HEENT- PANCE
vitreous hemorrhage
bleeding into vitrea; can be caused by retinal tear, macular degeneration, straining, etc.; causes sudden loss of vision & floaters; tx w/ surgery
ciprodex
combination of ciprofloxacin hydrochloride & dexamethasone; used to treat otitis externa; okay to use with TM perforation
congenital nasolacrimal duct obstruction
common in infants; blocked tear duct
optic neuritis
common in multiple sclerosis sudden loss in 1 eye MRI --> demyelination Tx: methylprednisone IV and neuro consult
What finding would help to differentiate between labyrinthitis and vestibular neuronitis?
Labyrinthitis commonly has hearing loss - Vestibular neuronitis does not have hearing loss
treatment for otitis media
amoxicillin macrolide augmentin
What is the first line antibx for OM?
amoxicillin, treatment with cephalosporin, bactrim or azithromycin may be acceptable in resistant cases, cefaclor or augmentin may be beneficial
blowout fracture
-sx- decreased visual acuity, diplopia with upward gaze, orbital emphysema, ENOPHTHALAMOS -dx- CT scan -tx- initial- nasal decongestants, avoid blowing nose, predisone---Opthlo Referal!!!
It's rare, but these two bugs can cause bacterial conjuncitvitis. Normal bugs are (strep pneumo, staph aureus, haemophilus aegyptius and moraxella)
chlamydia tachomatis and neisseira gonorrheae
blepharitis
chronic bilateral inflammatory condition of lid margins; presents with eye irritation, crusting, scaling, red-rimming of eyelid, eyelash flaking, etc
blepharitis
chronic inflammation of lid margins
8
chronic sinusitis is a sinusitis that lasts >___ weeks
describe open angle glauccoma
chronic, asymptomatic, and potentially blinding disease due to increased intraocular pressure
chalazion
chronic, nontender inflammation of a Meibomian gland;
What are RFs for developing sinusitis?
cigarette smoke or exposure to secondary smoke, hx of trauma and presence of a foreign body
treatment for otitis externa
cipro drops; if the external auditory canal is edematous use an ear wick and removve in 2-3 days
sx of allergic conjunctivitis
cobblestoning, stringy discharge
triamcinolone
common topical steroid used to treat aphthous ulcers
S&S of acute OM
ear pain, decreased hearing
visual acuity
how clearly the patient sees
This condition can occur with inadequate treatment of OM. Signs and symptoms are spiking fever and post auricular pain, erythema and fluctuant painful mass.
mastoiditis
posterior ischemic optic neuropathy
neuropathy involving the retrobulbar optic nerve; doesnt cause any optic disk swelling; can be caused by severe blood loss, nonocular surgery or dialysis
Your diabetic pt has venous dilation, microaneurysyms, retinal hemorrhages, retinal edema, hard exudates is this a sign of non proliferative or proliferative diabetic retionopathy
non
tx of macular dengeration
none laser tx or monoclonal AB (anti-VEGF) injections may slow progression
lymphadenopathy
normal lymph nodes <1cm in length; can be mono (posterior) or strep (anterior); treat underlying condition
early SCC
raised, firm pearly or verrucous plaque in the mouth
sx of barotrauma to ear
slight hearing loss, ear pain, dizzy, feeling of fullness in ear
lymphadenopathy
solitary lymph node > 1 month? consider lymphoma
common orgs in dacryocystitis
staph aureus, beta-hemolytic strep, h flu
preseptal orgs
staph aureus, staph epi, strep sp.
postseptal orgs
staph aureus, strep pneumo, anaerobes
Pterygium
starts from nasal conjunctiva triangular surgery
What is usu. the bacterial etiology of sinusitis? (bugs)
step pneumo, h. influenzae and less often s. aureus
enophthalmos
sunken eyes
sx of macular dengeration
drusen deposits, loss of nutritional supply, atrophy, neovascularization, gradual vision loss, metamorphopsia (wavy vision), mottling and hemorrhages on retina
trachoma
effect from chlamydial conjunctivitis; #1 cause of infectious blindness worldwide
what defines chronic otitis media
effusion greater than 3 months and refractory to antibiotics. 3 or more infections in 6 months 4 or more infections in one year
pterygium
elevated, superficial, fleshy, triangular-shaped "growing" fibrovascular mass - MC in inner corner/ nasal side of eye and extends laterally - thickening of bulbar conjunctiva - associated with increased UV exposure in sunny climates as well as sand, wind, dust - observation in most cases (artificial tears) - removal if growth affects vision
cause of Retinal artery occlusion
emboli, THROMBOTIC event, vasculitis
What a serious consequence of untreated otitis media in the pediatric patient? (conjunctivitis, meningitis, mastoiditis, sepsis)
mastoiditis
Septum, turbinate, and floor
mucosa is pink and moist without lesions
Patency
nasal passageways are patent
Neck motion
neck is supple
External Eye
no exophthalmos, ptosis, periorbital discoloration, edema or skin lesions
tx of Retinal artery occlusion
ohpthalmologist-->vessel dilation and paracentesis workup and manage atherosclerotic ds
erythromycin, bacitracin
ointment used to treat hordeolum, acute anterior blephraitis, corneal abrasion & bacterial conjunctivitis
clinical features of a blowout fracture
swelling and misalignment. movement restricted especially inability to look up due to entrapment of infraorbital nerve. double vision and sub-q emphysema
labyrinthitis
swelling of inner ear from infection, autoimmune
Etiology of apthous ulcers
Idiopathic or herpes
Risk factors of Macular degeneration?
Age Smoking CAD Fam history
Retinal artery occlusion
Amaurosis fugax. Pale retina
Small, mildly painful nodule within a gland on the eyelid
Hordeolum
preseptal cellulitis associated with what illness
URI
cyclosporin (restasis)
immunosuppressant treatment for keratoconjunctivitis
the inflammation of what gland is involved with a chalazion
meibomian gland
What is the final step in Glaucoma work-up?
1. Cup:disc ratio > 0.5 2. Tonometry > 21mmHg 3. Peripheral field testing
Painless nodule of the eyelid?
Chalazion
Laryngitis
typically viral and follows URI
A white plaque-like oral lesion which does scrape off?
Oral candidiasis
ocular steroids
- increase IOP, cataracts, scleral thinning and corneal metling - predisnolone
for conjunctitvis must rule out
- ueitis, acute glaucoma, corneal disorders
chalazion
PAINLESS, indurated lesion, redness tx warm compress, I&D if not resolved
entropion
turns in
Retinal detachment:
"FLOATERS" or flashes of light. field loss. curtain.
herpes simplex tx
- oral acyclovir - topical antivirals - topical steroids may worsen disease
Acute OM -1st line Abx
-Amoxicillin
Complication of OM
-Mastoiditis
A patient has a 2-day history of an itchy red left eye and marked tearing. There is no history of injury. On physical exam the conjunctiva appear markedly erythemic. What physical finding would help most in differentiating this as a viral conjunctivitis?
