Know Presentation, Diagnosis, and Management

Diagnoses List

1. Acute Bronchitis

• Description: Acute bronchitis is characterized by an inflammation of the bronchioles, bronchi, and trachea, leading to a persistent cough. This condition typically follows an upper respiratory infection or exposure to chemical irritants.
• Etiology: The primary causes of acute bronchitis include viral infections such as Adenovirus, Rhinovirus, Influenza A and B, and Parainfluenza.
• Risk Factors: Several factors increase the likelihood of developing acute bronchitis, including recent upper respiratory infections, exposure to air pollutants, smoking, secondary exposure to smoke, reflux esophagitis, allergies, chronic obstructive pulmonary disease (COPD), acute and chronic sinusitis, infancy, old age, and immunosuppression.
• Assessment Findings: Common symptoms include a cough that starts dry and nonproductive and may become productive and purulent over time, upper respiratory infection symptoms, fatigue, fever (especially in bacterial infections, smokers, or patients with COPD), chest discomfort, crackles or wheezes, and chest wall pain.
• Differential Diagnosis: Conditions to consider in differential diagnosis include pneumonia, tuberculosis, and asthma.
• Diagnostic Studies: Chest radiographs are advised if there is tachypnea, hypoxia, fever, or an abnormal lung exam. A chest X-ray is recommended if there is a high suspicion of pneumonia or superimposed heart failure. Consider PPD testing, with the expectation of a negative result.
• Prevention: Preventive measures include smoking cessation, avoiding known respiratory irritants, and treating underlying conditions such as asthma or gastroesophageal reflux disease. Influenza immunization is recommended for high-risk populations.
• Nonpharmacologic Management: Non-drug therapies include increasing fluid intake, using a humidifier, getting adequate rest, and smoking cessation. Honey may be considered for children older than one year. Patient education on disease management, treatment expectations, and emergency actions is crucial.
• Pharmacologic Management: Medications include cough suppressants for nighttime relief, with caution against using antihistamines. Antibiotics are indicated if the cause is bacterial, and antivirals may be used if influenza is diagnosed. Decongestants and antihistamines are generally ineffective unless sinusitis or allergy is present. Bronchodilators may be prescribed if there is wheezing or a history of asthma.

2. Acute Laryngopharyngitis

• Description: Acute laryngopharyngitis is an inflammation of the pharynx and tonsils, primarily caused by viruses. Accurate diagnosis and treatment are crucial to prevent complications such as rheumatic fever, post-streptococcal glomerulonephritis, peritonsillar abscess, lymphadenitis, and mastoiditis.
• Etiology: Common viral causes include Rhinovirus, Adenovirus, Parainfluenza, Epstein-Barr virus (mononucleosis), and Respiratory Syncytial Virus (RSV). Bacterial causes may involve Group A beta-hemolytic Streptococcus, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Neisseria gonorrhoeae.
• Incidence: Acute laryngopharyngitis is prevalent in school-aged children but can affect all age groups. It is more common during winter months and accounts for a significant percentage of pharyngitis cases in both children and adults.
• Risk Factors: Risk factors include age, exposure to Group A beta-hemolytic Streptococcus during outbreaks, and a family history of rheumatic fever, which increases the risk if GABHS is untreated.
• Assessment Findings: Symptoms include a sore throat, pharyngeal edema, tonsillar exudate, malaise, and fever. Signs suggestive of streptococcal pharyngitis include cervical adenopathy, high fever, absence of other upper respiratory symptoms, petechiae on the soft palate, and a distinct odor associated with streptococcal tonsillitis.
• Differential Diagnosis: Differential diagnoses include upper respiratory illness, tonsillitis, and mononucleosis.
• Diagnostic Studies: Rapid antigen strep tests are highly specific and should be confirmed with a throat culture in children if negative. Adults typically do not require confirmation due to a lower risk of complications.
• Prevention: Preventive measures include avoiding contact with infected individuals, practicing good hand hygiene, and promptly treating those with a family history of rheumatic fever.
• Nonpharmacologic Management: Treatment includes gargling with warm salt water, increasing fluid intake, and educating patients on disease management. Changing toothbrushes after treatment is recommended to prevent reinfection.
• Pharmacologic Management: First-line antibiotics for streptococcal pharyngitis include amoxicillin and penicillin V. For penicillin-allergic individuals, alternatives include cephalexin, cefadroxil, clindamycin, or macrolides. Antibiotics are not beneficial for non-strep pharyngitis, except in cases involving specific pathogens like Corynebacterium diphtheriae or Neisseria gonorrhoeae.

