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Contains codeine 12 mg and acetaminophen 120 mg per 5 ml.

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Please respond to the 2 following discussion posts separately with separate reference lists. References to be no older than 5 years.

1. Marilynn Bohnstedt-Casey posted Sep 8, 2022 6:54 PM
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Pediatric Peritonsillar Abscess (PTA)

PTA or quinsy is the most common abscess of the head and neck region, presenting as a suppurative infection of the tissues between the capsule of the palatine tonsil and pharyngeal muscles (Medscape.com, 2022).

Etiology:

Most PTAs are polymicrobial, aspiration is utilized to assess the bacteria, more than half of the aerobic and anaerobic isolates can be beta-lactamase producers, and streptococcus pyogenes may be absent in over half of the cases, with the causative organisms being anaerobic bacteria (Medscape.com, 2022).

Epidemiology:

Most pediatric cases are in children 10 years of age or older, but may occur in younger children, 14 pediatric cases per 100,000, 25% to 30% of cases in the United States.

Pathophysiology:

PTA usually manifests in the superior pole of the tonsil but may occur in multiple locations in the peritonsillar space. Two pathways are speculated to contribute to the development of PTA, beginning with the inadequate treatment of bacterial tonsillitis, or originating in the Weber glands, salivary glands within the supratonsillar fossa, it can be a gradual process starting as peritonsillar cellulitis, which is either untreated or insufficiently (Medscape.com, 2022).

Clinical Manifestations:

PTA presents with a sore throat, uvula deviation, fever, trismus, tenderness, neck swelling, and dysphagia (Allen et al., 2019). Condition also lasting from 5 to 7 days and is not improved with antibiotics (Medscape.com, 2022). Treatment may be delayed if mistaken for peritonsillar cellulitis, which can lead to serious complications such as a compromised airway, sepsis, and brain abscess (Allen et al., 2019). Aside from peritonsillar cellulitis, differential diagnosis includes dental abscess, epiglottitis, intratonsillar abscess, Lemierre syndrome, lymphoproliferative disorders, retropharyngeal abscess, severe tonsillopharyngitis, and supraglottitis (Medscape.com, 2022).

Work-Up:

Almost all patients respond following drainage and antibiotic therapy, regardless of culture results. Determining antimicrobial susceptibility is a prudent measure in directing antimicrobial therapy particularly with complications and in immunocompromised patients (Medscape.com, 2022). Labs include CBC with differential, serum electrolyte levels if patient is dehydrated, throat culture, and serum blood culture for both anerobic and aerobic bacteria.

Treatment:

Direction of treatment depends upon the degree of airway obstruction, if the child is in distress, drooling, and posturing, continuous monitoring is essential, hospitalization may be required in case emergency cricothyroidotomy or tracheotomy is necessary (Medscape.com, 2022). Three drainage procedures are needle aspiration, incision and drainage, and tonsillectomy.

For outpatient management, a beta-lactam antibiotic is preferred. Amoxicillin plus clavulanate (Augmentin) is the drug of choice. For children >3 months, base dosing protocol on amoxicillin content, due to different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250 mg chewable-tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Analgesic recommended, acetaminophen with codeine elixir, for the treatment of mild to moderate pain. Contains codeine 12 mg and acetaminophen 120 mg per 5 mL.

Follow-Up & Education

Checking in response to treatment within 24 hours is recommended. Educating parents on finishing antibiotics as prescribed and alerting providers if any changes, and keeping the child hydrated.

References

Allen, D.Z., Rawlins, K. Onwuka, A., Elmaraghy, C.A. (2019). Comparison of inpatient versus

outpatient management of pediatric peritonsillar abscess outcomes, International Journal

of Pediatric Otorhinolaryngolog. https://doi.org/10.1016/j.ijporl.2019.04.025.

Medscape.com (2022). Pediatric peritonsillar abscess. Retrieved from

https://emedicine.medscape.com/article/970260-overview#a7

2. Bernardo Isla posted Sep 8, 2022 12:38 PMLast edited: Thursday, September 8, 2022 12:40 PM PDT
Etiology

Asthma is a syndrome characterized by airflow obstruction that varies spontaneously and with specific treatment. Chronic airway inflammation causes airway hyperresponsiveness to various triggers, leading to airflow obstruc­tion and respiratory symptoms, including dyspnea and wheezing. Although asthmatics typically have periods of normal lung function with intermittent air­flow obstruction, a subset of patients develops chronic airflow obstruction (Copstead & Banasik, 2019).
Epidemiology

Asthma generally affects almost 25 million people in the United States, and it is considered the most common chronic disorder in children, with an estimated 15% of total cases (Cash et al., 2021).