A palpable pre-auricular lymph node is most often seen with viral conjunctivitis and rarely seen in bacterial conjunctivitis.
Most Conjunctivitis is likely caused by which type of microorganism?
A virus (adenovirus, herpes zoster), which is *very* contagious!
What type of antibiotic (delivery method) should be used for corneal abrasions/ulcers?
Abx Ointment
tx of auricular hematoma
All should be drained ASAP after injury >7 days refer to an otolaryngologist or plastic surgeon for debridement of new perichondrial growth and any remaining hematoma.
preseptal cellulitis tx
Amoxicillin/Clavulanic Acid or 1st gen ceph
Which type of Glaucoma is an *acute* issue?
Angle-closure
Treatment for brachial cleft cyst?
Antibiotics for acute infection; surgical excision for definitive treatment
Cold Thyroid Nodule
Associated with thyroid cancer
Treatment for acute labyrinthitis?
Bed rest hydration diazepam and short course steroids if needed
An unvaccinated 6 year old male presents with bilateral parotid swelling and pain with eating. What is the most likely pathogen causing his condition?
Paramyxovirus
Acute onset of copious purulent discharge from both eyes
Bacterial Conjunctivitis clinical features
If you suspect mastoiditis after an OM infection what can help you with the dx?
CT
What is imaging test done for orbital cellulitis?
CT
dx of cavernous sinus thrombosis
CT, MRI or MR venogram CBC blood cultures and sinus cultures
How will retinal artery occlusion appear on fundoscopic exam?
Cherry red spot on macula
Mucopurulent discharge with a marked follicular response on inner lids (bacterial conjunctivitis)
Chlamydia bacterial conjunctivitis
Painful eye and loss of vision Anterior chamber narrowed Intraocular pressure elevated EMERGENCY
Closed-Angle Glaucoma clinical features
IV carbonic anhydrase inhibitor (Acetazolamide) Topical BB Osmotic diuresis (mannitol)
Closed-Angle Glaucoma treatment
What is a Cataract?
Clouding of the lens
"Pink eye" is aka...
Conjunctivitis
18
Come closer - look at all 4 quadrants - brace with hand
What is the treatment for a pt undergoing Retinal artery occlusion?
Considered a form of stroke - Stroke protocol must be taken
peritonsillar abcess
MC- S. virdians -sx- hot potato voice, uvular devated to contrlateral side -dx- CT -tx- I and D. clindamycin
Strabismus
Correct by 4 months. Cover/uncover test
Sinutitis
MC= maxillary. chronic= staph A. MC, mucurmycosis in pts with DM -sx- cocurrent rhinitis that follows URI. sinus tenderness on palpation. 1-4 weeks -dx- CT scan. Xray= waters view -tx- amoxicillin 10-14 days, intranasal glucocorticoids (nasacort)
What is the treatment for a ptergyium?
Excision if it interferes w/ vision, recurrence is common
What is the preferred treatment for a thyroglossal duct cyst?
Excision of cyst and tract (after acute infection resolves)
What is the first line treatment for bacterial sinusitis?
First line empiric treatment: Amoxicillin-clavulanic acid - Consider doxycycline, levofloxacin or moxifloxacin
Introduction
I am PA-S Rock star
5 - EARS
Inspect - external ears - mastoid process
Allergic Conjunctivitis
Itch, bilateral eye condition Tx with oral antihistamines.
Macula
Look into the light: macula is without lesions
sinusitis
MCC is VIRAL Dx: plain film Water's view Gold Std = CT SCAN adult = MAXILLARY pediatric = frontal
What is contraindicated for hyphema?
NSAIDS - increased bleeding
What is the condition of acute inflammation & demyelination of the optic nerve?
Optic Neuritis
Ptosis, eyelid edema, exophthalmos Purulent discharge, conjunctivitis EMERGENCY
Orbital Cellulitis clinical features
Organism which causes malignant otitis externa?
Pseudomonas
Most common type of laryngeal cancer?
Squamous cell
Findings seen on lateral neck X-ray in patient with epiglottitis?
Thumbprint sign
Name BB's used for OA Glaucoma tx
Timolol Betaxolol
Other tx for acute angle closure glaucoma?
Timolol Pilocarpine Apraclonidine Laser iridotomy
Which of the following examinations is a major component of routine monitoring of chronic, open angle glaucoma?
Tonometry, gonioscopy, monitoring of the disc-to-cup ratio, and visual field examination are the routine exams done when monitoring primary open angle glaucoma.
Treatment for otitis externa?
Topical antibiotic drops to affected ear (fluoroquinolone or other covering pseudomonas)
Lesion of the RIGHT optic nerve will cause what visual symptoms?
Total blindness of the right eye.
Patients who have nasal packing placed to control epistaxis must a have close follow up to remove packing in order to decrease the chance of what complication?
Toxic Shock Syndrome
What are the TORCH infections?
Toxoplasmosis Other (Syphilis) Rubella Cytomegalovirus Herpes Simplex Virus
Pharyngitis
Treatment of this condition with ABX is intended to prevent rheumatic myocarditis, scarlet fever, local abscess formation, and glomerulonephritis. May present with a sore throat, odynophagia, fever, anterior cervical adenopathy, tonsillar exudates, scarlatiniform rash. Dx with rapid antigen testing and culture. CBC may show leukocytosis. Most commonly caused by Group A Beta Hemolytic Strep (Strep pyogenes). Other causes may be N gonorrhea, mycoplasma, Chlamydia, corynebacterium, diphtheria, clostridium. Tx with Pen VK for 10 days. Erythromycin for PCN allergic pts. Supportive treatment with analgesics, NSAIDs, salt water gargling, and anesthetic lozenges.
T/F: Cataracts tend to be *bilateral*?
True
Tx of Hordeolum?
Warm Compress Oral abx c/ staph coverage only if local cellulitis
Hordeolum
Warm compress
bacterial keratitis
bacterial infection of the cornea; diagnosed with a hazy cornea with a central ulcer & adjacent stromal abscess; treated wtih topical fluoroquinolones
How do you treat a hordeolum (stye)?
Warm compress several times a day for 48 hrs, topical antibiotics if secondary infection develops Incision and drainage may be indicated if it does not resolve
What's the tx for a Chalazion?
