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This allows for equalization of pressure in the middle ear while the Eustachian tubes fully develop cholesterol jumped 40 points buy 5 mg lipitor free shipping. Pneumatic Otoscopy- A rubber bulb is attached to the otoscope and inserted into the ear canal with the speculum fitting snuggly in the canal cholesterol medication crestor buy lipitor 10mg with amex. Hearing loss is always a concerning complaint in a child cholesterol in eggs organic purchase lipitor, especially during the years of early language and speech development cholesterol test preparation alcohol discount 10 mg lipitor with mastercard. The bones of the middle ear that transmit sound waves cannot function properly when they are surrounded by fluid, as in the case of otitis media. Inefficient transmission of sound waves results in mild to moderate hearing loss, especially causing muffledsounding speech. Fortunately this hearing loss is temporary, but chronic ear infections may eventually erode the bones of the middle ear, resulting in significant and permanent hearing loss. Chronic ear infections are also a risk factor for the development of a cholesteatoma, a retraction pocket or cyst that fills with cellular debris and can erode middle ear structures, causing hearing loss. Bacteria are the primary cause of acute otitis media, but viruses play a significant role as well. Streptococcus pneumoniae is the most common bacterium (40-80%), followed by non-typable Haemophilus influenzae and Moraxella catarrhalis. Other less common organisms include Staphylococcus aureus and Streptococcus pyogenes. The decision must be based on an open discussion between the otolaryngologist and the parents. Other factors to consider include whether or not the child in is daycare, how many children live at home, and the current season. Many otolaryngologists are hesitant to put tubes in a child if summer is approaching. With tubes in place, ears must be kept dry during prime swimming months, and often children will achieve full eustachian tube development before the next winter cold and flu seasons. With antibiotic-resistant organisms on the rise due to incorrect usage and over-prescribing, there has been a shift to watchful waiting in a select group of patients as the first line of therapy. Children over 2 may be treated with antipyretics and watchful waiting for 2-3 days before beginning antibiotics. If it is determined that an antibiotic is needed, high dose amoxicillin is the first line of treatment, with a switch to amoxicillinclavulanic acid if there has been no clinical improvement in three full days of treatment. In children with symptoms of snoring and mouth breathing, adenoidectomy opens up the airway, allowing for improved air circulation. In young children, the adenoids may also be a nidus for ear infections, as they are located very near to the eustachian tube opening and infections of the adenoids may ascend to the middle ear. Removal of the adenoids tends to improve rhinosinusitis and decrease the incidence of otitis media. Trying to use the insufflating bulb is so annoying and challenging on a squirmy, sick child. In all seriousness, the insufflation bulb can be a very useful tool in evaluating the ears of a young child. In this case, insufflation may distinguish the two with ease, with an infection causing a decrease in mobility. Although unpleasant for all parties involved, use of the insufflating bulb is an important part of the proper ear exam. A good seal between the ear canal and the insufflator is necessary, as the escape of air will compromise the validity of the test. Treatment in four months ­ If on follow up examination this patient continues to have fluid in the middle ear; more steps may need to be taken. It is also possible to try a trial of antibiotics before tube placement in a family with reliable follow up. Suggestions for Learning Activities: · Ask students the questions from the clinical reasoning section and discuss the answers. Provide otoscopes with insufflating bulbs · and have students practice pneumatic otoscopy on their classmates. P a g e 78 Common Acute Pediatric Illnesses: Abdominal Pain, Case #1 Written by Noemi Adame, M. A ten-month-old presents with bouts of irritability during which he draws up his legs and appears to be in pain. Definitions for Specific Terms: Irritability- Inconsolability; over-response by an infant to harmless stimuli; fussiness and fretfulness despite attempts to comfort and console by caregiver.