Clinical Manifestation

Common respiratory symptoms of Asthma include wheezing, dyspnea, and cough. These symptoms often vary widely within a particular individual, and they can change spontaneously or with age, the season of the year, and treatment. Symptoms may be worse at night, and nocturnal awakenings are an indicator of inadequate asthma control. Sometimes there are variations in symptoms regarding the current season or environment. Some even complain of chest discomfort and tightness during activity (Cash et al., 2021).

Pathophysiology

Asthma is a type of airway obstruction due to the activation of mast cells. The process begins after exposure to an allergen. Then, 30 minutes later, a rapid Immunoglobulin (IgE) response occurs due to environmental substances leading to vasodilation, smooth muscle contraction and excessive mucus production. Some common triggers are animal dander, dust mites, weather changes, certain drugs and viral infection. Then, the late phase reaction happens two to four hours after the acute phase. This late phase is famous for infiltrating the inflammatory cells into the airway, which is the main culprit in the chronic inflammation seen in the disease.

Diagnostic Tests

The gold standard in diagnosing Asthma is spirometry. In the clinic, patients are evaluated for the forced vital capacity and expiratory volume in one second and do it before and after a bronchodilator (cash). On lung examination, wheezing and rhonchi may occur throughout the chest, typically more prominent in expiration than inspiration. When Asthma is adequately controlled, a physical exam may be normal. Spirometry often shows airflow obstruction, with a reduction in forced expira­tory volume in 1 second (FEV1) and FEV1/forced vital capacity (FVC) ratio. Bronchodilator reversibility is demonstrated by an increase in FEV1 by ≥200 mL and ≥12% from baseline FEV1 15 min after a short-acting β agonist (Papadakis et al., 2021). A chest radiograph and a complete blood count are also ordered to rule out the possibility of other infectious processes causing respiratory symptoms.

Diagnosis is also confirmed thru analysis of PEFR after the patient inhales the short-acting bronchodilator; if there is a 15%incerase in PEFR after 15 to 20 minutes, or the PEFR varies more than 20%or, there is greater than 15 % in PEFR after six minutes of exercise then Asthma is also confirmed (Cash et al., 2021).

Management

The most widely used class of bronchodilators is B2-adrenergic agonists, which relax airway smooth muscle by activating B2-adrenergic receptors. Two inhaled B2 agonists are commonly used in asthma treatment: short-acting B2 agonists (SABAs) and long-acting B2 agonists (LABAs) (Rosenthal & Burchum,2021). SABAs, which include albuterol, are effective rescue medications, but excessive use indicates inadequate asthma control. SABAs can prevent exercise-induced Asthma if administered before exercise. LABAs, which include salmeterol and formoterol, have a slower onset of action but last for >12 h. LABAs have replaced the regularly scheduled use of SABAs; they do not control airway inflammation and should not be used without inhaled corticoste­roid (ICS) therapy. Combinations of LABAs with ICS reduce asthma exacerba­tions and provide an excellent long-term treatment option for asthma severity of persistent moderate degree or more significant (Rosenthal & Burchum,2021). Another excellent resource to use in managing Asthma is located at this website www.ginastma.org. This website contains the latest information about asthma management and recommendation.

Patient education

Patient education will focus on reducing the triggers of Asthma, such as furry animals, cockroaches, dust mites, pollens and moulds. In addition, creating an asthma action plan with the patient is also recommended. This plan must stipulate the essential activities or reminders a patient must have or remember to decrease the attacks and severity of Asthma. Finally, education about the different medications for Asthma must be reinforced during every clinic visit to make sure that the patient understands the action and proper usage of the medicines.

References

Copstead, L. E., & Banasik, J. L. (2019). Pathophysiology. Elsevier Saunders.

Cash, J. C., Glass, C. A., & Mullen, J. (2021). Family practice guidelines. Springer Publishing Company.

Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2021). Current Medical Diagnosis & Treatment. McGraw-Hill Education.

Rosenthal, L.D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for Advanced Practice Nurses. (2nd ed.). St. Louis, MO: Elsevier.

 

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