Warm compresses, possibly incision & curettage
What MUST be considered when a hyphema occurs but no mention of trauma?
Underlying blood dyscrasia or coagulopathy
Dacroadenitis may be caused by stone, debris or dacryostenosis. Dacrostenosis may be congenital malformation and the duct does not open in the first year of life. What is tx in that case?
Usually self-resolving within first year of life.
15
Visual acuity (Snellen chart)
water's view
X-ray view to diagnose acute sinusitis
treatment for macular degeneration
anti-VEGF
nasal polyps
benign growths in the nose; unknown cause; seen with allergic rhinitis; causes chronic nasal obstruction, snoring & post-nasal drip; treated with intranasal or oral corticosteroids, polypectomy
vocal fold paralysis
can be caused by thyroid/neck surgery, or tumors; causes breathy dysphonia & effortful speech; treated with speech therapy
SCC of larynx
cancer of the larynx almost exclusively seen in smokers; causes change in voice quality
aphthous ulcers
canker sores; causes single/multiple, painful, small, round ulcers; treated with topical analgesics or steroids
acetazolamide
carbonic anhydrase inhibitor used to treat acute angle-closure glaucoma & retinal artery occlusion
slow loss of vision, contrast sensitivity, glare, halo around lights. what dx
cataract
hematoma of external ear
cauliflower ear must drain blood and pressure to prevent deformity boxers, trauma
infectious mononucleosis
caused by EBV; causes severe tonsillitis, splenomegaly/hepatomegaly, fatigue, posterior lymphadenopathy, etc; diagnosed with monospot; treated with supportive care, corticosteroids, pain relievers
fungal sinusitis
caused by aspergillus; almost always seen in immunocompromised patients; symptoms similar to bacterial rhinosinusitis; treated with surgical debridement & amphotericin B IV
chronic otitis media
complication of acute otitis media; caused by p. aeruginosa, proteus, & staph aureus; causes purulent aural drainage & conductive hearing loss; treated with removal, earplugs, & antibiotics
herpes zoster opthalmicus
complication of herpes zoster on the face that affects ophthalmic division of trigeminal nerve; treated with acyclovir, valcyclovir, famcyclovir
Peritonsillar abscess
complication of strep throat
artificial tears
eye drops used to treat keratoconjunctivitis sicca & pterygium
tonal tinnitus
hearing "tone" sounds
uveitis
intraocular inflammation
macular degeneration
leading cause of permanent vision loss in older population; presents with graudal bilateral blurred or loss of central vision, scotomas, micropsia, etc; treated with vitamin supplements, laser coagulation & intra-vitreal injections
sialogogues
lemon drops; used to treat sialadenitis & sialolithiasis
dacryocystitis tx
lid hygiene topical bacitracin and erythromycin OR systemic if severe with tetracycline
MCC dental abscess
periapical abscess, and the second most common is a periodontal abscess
sx of orbital vs periorbital cellulitis
periorbital: NONTENDER EOM, normal visual acuity orbital: TENDER EOM, impaired visual acuity, proptosis, OPTHALMOPLEGIA -hx of sinusitus, strep pneumo
acute angle closure glaucoma
peripheral vision loss
Leukoplakia
precancerous white oral plaque
presbyopia
the natural loss of accommodative capacity with age (starts ~45); corrected with plus lenses
Trachea positon
trachea is midline and mobile
causes of hyphema
trauma eye cancer DM sickle cell
consists of bogginess of the nasal mucosa associated with a complaint of stuffiness and rinorrhea. symptoms are labile and can clear quickly
vasomotor rhinits
AV nicking
venous compression at artery-venous junction by increasing arterial pressure; may lead to central retinal vein occlusion; seen with hypertensive retinopathy
true or false: ectropion and entropion are common in older people
true
wet vs dry macular dengeration
wet: new blood vessels grow under macula, leak dry: light sensitive cells in macula slowly break down, straight lines appear crooked
If a patient is having a POSTERIOR nasal bleed, what is the usu. location?
woodruff plexus anterior would be keissenbachs plexus
ectropion
turns out
treatment for chronic otitis media
tympanostomy tubes
traction
type of retinal detachment; adhesions separate retina from its base
tx of papilledema
underlying cause
How would Fundoscopic exam show with retinal vein occlusion?
"Blood and thunder retina" Superficial retinal hemorrhages
Otitis Externa
"Swimmers Ear" Caused by gram-negative rods (Pseudomonas, Proteus), or fungi (Aspergillus). May present with a history of water exposure or mechanical trauma. Painful erythema and edema or external auditory canal. Purulent exudate and pruritus. May evolve into osteomyelitis of skull base (malignant variant) in diabetic or immunocompramised patients (think pseudomonas). Dx with CT and radionuclide scanning. Prevent exposure to moisture or trauma. Remove purulent debris. Tx with drying agent, otic abx drops (aminoglycoside or quinolone with or without corticosteroid). Treat malignant variant with prolonged IV or oral antipseudomonal abx.
orbital floor fracture
"blowout fracture"; fracture of the orbital floor due to trauma; presents with decreased visual acuity, enophthalmos, diplopia with upward gaze & orbital emphysema; treated with nasal decongestants, oral antibiotics, ice packs & surgical repair
follow up for corneal abrasion
- 48 hours and avoid contacts for 1 week after healing
cataract locations and tx
- cortical, nuclear, posterior subcapsular - surgery - improvement in 95% of patients
blowout fracture
- direct trauma to zygomatic prominence or to soft tissue of the orbit - pressure blows out weak orbital floor - double vision: entrapment of inferior rectus or inferior oblique - limited upward gaze - infraorbital anesthesia - diagnosis: plain films and CT scan - tx: surgery may be required
corneal abrasion
- superficial irregularities of the cornea - caused by foreign bodies - injury, welders arc, contact lens - pain, PHOTOPHOBIA, redness, blurry vision, small pupil - check visual acuity first - flourescein stain - stained abrasion with cobalt filter
Resistant Acute OM -Abx
-Amox-clavulanate (Augmentin)
*growth of keratinizing aquamous epithelium of middle/mastoid process
-Cholesteatoma
Otitis Externa x3 MC pathogens
-Pseudomonas aeruginosa -Proteus -Fungi
Systemic sclerosis
-sx= tight, shiny, thickened skin. Crest syndrome= calinosis cutis, raynouds, claw hand (Sclerodactyly) sclerosis- trunk and proximal extremities -dx- + anti-centromere Ab, * Anti-SCL -tx- dmards, raynouds- CCBs
do not patch for more than
24 hours
Metallic foreign bodies may cause which finding in the eye?