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If influenza is suspected foods raise bad cholesterol order 5mg lipitor fast delivery, rapid testing may be indicated if antiviral therapy is to be offered ­ however cholesterol q10 lipitor 10mg on-line, if an influenza epidemic is ongoing cholesterol study order lipitor with a visa, then it is also a clinical diagnosis and testing is unnecessary before treatment is rendered cholesterol levels reduce naturally discount lipitor online visa. Most patients with atypical pneumonia may be treated as outpatients, with oral therapy ­ hence the nickname "walking pneumonia" for mycoplasmal disease. Older patients could be treated with a quinolone such as levofloxacin which would cover other agents of community acquired pneumonia, however, they are not labeled for use in growing children because of concerns about effects on cartilage. P a g e 34 Doxycycline could also be used ­ this patient is old enough ­ but the side effect profile and number of drug-drug interactions make the macrolides a more attractive choice. Diagnosis Atypical pneumonia, most likely due to Mycoplasma pneumoniae or Chlamydia pneumoniae. Suggestions for Learning Activities · Ask the student(s) the questions listed under "clinical reasoning" to probe their thinking about the case · Review chest radiographs of different types of pneumonia (Google image search or your local · · radiologist may be good sources) Practice writing a prescription for this patient ­ you would need to provide a weight. Role play ­ have the students explain to you as the "parent" what the problem is with this patient and what they plan to do about it. Be sure they include explanations about the expected course and when to bring the child back if there is no improvement. P a g e 35 Common Acute Pediatric Illnesses: Cough, Case #2 Written by Judy Rowen, M. A two-month-old afebrile infant with a history of conjunctivitis at 10 days of age presents with a staccato cough and tachypnea. Definitions for Specific Terms: Staccato cough ­ this is a cough which occurs in runs of short, dry coughs. The term comes from music ­ for an example of staccato music on harmonica, watch the 20 seconds of this video from 2:2102:43. Increased number of eosinophils ­ the absolute eosinophil count should be below 350 in most patients. Calculate this by multiplying the total white count by the percentage of eosinophils on the differential, for example a patient with a total white count of 10,000 with 5% eosinophils has an absolute eosinophil count of 500. Review of Important Concepts: Historical Points Assess the severity of illness and its impact on the child. Pertussis has associated rhinorrhea (the catarrhal phase), so this is not absolute. Viral and chlamydial conjunctivitis are more likely to lead to mucoid discharge, and a parent could conceivably care for it at home without seeking medical attention. P a g e 36 Physical Exam Findings What signs may indicate respiratory distress in a baby of this age? Note: Ensure that the student knows how to look for retractions and can recognize abnormal respiratory patterns. Clinical Reasoning this case presents a classic pattern that an experienced pediatrician will immediately recognize. The student may not have built this pattern yet, so questions 13 below could be used to derive a list of possibilities, and the most likely answer will be the one that appears on all three lists. Some children will have dacrocystitis and will have eye drainage, but generally they will also have a small swelling over the blocked tear duct at the medial canthus as well. Some viruses may cause both conjunctivitis and pneumonia, but usually concurrently, not 6 weeks later. Asthma may affect an infant as young as this and may have an associated increase in eosinophils. Premature neonates have been best studied, and we know that eosinophilia is fairly common with most infectious processes seen in that population. Chlamydia is the most likely to be seen in an afebrile child, but some viral infections may not have much associated fever. If the baby acquired the infection during birth, why is it just now presenting at age 2 months? Chlamydia is an intracellular pathogen that probably first infected the conjunctival epithelium after spread from infected maternal secretions, and from there colonized the nasopharyngeal mucosa and eventually spread down the airway to the lungs. Would things be different if the baby had been treated for the conjunctivitis at age 10 days?

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Superimposed on atherosclerotic coronary artery narrowing cholesterol ratio 3.3 quality lipitor 5mg, such factors as increased cardiac oxygen demand cholesterol free diet foods order lipitor 5mg with amex, decreased flow related to coronary artery spasm cholesterol lowering breakfast foods discount lipitor amex, or arrhythmias may be contributory cholesterol food free generic lipitor 5 mg amex. Main Features Prevalence: common in middle and older age groups, especially males. Associated Symptoms Breathlessness, sweating, nausea and vomiting, apprehension, and lightheadedness are common. Signs and Laboratory Findings Physical examination may be normal but may show hypertension, S3 or S4 gallop rhythm, and papillary muscle dysfunction with a mitral regurgitant murmur, as well as signs of forward or backward cardiac failure. Usual Course In patients surviving myocardial infarction the severe pain tends to diminish and disappear over several hours to a day or two. Often the patient is then pain free, although recurrent pain may represent angina or reinfarction. Complications Sudden cardiac death, arrhythmias, congestive heart failure, cardiogenic shock, post-myocardial infarction syndrome, pericarditis, septa] perforation, valve cusp rupture, mural thrombus and embolism, myocardial aneurysm, deep vein thrombosis, and pulmonary embolism. Social and Physical Disability Myocardial infarction is a major cause of death and disability. Recovery frequently takes several months, and physical and psychological complications may prolong recovery and affect not only the patient but family members, friends, and employers. The significance of the heart as the source of life makes interpretation of this type of pain particularly threatening. Pathology the main pathogenic process is atherosclerosis of the coronary arteries. Other factors such as coronary artery spasm or arrhythmias, or decreased blood volume, or decreased total peripheral resistance may also be significant as "last straws. Differential Diagnosis Angina pectoris, dissecting aneurysm, pulmonary embolism, esophageal spasm, hiatus hernia, and pericarditis. Social and Physical Disabilities Probably only significant in chronic cases where weight loss and generalized debility are part of the syndrome. Etiology A wide range of etiologies can cause pericarditis and its subsequent pain. The most treatable causes are infections, collagen, vascular, and drug-induced effects. Differential Diagnosis Angina, myocardial infarction, pulmonary embolism, hiatus hernia, and esophageal spasm, etc. Site the pain is classically in the precordium but may radiate through to the midthorax posteriorly or follow the pattern of angina, or to the superior border of the trapezius muscles. Main Features Most cases are acute, and this is particularly true of pericarditis causing pain. Associated Symptoms Weight loss, fatigue, and fever are common especially in chronic cases. If there is a significant effusion, heart sounds may be decreased and a paradoxical pulse may be elicited. Laboratory signs include a "water bottle" configuration on chest X-ray if there is an effusion, as well as changes in fluoroscopy, echocardiography, or angiography. Usual Course the course varies depending on the etiology and may range from being acute to chronic. Main Features Deep, diffuse, aching central chest pain is associated with large aneurysms. Page 140 Signs and Laboratory Findings A discrepancy may develop between pulses or blood pressures in the two arms. Usual Course If there is a large aortic aneurysm, there can be chronic dull, central chest aching. Acute complications include acute aortic valvular incompetence, occlusion of major vessels, hypotension, and death. Social and Physical Disability the main problems with aortic aneurysms are life and death considerations. Pathology "True" aneurysms involve all three layers-intima, media, and adventitia.

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