respiratory centre
injury (crescendo- decrescendo pattern,
apnoea)
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Respiratory type (2)
• Biot's breath - CNS injury (deep breath and
apnoea)
• agonal breath (gasping respiration)
• groaning breath- expiratory groaning
(expiratory dyspnoea)
• stridor (whooping cough, tetanus)
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5. Respiratory path
• Physiology:
• abdominal in infants
• chest 2-7 years
• over 7 years old:
- girls - chest - abdominal
- boys - abdominal - chest
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6. Signs of hypoxia
1. Skin paleness
2. Grey shadow around the nose ang mouth.
3. Cyanosis, decreasing during child’s crying
4. Clubbed finger (chronic hypoxia)
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Clubbed finger in hypoxia
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Nail cyanosis in hypoxia
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Palpation of respiratory system
1. Respiratory mobility
2. Pectoral fremitus
3. Pleural rub
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1. Chest mobility
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2. Pectoral fremitus (1)
Diminished:
• pneumothorax
• pleural exudate and transudate
• lung tumour
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Pectoral fremitus (2)
Increased (non-obstructed bronchus)
• lobar pneumonia
• pulmonary cavity
• above pleural exudate
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Estimation of pectoral fremitus
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3. Pleural rub
- sound heard during the inspiratory and
expiratory phases
- causes:
– adhesive pleurisy
– suppurative or wet pleurisy outcome
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Percussion of respiratory system
Target:
1. Estimation of lower lung borders
2. Estimation of breath lung mobility
3. Estimation of percussion sound
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1. Estimation of lung borders (1)
• Midclavicular line:
left
• 0-2 years II c
• 2-5 years II ic
• >5 years III c
• Midaxillary line
• 0-2 years VIII ic
• 2-5 years
VIII ic
• >5 years
IX c
right
V ic
VI ic
VI c
VI ic
VII ic
VII ic
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Estimation of lung borders (2)
• Scapular line
• 0-2 years
• 2-5 years
• > 5 years
left
IX c
Xc
X ic
right
IX c
Xc
X ic
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Lowering of lower lung borders
• Emphysema in course of:
-obstructive bronchitis
-bronchial asthma
-whooping cough
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High position of lower lung borders
a) abdominal flatulence
b) peritoneal fluid
c) considerable hepato-, splenomegaly
(concomitant)
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High position of one lung lower
border
a) phrenic nerve paralysis
b) hepato-, splenomegaly
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2. Estimation of percussion sound:
• vesicular resonance - physiological
• dull percussion sound
- pleural changes (exudative pleuritis, transudate in
nephrotic syndrome, in circulatory failure)
- changes in lung parenchyma (lobar pneumonia,
atelectasis, abscess, malignant infiltration,
aspirtaion of amnioclepsis, lung agenesis or
aplasia)
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Respiratory system auscultation
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Auscultatory sounds
1. Basic sounds:
• normal alveolar
• bronchial
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Normal alveolar breath sound
• only expiratory
phase is heard
• physiological
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Louder alveolar breath sound
• heard inspiratory and expiratory phase
• physiologically in infants
• in bronchitis
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Diminished or absent alveolar
breath sound
•
•
•
•
lobar pneumonia
pleural fluid
pneumothorax
atelectasis (airlessness of the lungs)
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Bronchial breath sound
• Physiologically in
interscapular area and
above trachea
• Lobar pneumonia with
non-obstructed big
bronchus
• Exudative pleuritis
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Laryngeal-tracheal
Stridor,Grunting
Tracheal-bronchiole
Rhonci,Wheezing
Bronchiol-alveoli
Rales
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Auscultatory sounds
2. Accessory sounds
• Wheezing
• Stridor
• Rhonchi
• Fine rales
• Crepitatnt rales (Crackles)
• Pleural rub
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Auscultatory sounds
2. Abnormal sounds
Breath sounds are considered abnormal if they are
heard outside their usual location in the chest or if
they are qualitatively different from normal breath
sounds (e.g. decreased or absent).
They are divided into two categories:
(1) continuous wheeze, rhonchus, pleural rub
(2) non-continuous lung sounds - fine rales, cracles
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Abnormal lower airway
(adventitious) sounds
• include rhonchi, wheezes, and crackles.
• A sonorous rhonchus is an inspiratory or expiratory noise
(r/o transmission of upper respiratory stertor) which
suggests the presence of fluid or exudate in larger airways,
as with bronchitis or pneumonia.