A rust-colored discoloration at the point-of-entry
Unilateral, progressive hearing loss Impaired speech discrimination Continuous Vertigo
Acoustic Neuroma clinical features
Amoxicillin
Acute Otitis Media treatment
Demographically speaking, in whom is glaucoma *most common*?
African american pts >40 yrs who have a + Family Hx
Name the risk factors of developing Cataracts
Age Smoking ETOH Chronic systemic steroid use Sunlight exposure DM Metabolic syndrome Congenital TORCH infections
Which of the following is the third component of the atopic triad, besides allergic rhinitis and asthma?
Atopic dermatits, or eczema, is the third chronic finding, along with asthma and allergic rhinitis, in patients who are atopic. Urticaria are common in acute and chronic allergies.
Recurrent episodes of vertigo exacerbated by head movements?
BPPV (Benign Paroxysmal positional vertigo)
A 25 year old female has dizziness and a positive Dix-Hallpike. Her initial work up is negative. What is the most likely diagnosis?
Benign Paroxysmal Positional Vertigo
Who is at increased risk of developing Corneal Abrasions?
Contact lens users
Most common cause of blindness from retinal disease is a result of having...?
Diabetes
Which medical condition predisposes patient to malignant otitis externa?
Diabetes
Blindness in adults
Diabetic Retinopathy is the leading cause of...
Common complaints with Macular degeneration?
Difficulty driving & reading
Pharyngitis with progressive growth of grey-white membrane?
Diphtheria
Mono
EBV. maybe CMV fever/ cervical LAD/ pharyngitis
sx of blow out fracture
Enophthalmos (the eye is receded into the orbit) Orbital dystopia (the eye on the affected side is lower in the horizontal plane than the other) A significant consequence of fractures of the orbital floor is entrapment of the inferior rectus muscle and/or orbital fat
Blow out fracture
Enopthalmos and Distopia. Periocular ecchymosis, diplopia, infraorbital nerve damage.
Lid and lashes turned in secondary to scar tissue or spasm of orbicularis oculi muscles
Entropion
History & Physical/ENT/Ophthalmology A patient presents with the complaint of irritation of the left eye one day after gardening. He states "I think there is something in my eye." Which of the following findings is consistent with your suspected diagnosis? A. increased intraocular pressure B. rust ring C. hazy cornea D. fluorescein uptake
Explanations (u) A. Elevated intraocular pressure is seen with glaucoma. (u) B. Rust ring is seen with metallic foreign bodies. (u) C. Hazy cornea is seen with glaucoma. (c) D. Fluorescein dye uptake is diagnostic for corneal abrasion.
Inflammation and infection of the Moll or Zeis glands
External Hordeolum
Tx of hyphema?
Eye protection rest HOB at 30 degrees Beta adrenergic blockers or Carbonic anhydrase inhibitors
T or F. Coryza, hoarseness and cough are suggestive of strep pharyngits.
FALSE
T/F: Topical anesthetics are recommended for tx'ing Corneal Abrasions.
FALSE!! Do *NOT* give topical anesthetics for a Corneal Abrasion!!
What gastrointestinal disorder can lead to laryngitis if not treated?
GERD can cause laryngitis as acid may burn the laryngeal structures at night
Use of which of the following medications can result in hearing loss?
Gentamycin is an aminoglycoside, and can cause ototoxicity. Peak and trough levels must be drawn to determine the lowest effective dose. The remaining medications do not interfere with vestibular function.
Which multiple endocrine neoplasms (MEN) have medullary thyroid cancer?
MEN 2a and MEN 2b
Low sodium diet Diuretics (acetazolamide)
Meniere Disease treatment
S pneumoniae
Most common bacterial pathogen of Acute Sinusitis
Viral
Most common pathogen of Acute Pharyngitis
Retinal Vein Occlusion
Most commonly occurs secondary to a thrombosis event. May present as sudden, painless, unilateral blurring of vision, or complete vision loss. Afferent papillary defect on exam with "BLOOD AND THUNDER" retina (dilated veins, hemorrhages, edema and exudates). Vision typical resolves with time, at least partially. Thrombotic workup is warranted. 2 types: BRVO and CRVO
Known as "swimmer's ear"
Otitis Externa
Ear pain (esp with movement of tragus, auricle) Redness, swelling of ear canal Purulent exudate Associated with water exposure
Otitis Externa clinical features
Antibiotic drops - fluoroquinolone, aminoglycosides
Otitis Externa treatment
A 65-year-old male presents to you with complaints of decreasing hearing, along with difficulty discerning words when in conversations in noisy environments, such as restaurants. His only medication is simvistatin for hyperlipidemia. The following is his audiogram. He has bilateral decreased high frequency hearing loss, and decreased speech recognition. What is the most likely diagnosis?
Presbycusis is age related bilateral loss of high frequency hearing, and decreased word recognition. Presbystasis is age related balance disorder. Vestibular schwannoma (acoustic neuroma) causes unilateral hearing loss. Vestibulobasilar insufficiency results from atherosclerosis of the vertebral arteries, and can cause many symptoms including double vision, speech defects, vertigo, ataxia, and drop attacks.
Cimetidine
Recurrent Aphthous Ulcers treatment
Acute onset of painless blurred/blackened vision "curtain sign"
Retinal Detachment clinical features
Retinal artery occlusion
SUDDEN ONSET vision loss in 1 eye (monocular vision loss = amaurosis fugax)
List two infectious diseases which may cause hearing loss?
Syphilis - Lyme disease
Which pharmacologic agents have phototoxicity as a side effect? A. Tetracycline, penicillin, and metoprolol B. Penicillin, ketoconazole, and metrogel C. Doxycycline, hydrochlorothiazide, and naproxen D. Cephalexin, acetaminophen, and metoprolol
The answer is C. EXPLANATION: A phototoxic reaction is one that results from exposure to the drug and exposure to UV light. The reaction occurs in exposed sites.
A 73-year-old female with type 2 diabetes, hypertension, and hyperlipidemia presents to the outpatient clinic complaining of left ear pain, and a yellowish-green, foul-smelling discharge that began about 3 weeks ago. On physical examination, the patient is afebrile and examination reveals a markedly edematous left ear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized. Which of the following is the most likely causative agent for this patient's diagnosis? A. Escherichia coli B. Moraxella catarrhalis C. Pseudomonas aeruginosa D. Staphylococcus aureus
The answer is C. EXPLANATION: Malignant otitis externa is most commonly caused by pseudomonas (C). E coli (A) and S aureus (D) are less common causes of otitis externa, while S pneumoniae (E) and M catarrhalis (B) are common etiologies of acute otitis media.