3. Acute Maxillary Sinusitis

• Description: Acute maxillary sinusitis, also known as acute rhinosinusitis, is an inflammation of the paranasal sinuses, often following a viral upper respiratory infection. It can be caused by bacteria, viruses, fungi, or allergens and may progress to a more chronic condition if left untreated.
• Etiology: Common bacterial causes include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Viral causes often involve Rhinovirus, Coronavirus, Influenza A and B, and Parainfluenza virus.
• Incidence: Sinusitis affects individuals of all ages, with a slightly higher prevalence in women. It is most common during early fall and spring, affecting 13% of adults annually.
• Risk Factors: Risk factors include allergies, asthma, dental abscesses, smoking, upper respiratory infections, cystic fibrosis, immune deficiencies, and anatomical abnormalities such as nasal polyps or a deviated septum.
• Assessment Findings: Symptoms include persistent upper respiratory infection symptoms lasting more than 10-14 days, nasal congestion, purulent or bloody discharge, headache, facial pain or pressure, sore throat, anosmia, halitosis, and postnasal discharge.
• Differential Diagnosis: Conditions to consider in differential diagnosis include viral URI, allergic rhinitis, nonallergic rhinitis, dental abscess, headaches, nasal foreign body, and Wegener’s granulomatosis.
• Diagnostic Studies: Diagnostic studies may include CBC to assess for elevated WBC count, sinus X-rays to detect opaque areas or air-fluid levels, and CT scans to evaluate recurrent sinusitis. Transillumination may also be used to detect opacification with air-fluid levels.
• Prevention: Preventive measures include avoiding irritants that cause mucosal swelling, practicing good hand hygiene, and managing allergic rhinitis.
• Nonpharmacologic Management: Management strategies include avoiding environmental irritants, using humidified air, increasing fluid intake, elevating the head of the bed, and patient education on disease and treatment options.
• Pharmacologic Management: Watchful waiting is recommended for acute infections lasting less than 10 days. Antibiotics such as amoxicillin-clavulanate are first-line treatments for bacterial infections. Decongestants, analgesics, topical intranasal steroids, and saline irrigation may also be used. Chronic rhinosinusitis may require oral steroids, and saline irrigation is recommended as adjunctive therapy.

4. Allergic Rhinitis

• Description: Allergic rhinitis is an inflammatory condition affecting the mucous membranes of the nasal tract, characterized by IgE-mediated responses leading to mucosal edema, clear discharge, sneezing, and nasal stuffiness. It can be seasonal, perennial, or episodic.
• Etiology: Allergic rhinitis is triggered by substances that cause an IgE-mediated response, such as pollens, mold, animal dander, and dust mites.
• Incidence: The condition affects 10-20% of children and 20-30% of adolescents, with symptoms often diminishing with age. It typically presents between the ages of 10 and 20.
• Risk Factors: Risk factors include a family history of allergies, other atopic diseases, repeated exposure to allergens, and nonadherence to treatment.
• Assessment Findings: Common signs include allergic shiners, conjunctival injection, pale and boggy nasal mucosa, a transverse crease on the nose (allergic salute), mouth breathing, dry lips, sore throat, and enlarged tonsils or adenoids.
• Differential Diagnosis: Conditions to consider in differential diagnosis include vasomotor rhinitis, rhinitis medicamentosa, infections, tumors, nasal foreign bodies, and the common cold.
• Diagnostic Studies: Diagnostic studies may include CBC to detect eosinophilia, allergy testing, and imaging studies such as a CT scan if infection is suspected.
• Prevention: Preventive measures focus on minimizing exposure to allergens, adherence to treatment, and avoiding known triggers.
• Nonpharmacologic Management: Management includes avoiding allergens, frequent vacuuming, and dusting, removing feather pillows, using air filters, and eliminating carpets. Immunotherapy or referral to an allergist may be necessary for refractory cases.
• Pharmacologic Management: Treatment options include saline nasal sprays, antihistamines, nasal steroids, combination therapies, systemic steroids, topical cromolyn, leukotriene modifiers, and decongestants.

5. Anxiety

• Description: Anxiety is a psychological and physical response to perceived threats, characterized by feelings of dread, apprehension, and panic. It can manifest as acute or chronic and is often associated with various psychiatric disorders.
• Etiology: Anxiety may result from genetic, behavioral, and biological factors, including dysregulation of neurotransmitters like norepinephrine, serotonin, and GABA, autonomic nervous system responses, and functional cerebral pathology.
• Incidence: Anxiety disorders are the most common psychiatric conditions in the United States, with a lifetime prevalence of 7.7%. They are more prevalent in women and typically begin in childhood or early adulthood.
• Risk Factors: Risk factors include organic causes like endocrinopathies and cardiorespiratory disorders, substance use, psychosocial stressors, and coexisting psychiatric disorders.
• Assessment Findings: In children, symptoms may include excessive anxiety about separation, unrealistic worry, and persistent fear. In adults, common symptoms include apprehension, restlessness, insomnia, somatic complaints, and excessive rumination.
• Differential Diagnosis: Differential diagnoses include obsessive-compulsive disorder, personality disorders, depression, bipolar disorder, PTSD, cognitive disorders, and medical conditions that stimulate the sympathetic nervous system.
• Diagnostic Studies: Diagnostic evaluations may include TSH, CBC, urinalysis, urine drug screen, and psychological testing such as the Hamilton Anxiety Scale or the Zung Anxiety Self-Assessment.
• Nonpharmacologic Management: Management strategies include psychotherapy, regular exercise, a healthy diet, adequate sleep, and relaxation techniques. Education about the condition and treatment plan is essential.
• Pharmacologic Management: Pharmacologic options include selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), benzodiazepines (for short-term use), and beta blockers for specific phobia-related anxiety. Careful monitoring and patient education are essential, particularly regarding the risk of increased suicidality in children and adolescents taking SSRIs.