• Wheezes (sibilant rhonchi) are high-pitched expiratory
sounds typical of bronchial narrowing. The usual
associations are bronchial disease (bronchitis, asthma) or
attenuation of a main bronchus caused by left atrial
dilation, hilar lymphadenopathy, primary bronchial
collapse, or a pulmonary mass lesion.
Abnormal lower airway
(adventitious) sounds
• Crackles (“rales”) are discontinuous sounds
similar to radio static
• These sounds are caused by the explosive opening
of collapsed small airways. Though there is a
tendency to relate these to “fluid in the lungs,”
there is not a consistent correlation as crackles
may be detected with pulmonary edema,
pneumonia, bronchitis, or pulmonary fibrosis. The
loudest crackles are typically detected in primary
lung diseases. Subtle crackles are evident only
after a deep breath.
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Wheezing – bronchi
obstruction
• Changes more intense
during expiratory phase
• Bronchial asthma
• Obstructive bronchitis
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Wheezing
• Asthma in 8 years
old patient
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Wheezing
• 11 years old child
severe asthmatic
state
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Stridor – respiratory tract
obstruction at the larynx and
trachea level
• Mostly during
inspiratory phase
• Laryngitis
• Bronchiolitis in
infants
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Rhonchi - moist sounds in
bronchi
• Presence of excretion in bronchi
• Heard in bronchitis
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Fine resonant rales - moist
sounds in small bronchi
• Presence of excretion in small bronchi
• Heard in pneumonia
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Crepitant rale
- pulmonary alveolus unsticking by
air
• Haerd during the
inspiratory phase
• Lobar pneumonia
• Alveolar atelectasis
(near spine in new
borns, liver and heart
pressure)
• Tuberculotic infiltration
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Crepitant rale
Pneumonia in course
of systemic lupus
erythematosus in 18
years old female
patient
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Crepitant rale
• 9 years old patient
pneumonia
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Pleural rub
• exudative pleuritis regression
• dry pleuritis
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Right - sided pneumothorax
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Lobar pneumonia
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Bronchitis
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Pleurisy
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Tasks for independent solution
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Lung auscultation - Quiz
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Bronchial sound
• What kind of
sound is it?
• In what
situations is
heard?
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Stridor
• What kind of
sound is it?
• In what
situations is
heard?
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Wheezing - bronchial
obstruction
• What kind of
sound is it?
• In what
situations is
heard?
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Inflammatory changes in lungs
• What kind of
sound is it?
• In what
situations is
heard?
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Normal breath sound
• What kind of
sound is it?
• In what
situations is
heard?
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Rhonchi - bronchitis
• What kind of
sound is it?
• In what
situations is
heard?
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Pleural rub
• What kind of
sound is it?
• In what
situations is
heard?
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Examples of X – rays changes Quiz
Wilhelm Roentgen
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Question 1.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
Lobar pneumonia
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Question 2.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
Right lung abscess
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Question 3.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
Left- sided pneumothorax
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Question 4.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
Pleural exudate
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Question 5.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
Lymphoma
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Question 6.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
Lobar pneumonia in the right
lung
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Question 7.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
Radiological changes in the
interstitial pneumonia
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Question 8.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
• What is the procedure?
Persistent thymus
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Question 9.
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• What X-ray presents?
• What kind of auscultatory changes can be
expected?
• What is the diagnosis?
• What is the procedure?
Mycoplasmatic pneumonia
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Viral and bacterial infections of
upper respiratory tract in children.
Why is this subject so important?
• The respiratory system is the most
commonly infected system.
• Health care providers will see more
respiratory infections than any other type.
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Overview
The respiratory system
• A major portal of entry for infectious
organisms
• It is divided into two tracts – upper and
lower.
– The division is based on structures and
functions in each part.
• The two parts have different types of
infection.
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Anatomy of the Respiratory system
Anatomy of the Respiratory system
• The upper respiratory tract:
– Nasal cavity, sinuses, pharynx, and larynx
– Infections are fairly common.
– Usually nothing more than an irritation
• The lower respiratory tract:
– Lungs and bronchi
– Infections are more dangerous.
– Can be very difficult to treat
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Anatomy of the Respiratory system
• The most accessible system in the body
– Breathing brings in clouds of potentially infectious
pathogens.
• The body has a variety of host defense mechanisms.