Which physical exam finding differentiatesacne rosacea from acne vulgaris?
The characteristic lesions of acne rosacea are small papules,papulopustules, and telangiectasias with flushing. There are nocomedones present in acne rosacea.
An 8-year-old male with a history of atopicdermatitis presents with a localized rash, consisting of vesiclesand eroded lesions. He has a low-grade fever, but no other symptoms. Whatis the appropriate treatment?
The classic lesion of eczema herpeticum is described as a "punchedout" lesion, which refers to vesicles that have becomeeroded. Mild cases of eczema herpeticum can be treated on an outpatientbasis with oral acyclovir. More severe cases must be treated onan inpatient basis with IV acyclovir and oral antibiotics if superinfected.
A 54 year old male presents with dark thickened skin and soft pedunculated papules around his neck. He states that the lesions are asymptomatic. What disease process are the findings commonly associated with?
The thick dark plaque around the patient's neck is acanthosis nigricans. The papules are acrochordons (or skin tags). Both conditions are associated with metabolic syndrome. (Wolff & Johnson, p231)
A 46-year-old male comes into the emergency department complaining of severe left eye pain after a champagne cork hit his eye while trying to open a bottle on his honeymoon night. Visual acuity to the affected eye is limited to identifying finger movements only. A physical exam reveals the following findings. What is your diagnosis?
This image demonstrates a traumatic hyphema. There is an air-fluid level of blood in the anterior chamber of the eye. Treatment includes elevation of the head and dilation of the pupil. A corneal abrasion would demonstrate fluorescein staining of the cornea. A hypopyon is a collection of wbc's, or pus in the anterior chamber. A retinal detachment would only be visualized in the posterior eye with a direct ophthalmoscope.
Foreign Body in Auditory Canal
This might be where you find Barbie's missing shoe. Frequent in children. Remove material with hook or loop. Irrigation may be attempted unless material is organic (beans, insects) due to potential for item to swell. Immobilize insects with lidocaine before removal.
Gold standard to diagnose bacterial pharyngitis?
Throat culture
A 7 year old male presents with a soft, mid-line neck mass which rises with protrusion of his tongue. What is the most likely diagnosis?
Thyroglossal duct cyst
What condition must be ruled out in a patient who presents with vertigo and syncope?
Vertigo + syncope = vertebral basilar insufficiency until proven otherwise
When would Cobblestoning of palpebral conjunctiva occur?
Viral conjunctivitis - Recent URI? (Adenovirus most common) Allergic conjunctivitis - Other allergic triggers?
Most common site for posterior nose bleeds?
Woodruff's plexus
nystagmus
a rhythmic oscillating movement of the eyes & may be vertical or horizontal in nature; common with vertigo
viral conjunct common org
adenovirus 3
chronic OM tx
cipro abx drops
dx of cholesteatoma
clinical CT to check bony defects
neonatal conjunctivitis
conjunctival inflammation occurring within the first 30 days of life
photopsia
flashing lights
conductive hearing loss
otosclerosis, cerumen
hordeolum
painful. MCC staph
if you see a rust ring on when examining for foreign body of eye what is the treament
remove with rotating burr or refer to ophthalmologist
sx of papilledema
swollen disc blurred margins obliterated vessels asx or transient visual alterations
nasal polyps
sx- allergies, asprin allergy causing severe bronchospasms TRIAD- polys, allergies, asthma -dx- MUST R/O CYSTIC FIBROSIS -tx- 3 month course of topical corticosteroids
Gout/ pseudogout
sx- gout- 1st MTP. pseudogout- Knee. -dx- gout- rod shaped neg, birefinged urate crystals. mouse bite xray pseudogout- rhomoid shaped crystals. chondracacinosis xray -tx- NSAIDS ( indomethcin). pseudo- costicosteroid injections.
papilldema
sx- swelling of optic disk due to increase intracranial pressure. swollen optic disk, blurred disk cup margins****** -dx-MRI/CT to rule out head mass. LP (CSF increased pressure)*** -tx- underlying disorder. diruetics= acetazolamide
Hair and scalp inspection
symmetrical hair distribution, hair and scalp are without infestation, scaling, and lesions
Cranial nerve 12
tongue is midline with protrusion
physical exam for cataract
translucent yellow discoloration of lens. appears black on a red background on fundoscopy
causes of epistaxis
trauma, dry mucosa, coagulopathy
decongestants
treatment for ET dysfunction, barotrauma
30
treatment for chemical burns of the eye includes immediate irrigation for _____ mins or at least 2L of NSS
chemical labyrinthectomy
treatment for meniere syndrome; causes destruction of vestibular apparatus while retaining hearing
complete labyrinthectomy
treatment for meniere syndrome; results in complete loss of hearing
cyclopentolate
treatment for ultraviolet keratitis
vincent's angina
trench mouth
BPPV tx
watch and see 2 months eppley maneuver
test to help differentiate bettween conductive and sensorineural hearing loss
weber test
ectropion
- advanced age, trauma, infection, or palsy of the facial nerve
dry eye treatments
- artificial tears - lubricating eye ointment - restasis (cyclosporine)
chalazion
- painless granuloma of the internal meibomian sebaceous gland -sx- hard nontenfer eye swelling -tx- eyelid hyigene
allergic conjunctivits
- seasonal - patients with atopy (asthma, eczema) - hayfever - pruritis (severe) - PE: injection, mucoid discharge tx: topical vasoconstrictors or antihistamines - topical mast cell stabilizer
entropion
- secondary to scar tissue or spasm of the orbicularis oculi muscles
vernal conjunctivitis
- seen in teens/young adults - associated with systemic atopy - mainly seen in the spring - cobblestone apperance - tx: topical steroids
carpal tunnel syndrome
-sx- parasthesias and pain of 1st 3rd digits esp thenar muscle wasting -dx- tinels sign-percussion of median nerve proceduces symptoms phalens sign- flex both wrists for 30-60 sec reproduces symptoms -tx- volar splint
Achilles tendon rupture
-sx- sudden heel pain with push- off movement, pop, sudden, sharp calf pain, -dx- +thompsons test- weak absent plantar flexion -tx- surgical management
the end
...
age of epiglottitis
2-7 years or 45-65 years
Prevalence of age related macular degeneration increases after what age
50
What is the most common primary source for metastasis to the lymph nodes of the neck?
85% of metastasis to the lymph nodes of the neck originates from primary tumors of the aerodigestive tract
Acoustic Neuroma
8th Cranial nerve. Benign tumor. Sensorineural hearing loss.
What is a Pterygium?
A growth that starts from the nasal conjunctiva and grows toward and into the cornea.
