Download URI/AR/sinusitis Resident - Stony Brook University School of Medicine

Stony Brook Children’s Pediatric Primary Care Clinic Curriculum
URI/AR/Sinusitis
June 2016
Materials developed by Susan Walker, MD
Goal: To become competent at the diagnosis, differentiation, and management of upper
respiratory infection (URI), allergic rhinitis, and sinusitis in children.
Objectives:
1.
Understand the cause of URIs
2.
Understand the mode of transmission of URI-causing viruses.
3.
Competently counsel parents on the use of over-the-counter medications
for coughs and rhinorrhea
4.
State the physical exam findings suggestive of allergic rhinitis
5.
Describe the management options for allergic rhinitis
6.
Discuss the pharmacotheraputic options for allergic rhinitis, including
pros/cons of each.
7.
Know the clinical practice guidelines for sinusitis, including diagnosis and
treatment.
ABP Content Specifications:
Allergic rhinitis
1. Recognize the common characteristics of allergic rhinitis, and manage appropriately
2. Understand the association between allergic rhinitis and sinusitis and/or otitis media
3. Differentiate the historical and clinical findings of allergic rhinitis from those of non-allergic rhinitis
Adenovirus
a. Understand the epidemiology of adenovirus
b. Recognize the clinical features associated with adenovirus infection
Rhinovirus
a. Recognize the epidemiology of rhinovirus infection
b. Recognize the clinical features associated with rhinovirus infection
Upper respiratory tract infection
a. Understand the natural history of an upper respiratory tract infection
b. Identify the etiology of an upper respiratory tract infection
Acute sinusitis
a. Understand the natural history of acute sinusitis
b. Formulate a differential diagnosis of acute sinusitis
c. Recognize the clinical findings associated with acute sinusitis in patients of various ages
d. Plan the appropriate management of acute sinusitis
e. Plan the appropriate diagnostic evaluation of acute sinusitis while recognizing the limitations of
some modalities
f. Recognize complications associated with acute sinusitis
Readings:
Clinical practice guidelines for allergic rhinitis
http://oto.sagepub.com/content/152/2/197.full
Clinical practice guidelines for sinusitis
http://pediatrics.aappublications.org/content/early/2013/06/19/peds.2013-1071
URI
http://pedsinreview.aappublications.org/content/36/12/554
Principles of judicious antibiotic use
http://pediatrics.aappublications.org/content/132/6/1146
To do:
1. For each article, please write down two “pearls” to share with your clinic group
2. Answer the following questions:
It is a cold January morning, and you are seeing a three-year-old patient in your office for
what her mother describes as “her fifth cold since she started pre-school”. She has had
nasal congestion for seven days, with mild cough and slightly decreased PO intake. Her
nasal mucous was initially clear but then turned greenish, which prompted her mom to
bring her in “for antibiotics”. She had fever for the first 24 hours of this illness, but since
then has been afebrile. Physical exam shows a happy preschooler with erythematous
nasal turbinates and some nasal congestion. Temperature and respiratory rate are normal
for age. Lungs are clear.
What is your diagnosis?
Her exasperated mother tells you, “Why does she keep getting sick like this? Is there
something wrong with her immune system?” What do you tell her?
“OK”, she says, “but she’s had five colds since she started pre-school in September!
That’s too many!” Is it?
“But her mucous is green- that means infection, right? She needs antibiotics!” Does she?
You’ve convinced the mom that antibiotics are not necessary, but, “You have to give her
something for the cough, she’s up all night.”
What do you tell the mom in terms of available treatment for her daughter’s illness?
Thankful for your explanation and advice, the mom agrees to your recommendation for
supportive care. One week later, she returns to your office with a now droopy-appearing
preschooler in tow. You enter the room to find her lying down on the table, shivering
under a blanket. After giving her some ibuprofen for her fever, you ask the mother for an
update. “She was getting better until last night! She took a three-hour nap, woke with a
fever, and didn’t eat any dinner.” On exam, you note copious nasal discharge. Tympanic
membranes have normal color and mobility. Lungs are clear. What’s going on now?
What will you do for her? How long will you treat her for? When will you have her
return if she is not better?
You hear no more from her until that May, when she returns with her now four-year-old
daughter. “Her nose is running non-stop for the past two weeks! Is this another cold?”
She has associated sneezing and has been rubbing her eyes. Review of systems is
unremarkable- she has had no fever and is eating, drinking, and sleeping well. Physical
exam is remarkable for an afebrile, fidgety child with slightly injected conjunctiva
without discharge, boggy, bluish nasal turbinates, clear copious nasal discharge, and
‘allergic shiners’.
Is this another cold? If not, what might it be?
What other elements of the history and physical suggest an allergic rather than a nonallergic cause of this child’s rhinitis?
“Well, I certainly hope there’s something we can do for her, she’s sneezing all dayespecially when she goes outside-and her nose just won’t stop running.” What
medication would you recommend to help her symptoms?
Are there any other therapeutic modalities to try?