– Innate immune response -the cells and mechanisms
that defend the host from infection by other
organisms, in a non-specific manner
– Adaptive immune - it is adaptive immunity
because the body's immune system prepares itself
for future challenges.
Anatomy of the Respiratory system
• Upper respiratory tract is continuously
exposed to potential pathogens.
• Lower respiratory tract is essentially a
sterile environment.
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Pathogenes of the Respiratory system
• Many bacterial organisms infect the
respiratory system.
• Upper respiratory tract also portal of entry
for viral pathogens.
• Vaccination has eliminated many
respiratory infections.
– Some still seen in underdeveloped parts of the
world.
Pathogenes of the Respiratory system
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Pathogenes of the Respiratory system
Respiratory pathogens are easily transmitted from
human to human.
They circulate within a community.
Infections spread easily.
Some respiratory pathogens exist as part of the
normal flora.
Others are acquired from animal source, water, air etc
Fungi are also a source of respiratory infection.
Usually in immunocompromised patients
Most dangerous are Aspergillus and Pneumocystis.
Pathogenes of the Respiratory system
• Some pathogens are restricted to certain sites.
– Legionella only infects the lung.
• Other pathogens cause infection in multiple sites.
– Streptococcus can cause:
• Middle ear infections.
• Sinusitis.
• Pneumonia.
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Sites of infections
• Frequent sites of infection are:
– Middle ear.
– Mastoid cavity.
– Nasal sinuses.
– Nasopharynx.
Defences of respiratory system
• The respiratory system has significant defenses.
• The upper respiratory tract has:
– Mucociliary escalator.
– Coughing.
• The lower respiratory tract has:
– Alveolar macrophages.
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Defences of respiratory system
Bacteria infecting the respiratory system
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Bacterial infections of the upper
repiratory tract
•
•
•
•
•
Laryngitis & Epiglottitis
Otitis media, mastoiditis, and sinusitis
Pharyngitis
Scarlet fever
Diphtheria
Laryngitis & Epiglottitis
• Laryngitis is swelling and irritation
(inflammation) of the voice box (larynx) that is
usually associated with hoarseness or loss of
voice-Haemophilus influenzae & Streptococcus
pneumoniae, could be fungal and viral.
• Epiglottitis- Inflammation of the cartilage that
covers the trachea (windpipe)-Haemophilus
influenzae, Streptococcus pneumoniae or
Streptococcus pyogenes.
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Otitis media
Infection or inflammation of the ear-fluid/exudates/pus/in
the middle ear due to Haemophilus influenzae,
Streptococcus pneumoniae or Streptococcus pyogenes.
Organisms reach ME cavity by:
• REFLUX from nasopharynx
Particularly if drum is perforated.
• ASPIRATION:
due to high –ve ME pressure
• INSUFFLATION during:
Crying
Nose- blowing
Sneezing
Swallowing
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Anatomic position of
Eustachian tube in adult
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Otitis media, mastoiditis, sinusitis
Middle ear, mastoid cavity, and sinuses are connected to the
nasopharynx.
Sinuses and eustachian tubes have ciliated epithelial cells.
◦ A virus initially invades the ciliated epithelium.
◦ This destroys the ciliated cells, allowing bacteria to invade.
Mastoiditis is uncommon but very dangerous. Mastoid cavity
is close to the nervous system and large blood vessels.
Sinusitis- Inflammation of the sinuses and nasal passages,
upper respiratory tract infection, the most common three
causative agents are Streptococcus pneumoniae, Haemophilus
influenzae and Moraxella catarrhalis
Pharyngitis
A variety of bacteria can cause infection in the pharynx.
A classic infection is strep throat.
Caused by Streptococcus pyogenes
Contains M proteins which inhibits phagocytosis
Produces pyrogenic toxins which cause the
symptoms seen with pharyngitis
Group A streptococci can cause abscesses on the tonsils.
S. pyogenes can cause scarlet fever and toxic shock
syndrome.
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Streptococcal Pharyngitis-reddened
adenoids -side of the throat (URT
Bacterial Diseases)
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Scarlet fever
• Caused by Group A streptococci
• Usually seen in children under age of 18 years
• Symptoms usually begin with appearance of a
rash.
– Tiny bumps on the chest and abdomen
– Can spread over the entire body
• Appears redder in armpits and groin
– Rash lasts 2-5 days
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Scarlet fever
• Symptoms can also include:
– Very sore throat with yellow or white papules
– Fever of 101˚F or higher
– Lymphadenopathy in neck
– Headache, body aches, and nausea
– A variety of antibiotic therapies is available
Diphteria
• Caused by the toxin produced by
Corynebacterium diphtheriae
– A potent inhibitor of protein synthesis
• It is a localized infection.