You are treating a 20-year-old female with multiple aphthous ulcers. She complains of a moderate amount of pain. You decide to prescribe "magic mouthwash" for the patient to swish and spit. Which of the following combinations of medicines is appropriate?
A very commonly used combination of medicines to promote relief of discomfort and healing include liquid diphenhydramine, antacid, tetracycline, and 2% viscous xylocaine.
A 45-year-old male who presents to the emergency department with sudden onset of lip swelling, which began shortly after awakening this morning. He denies any history of allergies and denies any new medications. His current medications include hydrochlorothiazide (HCTZ), captopril, atenolol, atorvastatin, and fexofenadine. What is the most likely cause of this gentleman's symptoms?
ACE inhibitor angioedema is a potentially life-threatening known side effect of captopril. The patient may need emergency intubation to ensure that his airway remains patent. Patients with a history of ACE inhibitor angioedema should not be placed on any ACE inhibitor or an ARB due to the possibility of similar reaction. HCTZ (a diuretic) and atenolol (a beta blocker) are antihypertensives that are generally unlikely to be associated with angioedema. Atorvastatin (a statin) and Fexofenadine (an antihistamine) are unlikely to present with angioedema.
What is the Dx? Recurrent nasal congestion associated with pale/bluish boggy turbinates and allergic shiners.
Allergic Rhinitis
Most thyroid cancer is successfully treated and has a very good prognosis. What type of thyroid cancer is aggressive and has a poor prognosis?
Anaplastic thyroid cancer
Worst and most aggressive type of thyroid cancer?
Anaplastic thyroid cancer
What is the typical cause of Hyphema?
Blunt or penetrating trauma
Imaging for blowout fx?
CT - emergent surgery
Macular Degeneration
Central vision loss. >65. Smoking. Amsler grid. Drusen. AREDS 11 formulation
Chalazion
Chronic painless nodule
Pain, sensation of a foreign body Photophobia Tearing Injection Blepharospasm
Corneal Abrasion clinical features
malignant otitis externa
DM pseudomonas
causes of retinal detachment
DM, injury, age
A 5 year old female presents with large insect which is still moving in his ear. What must be done prior to further action?
Drown the insect before removal
Which (Dry or Wet) Mac Degen presents with Drusen on PE?
Drusen - yellow retinal deposits Found on dry Mac Degen
Extra ocular movements, and near reaction
EOM's are full and equal, eyes converge equally and pupils constrict with near focus
eustachian tube dysfunction
ET swelling inhibits the ability to auto-insufflate leading to negative pressure; often follows URI or allergic rhinitis; presents with ear fullness, popping of ears, intermittent sharp ear pain, disequilibrium, etc; treated with decongestants
A 6 year old male with chronic sinusitis presents for ENT evaluation. Enlargement of what structures is likely to be found?
Enlarged adenoids
Ceftizoxime and dexamethasone
Epiglottitis treatment
A 2-day-old infant presents with numerousred macules with central vesicles and pustules. The rash sparesonly the palms and soles. The infant has no fever and is nursingnormally. What is the most likely diagnosis?
Erythema toxicum is a benign rash seen in newborns. The causeof the rash is unknown and resolves spontaneously. The rash appearsas erythematous macules, which may develop central vesicles within24 to 48 hours. The palms and soles are spared.
History & Physical/ENT/Ophthalmology A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis? Answers A. Croupy cough and drooling B. Thick gray, adherent exudate C. Beefy red uvula, palatal petechiae, white exudate D. Inflammation and medial protrusion of one tonsil
Explanations (c) A. A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained. (u) B. Thick gray adherent exudate is suggestive of diphtheria. (u) C. Beefy red uvula, palatal petechiae, and white exudate are findings suggestive of streptococcal pharyngitis. (u) D. Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.
Clinical Therapeutics/ENT/Ophthalmology A patient with Type 1 diabetes mellitus was treated for otitis externa of the right ear for 2 weeks with topical ear drops. The patient presents today with persistent, foul aural discharge, granulations in the ear canal, and deep ear pain. Which of the following is the proper treatment at this time? A. ciprofloxacin (Cipro) IV B. cefuroxime (Zinacef) IV C. ampicillin-sulbactam (Unasyn) PO D. azithromycin (Zithromax) PO
Explanations (c) A. IV antibiotics directed against Pseudomonas, the most likely etiology, is needed for the treatment of malignant otitis media. (u) B. Cefuroxime, ampicillin-sulbactam, and azithromycin have no activity against Pseudomonas. (u) C. See B for explanation. (u) D. See B for explanation.
Diagnosis/ENT/Ophthalmology A 58 year-old patient presents with spells of dizziness which is described as a spinning sensation. This has occurred several times a day for the last month. The patient also complains of some mild hearing loss, fullness, and a blowing sound in the right ear. Which of the following is the most likely diagnosis? A. Meniere's syndrome B. Labyrinthitis C. Benign paroxysmal positioning vertigo D. Vestibular neuronitis
Explanations (c) A. The classic findings of Meniere's syndrome consists of episodic vertigo, with discrete vertigo spells lasting 20 minutes to several hours in association with fluctuating low-frequency sensorineural hearing loss, tinnitus, and a sensation of aural pressure. (u) B. Labyrinthitis is an acute onset of continuous, usually severe vertigo lasting several days to a week, accompanied by hearing loss and tinnitus. (u) C. Benign paroxysmal positioning vertigo is a type of vertigo associated with changes in head position, often rolling over in bed. (u) D. Vestibular neuronitis is a paroxysmal, usually single attack of vertigo that occurs without accompanying impairment of auditory function and will persist for several days to weeks before clearing.
Clinical Intervention/ENT/Ophthalmology A 10 year-old boy was playing with sparklers (magnesium sulfate) and got some of the "sparkle" in his right eye. Which of the following is the most appropriate initial treatment? A. irrigate the eye for at least 20 minutes B. apply Bacitracin ointment and patch the eye C. remove the sparkle with a moistened cotton swab D. protect the eye with a metal shield and refer to an eye ophthalmologist
Explanations (c) A. The magnesium from the sparkler combines with tears, producing an alkaline injury and should be treated with prolonged irrigation. Irrigation should be the first step in management of this case. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.
Scientific Concepts/ENT/Ophthalmology Bitemporal hemianopia is noted on physical examination in a patient with visual changes over the past 2 years. The central field of vision is spared. The lesion is located in the A. optic nerve. B. optic chiasm. C. temporal optic radiation. D. optic tract.