– Presents as severe pharyngitis
– Can be accompanied by plaque-like
pseudomembrane in the throat
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Corynebacterium diphtheriae
Diphteria
© Visuals Unlimited
Diphteria
• Toxemia can make diphtheria life threatening.
– Can involve multiple organ systems
– Can cause acute myocarditis
• Diphtheria is transmitted by:
– Droplet aerosol.
– Direct contact with skin.
– Fomites (to a lesser degree).
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Viral infections of the upper repiratory tract
• RHINOVIRUS INFECTION -There are several
hundred serotypes of rhinovirus.
– Fewer than half have been characterized.
– 50% that have are all picornaviruses.
– Extremely small, non-enveloped, singlestranded RNA viruses
• Optimum temperature for picornavirus growth is
33˚C.
– The temperature in the nasopharynx
Viral infections of the upper repiratory tract
• PARAINFLUENZA: There are four types of
parainfluenza virus.
– All belong to the paramyxovirus group.
– Single-stranded enveloped RNA viruses
– Contain hemagglutinin and neuraminidase
• Transmission and pathology similar to influenza
virus, but there are differences.
– Parainfluenza virus replicates in the cytoplasm.
– Influenza virus replicates in the nucleus.
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Parainfluenza
• Parainfluenza is genetically more stable than
influenza.
– Very little mutation
– Little antigenic drift
– No antigenic shift
• Parainfluenza is a serious problem in infants and
small children.
– Only a transitory immunity to reinfection
– Infection becomes milder as the child ages.
CASE 1
• JTM is a 15 y boy who presents with 2 days
of congestion, runny nose and sneezing. He
has a scratchy throat and feels tired. Over
the past day he has developed a cough so he
came in “before it got too serious”. On
exam, he is afebrile, in no distress and his
respirations are easy. His oral and nasal
passages are red and swollen and his lungs
are clear.
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Copyright ©2005, The Regents of the University of California.
The common cold
• The common cold is a viral infection with
prominent symptoms of rhinorrhea and
nasal obstruction, absent or mild fever, and
lacking systemic manifestations. It is often
referred to as rhinitis, but usually also
involves the sinus mucosa and is more
correctly termed rhinosinusitis
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Signs and symptoms
•
•
•
•
•
•
•
•
Nasal stuffiness and/or obstruction (80-100%)
Sneezing (50-70%)
Scratchy throat (50%)
Cough (40%)
Hoarseness (30%)
Malaise (20-25%)
Headache (25%)
Fever > 100° (0-1%)
Causes
• Usually due to one of 200 virus strains from 6
families
–
–
–
–
–
Influenza A, B, C virus
Parainfluenza virus
Respiratory syncytial virus
Coronavirus
Adenovirus
• Often no agent can be identified
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Risk factors
• Exposure to infected individuals
• Touching one’s nose or conjunctiva with
contaminated fingers
• Allergic disorders
Diagnosis
• The diagnosis is almost always based on
clinical findings
• In rare cases, virus is cultured from nasal
washings or identified by ELISA or RIA
methods
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Treatment: General
•
•
•
•
•
Rest, fluids and symptomatic measures
Reassurance that the usual course is 6-10 d
Humidification of inspired air
Discontinue any tobacco or alcohol
In infants-use bulb suction, position
mattress at 45°, use saline nasal drops
Case 2
• 25 year old medical student presents to the
office with the c/o sore throat,
• He felt febrile 2 days before
• One day before he had a presentation at the
pediatric rotation at CCH
• On the day of visit, the pain got worse and
he saw excudate on right tonsil
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Pharyngitis
Pharyngitis
• The inflammation of pharyngitis causes
cough, sore throat, dysphagia, and fever. If
involvement of the tonsils is prominent, the
term tonsillitis or tonsillopharyngitis is
often used.
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•Etiology
•Sore throat is mostly caused by virus or bacteria
•GABHS pharyngitis accounts for 15 to 30% of the
cases in children and 5 to 15 % of the cases in
adults
•Also caused by other conditions such as GE
reflux, post nasal drip to rhinitis, persistent cough
and allergy
Epidemiology
•Acute
pharyngitis is one of the 20 reported
primary diagnosis resulting in office visits
•Peak
season includes late winter and early
spring
•Transmission
of typical viral and GABHS
pharyngitis occurs mostly by hand contact
and incubation period 1-3 days
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GABHS
• Sore throat, fever, pharyngeal or tonsillar
exudates, anterior cervical
lymphadenopathy, and history of exposure
to GABHS infections are important
symptoms and signs
• Usually winter to spring. Age up to 5-25.
• However, no single element of history or
exam is sensitive or specific enough
Modified Centor Score
•
•
•
•
•
•
•
•
Criteria
Temp >38 c
Absence of cough
Swollen, tender node
Tonsillar exudate
Age: 3-14
15-44
45 or older
Points
1
1
1
1
1
0
-1
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Score and Risk of GABHS
•
•
•
•
•
•
Scores
0 or less
1
2
3
4 or more
Risk of GABHS
1-2.5%
5-10 %
11-17%
28-35%
51-53%
GABHS
• Untreated, GABHS pharyngitis lasts seven
to 10 days. Untreated patients are infective
during the acute phase of the illness and for
one additional week.
• Effective antibiotic treatment decreases the
infectious period to 24 hours and prevents
most complications
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Complications of GABHS
• Rheumatic Fever: Rare in the U.S.
• Peritonsillar abscess: toxic appearance,
fluctuant peritonsillar mass and deviation of
uvula
• Poststreptococcal glomerulonephritis
• Scarlet fever: sandpaper like exanthem
Recommendations using Centor
Criteria and Rapid antigen Test
• Empirically treat patients who have four
clinical criteria (Fever, tonsillar exudate,
tender anterior cervical lymph node, and
absence of cough)
• Do not treat with antibiotics or perform
diagnostic tests on patients with zero or one
criterion
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CASE 3
• MKR is a 45 yo female with an unremarkable
PMHx who presents with frontal headache
worsening over the past 4 days; she describes a
pressure feeling across her forehead present most
of the time; she feels congested and has no
rhinitis; she has not had a fever; she is a smoker
and states that she “gets these same symptoms
once a year about this time.” On exam, she has no
fever and is tender across her frontal sinuses. Her
exam is otherwise unremarkable.
Sinusitis
• Incidence/prevalence
–
–
–
–
16% of population with annual diagnosis
5% of office visits for young adults
5th leading reason for antibiotic prescription
Increases up to age 75
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2012-10-10
www.musckids.com/.../images/sinusesff.jpg
Signs and Symptoms
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Headache
Retro-orbital pain
Otaglia
Halitosis (bad breath)
Chronic cough
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2012-10-10
Causes
• Viral etiology as the vast majority
– Often rhinovirus, parainfluenza, adenovirus
• Bacterial superinfection complicates 0.2-2%
of viral cases
– Usually S. pneumoniae or H. Influenza
• Fungal
Risk factors
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Viral upper respiratory infection
Anatomical abnormality
Dental infection or procedure
Immunodeficiency
Asthma and allergies
Smoking
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2012-10-10
Symptoms suggestive of bacterial
sinusitis
• Symptoms persistent >7-10 days
• Purulent nasal discharge
• Maxillary tooth or facial pain (especially
unilateral)
• Worsening of symptoms after initial
improvement
• Poor response to decongestants
Diagnosis
• History and physical exam are sufficient for
majority of cases
• Imaging
– Sinus radiographs are discouraged
– Limited coronal CT of sinuses—useful in
evaluation of recurrent sinusitis—3 to 4 annual
episodes or non responders
• Transnasal endoscopy
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2012-10-10
Treatment: General
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Patient education!!
Adequate hydration (8-10 glasses daily)
Steam inhalation (20-30 min)
Saline irrigation or nose drops
Avoid irritant exposure
Avoid dehydrants
Symptom relief
Treatment: Antibiotics
• Indicated with purulent rhinorrhea and/or
symptoms greater than 7-10 days
• PCN or Sulfa as first line agent
– 10-14 day course
– Erythromycin or Cephalosporin if PCN allergy
• Recurrent/persistent infections
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2012-10-10
Adjunctive Drugs
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Antihistamines
Nasal steroids
Leukotriene inhibitors
Decongestants
Patient education
• Call if no improvement within one week,
symptom worsening or concerning
symptoms
• Medication side effects
• Adjunctive medications
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2012-10-10
Complications
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Orbital cellulitis
Meningitis
Osteomyelitis
Brain abscess
Cavernous sinus thrombosis
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