Explanations (u) A. A lesion in the optic nerve would result in loss of vision in the affected eye only and include loss of central vision. (c) B. A lesion in the optic chiasm would result in the loss of vision in the bilateral temporal fields and spare the central field of vision. (u) C. A lesion in the temporal optic radiation would produce superior contralateral quadrantopia. (u) D. A lesion in the optic tract would result in loss of vision in the temporal field of the ipsilateral eye.
History & Physical/ENT/Ophthalmology Which of the following is diagnosed by use of the cover/uncover test? Answers A. Adie's pupil B. Strabismus C. Glaucoma D. Myopia
Explanations (u) A. Adie's pupil is a sluggish pupil reaction to light and accommodation, evaluated by papillary reaction to light. (c) B. The cover/uncover test is used to diagnose strabismus. (u) C. Tonometry is used to measure intraocular pressure to evaluate for glaucoma. (u) D. Myopia is evaluated by using a Snellen chart.
History & Physical/ENT/Ophthalmology The most reliable sign of acute otitis media (AOM) is A. bulging of the tympanic membrane. B. loss of tympanic membrane mobility. C. reddening of the tympanic membrane. D. air bubbles behind the tympanic membrane.
Explanations (u) A. Bulging and air bubbles behind the TM represent OM with effusion. (c) B. Loss of tympanic membrane mobility during pneumoinsufflation is the most reliable sign for diagnosing acute otitis media. (u) C. Reddening of the eardrum is not reliable as it may be due to crying or other vascular changes. (u) D. See A for explanation.
Clinical Therapeutics/ENT/Ophthalmology Use of systemic corticosteroids can cause which of the following adverse effects in the eye? A. Cortical blindness B. Optic atrophy C. Glaucoma D. Papilledema
Explanations (u) A. Cortical blindness is a rare adverse effect when prescribing salicylates. (u) B. Optic atrophy can occur as an adverse effect with lead compounds, amebicides, and MAO inhibitors. (c) C. Glaucoma can be caused by the long-term use of steroids. (u) D. Papilledema can be a side effect to many systemic medications.
Scientific Concepts/ENT/Ophthalmology Which of the following does the macula provide? Answers A. Night vision B. Color vision C. Peripheral vision D. Central vision acuity
Explanations (u) A. Night vision is a function of rod photoreceptors, which are found in the peripheral retina. (u) B. Color vision is a function of cone photoreceptors. (u) C. The peripheral retina is responsible for peripheral vision. (c) D. The macula is responsible for central visual acuity.
Health Maintenance/ENT/Ophthalmology At what age does the first tooth usually erupt in an infant? A. 2-4 months B. 6-8 months C. 10-12 months D. 14-16 months
Explanations (u) A. See B for explanation. (c) B. The first tooth in an infant to erupt is the central incisor at the average age of 6-8 months. (u) C. See B for explanation. (u) D. See B for explanation.
Health Maintenance/ENT/Ophthalmology The most common cause of conductive hearing loss is Answers A. otosclerosis. B. cholesteatoma. C. impacted cerumen. D. chronic serous otitis media.
Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. The most common cause of conductive hearing loss is impacted cerumen. (u) D. See C for explanation.
Scientific Concepts/ENT/Ophthalmology Which of the following is the most likely organism in a 2 year-old child with acute otitis media? A. Staphylococcus aureus B. Moraxella catarrhalis C. Pseudomonas aeruginosa D. Streptococcus pneumoniae
Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. The most common pathogens in children with acute otitis media are Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.
Health Maintenance/ENT/Ophthalmology In addition to tobacco products, which of the following is also considered a major risk factor in the development of oral cancer? A. Sun exposure B. Alcohol abuse C. Occupational exposure D. History of oral candidiasis
Explanations (u) A. Sun exposure is a risk factor for cancer of the lip, but is not considered a major risk factor for oral cancer. (c) B. Major risk factors for development of oral cancer are use of tobacco products and alcohol abuse. (u) C. While occupational exposures and presence of premalignant lesions, such as leukoplakia, are risk factors for development of oral cancer, they are not considered major risk factors. (u) D. History of oral candidiasis has no correlation to development of oral cancer.
Diagnostic Studies/ENT/Ophthalmology A 26 year-old male presents with headache, sinus pressure, and sinus congestion for over a month. He has a thick nasal discharge in the mornings, but this improves as the day goes on. He is afebrile. On exam, there is tenderness over the face. TMs have normal light reflex. Nasal mucosa reveals thick yellowish discharge. Neck is supple, without lymphadenopathy. Which of the following is the diagnostic study of choice? A. transillumination of sinuses B. routine sinus films C. CT scan of sinuses D. nasal culture
Explanations (u) A. Transillumination is used in the initial evaluation of chronic or acute sinusitis, but is not sensitive or specific. (u) B. See C for explanation. (c) C. CT scan is more sensitive than plain films for the diagnosis and management of chronic sinusitis, and is considered the gold standard for sinus imaging. (u) D. Nasal culture is not indicated in the evaluation of chronic sinus infections.
Strabismus
Eye condition in which binocular fixation is not present. May occur in one eye or both and corneal light reflex will reveal misalignment. Cover-uncover test may reveal latent variant which may not otherwise be readily apparent. Estropia - inward misalignment Extropia - outward misalignment May be corrected with eye exercises (patch therapy) or in severe cases with surgery. Amblyopia will result if left untreated after age 2.
What type of oropharyngeal infection are patients who use inhaled steroid inhalers likely to have?
Fungal
Systemic corticosteroids
Giant Cell Arteritis treatment
Defined as an increased intraocular pressure w/ optic nerve damage.
Glaucoma
Increased intraocular pressure is AKA . . .
Glaucoma
Increased intraocular pressure with optic nerve damage
Glaucoma
Sx of acute sinusitis
HA, pain in face, worse with leaning forward, purulent drainage, fever, malaise, tooth pain
A 16 year old with infectious mononucleosis asks if he can play football this weekend. What should you advise him?
He may not - Activity must be limited due to the increased chance of splenic rupture
What disease is unilateral painless persistent cervical lymphadenopathy often linked to?
Hodgkin's lymphoma
Painful, (+/-) purulent eyelid nodule
Hordeolum
This is an acute development of small, mildly painful nodules or pustules within a gland in the upper or lower eyelid.
Hordeolum (STYE)
Slit-lamp Fluorescein stain
How do you look for a corneal abrasion?
How to tx recurring aphthous ulcers
Hydrocortisone
mastoiditis Tx
IV abx: ampicillin, cefuroxime
Painless, white oral lesion Can't be scraped of
Leukoplakia clinical features
What symptoms comprise the classic triad of Meniere's?
Low frequency hearing loss - Tinnitus with aural fullness - Vertigo
How is Optic Neuritis confirmed?
MRI
Symptoms related to distention of the inner ear's endolymphatic compartment
Meniere Disease
Recurrent vertigo Tinnitus One-sided aural pressure
Meniere Disease clinical features
Candida albicans
Most common pathogen of Oral Candidiasis
S pneumoniae
Most common pathogen of Orbital Cellulitis
Pseudomonas
Most common pathogen of Otitis Externa
Tx for dacryocystitis?
Oral Abx
Throat, mouth pain Creamy white patches Can be scraped off to reveal underlying erythematous mucosa
Oral Candidiasis clinical features
A white plaque-like oral lesion which does not scrape off?
Oral leukoplakia
What is the Dx? Acute painful swollen auricle tragal tenderness and otorrhea.
Otitis externa
What're the s/x of a Corneal Abrasion?
Pain, photophobia, redness, blurry vision, small pupil. The abrasion will also be visible w a fluoroscein stain
Most otitis media is caused by viral agents. What is the recommended first line treatment for a patient who has a bacterial otitis media?
Penicillin based antibiotics such as amoxicillin
fleshy triangle shaped protrusion on the inner bulbar conjunctiva
Pterygium is a complication of exposure to ultraviolet light and wind. It consists of hyaline and elastin tissue. If it encroaches on the cornea, surgical removal is indicated.
Complications of Strep throat (Group A strep)?
Rheumatic fever - Post streptococcal glomerulonephritis
Allergic Conjunctivitis
Ropy or stringy mucoid discharge. Pruritis
What are the three most common organisms involved in otitis media?
Streptococcus pneumoniae - Hemophilus influenzae - Moraxella catarrhalis
Which salivary gland is most often affected with sialolithiasis?
Submandibular gland
TM mobility
TM's are mobile
TMJ
TMJ is not tender and without swelling
A 54-year-old female presents complaining of decreased visual acuity to her right eye over the past few hours. She denies pain, and describes having wavy vision and seeing flashes of light. Her visual acuity in the affected eye is 20/200. What condition best describes the following physical finding? A. Retinal detachment B. Central retinal artery occlusion C. Open angle glaucoma D. Angle closure glaucoma E. Optic neuritis
The answer is A. EXPLANATION: The image demonstrates a detached retina. The superior aspect of the retina appears wavy and flowing.
Which of the following conditions is a cause for central vertigo? A. Meniere syndrome B. Labyrinthitis C. Vestibular neuronitis D. Acoutic neuroma E. Perilymphatic fistula
The answer is D. EXPLANATION: Acoustic neuroma, or eight cranial nerve schwannomas, are among the most common intracranial tumors, and a cause for central vertigo.
A 26-year-old female presents with a whitish coating on her tongue and lips. When you attempt to rub the plaque with a tongue depressor, a small amount of bleeding is noted from the oral mucosa. Her past medical history includes asthma. What diagnostic test would you perform to confirm your diagnosis?
The history and physical are consistent with oral thrush. A wet mount potassium hydroxide preparation will reveal fungal spores and nonseptated mycelia. A culture and sensitivity is used for suspected bacterial infections. A gram stain is used to identify whether a bacterial pathogen is gram positive or gram negative.
Name surgical option for glaucoma
Traveculoplasty
Describe Herpes simplex Keratitis
Under fluorescein stain, Dendritic ulcers
What is important to test in patients w a foreign body in their eye?
Visual Acuity (use that Snellen chart!)
Critical: Visual Acuity
Visual acuity is 20/20 for OD OS OU
Weber and Rinne test
Weber is midline, AC is greater than BC bilaterally
When is surgery indicated for a pterygium?
When it begins to effect vision (Obstruct cornea or induce astigmatism)
Oral candidiasis
White patch. Bleeds when wiped. Oral nystatin.
anterior (blepharitis)
_______ blepharitis involves the skin & eyelashes; commonly caused by staph aureus; treated with eyelid hygeine
vanco/clindamycin
antibiotics used to treat orbital cellulitis caused by MRSA
nortriptyline
antidepressant drug for tinnitus
hyperopia
far-sightedness, can see objects in the distance but close objects are blurry; corrected with plus lenses
dacryoadenitis
inflamed nasolacrimal duct Tx: gentamicin, tobramycin, erythromycin
sx of corneal abrasion
pain, foreign body sensation, photophobia, tearing, injection, blepharospasm
chalazion
painless
sx of blepharitis
red rims, adhered eyelashes, dandruff, scales
Critical: Head and face palpation
there are no masses and no tenderness elicited, the temporal artery is not tender
Trismus
"Lock Jaw" associated with peritonsillar abscess, ludwigs angina, dental abscess and tetanus.
allergic rhinitis
"hay fever"; causes pale/bluish nasal mucosa, possible nasal polyps or nasal crease; treated with intranasal corticosteroids & antihistamines
epistaxis
"nosebleed"; many causes; treated by direct pressure for 15 mins, nasal packing, possible surgery
vertigo
"room is spinning" Tx: meclizine + Romberg test = central vertigo
acute angle closure glaucoma
"steamy cornea" fixed DILATED pupil increased pressure in anterior chamber halo around lights pain decreased visual acuity decreased peripheral vision emergency
otitis externa
"swimmer's ear"; infection of the external ear canal; caused by swimming, mechanical trauma; causes ear pain, itching, & purulent discharge; treated with ear wick & antibiotics
Tx of Ectropion/Entropion?
(Entropion image) Surgical repair if needed
Define these two terms: Ectropion Entropion
(Image) Ectropion: eyelid propelled outward (Cause dryness) Entropion: Eyelid turns inward causing conjunctival irritation
external hordeolum
(stye) arises from eyelash follicles or a lid-margin tear gland
What're 3 common species of bacteria that cause Bacterial Conjunctivitis? What're two less common (but extra gross) causes?
*Common*: S. pneumo S. aureus H. flu *Uncommon*: Chlamydia Gonorrhea
orbital cellulitis
- 2try to sinus infection (ethmoid 90%) -sx- decreased vision, pain with ocular movement -dx- CT -tx- Vanco, clinda, cefotaxime DD-Preseptal cellulitis= URI, not associated with vision changes and ocular pain****
Acoustic neuroma
- CN8 schwannoma -sx- unilateral hearing loss in acoustic neuroma until proven otherwise -dx- MRI or CT -tx- surgery
What's the tx for a Corneal Abrasion?
- Cycloplegics (to dilate pupil and relieve pain) - Topical ABX (Erythromycin) - Maybe a pressure patch
scaphoid fracture
- FOOSH, MC fracture -sx-pain along radial surface, snuffbox tenderness -dx- fracture maynot be seen on xray for up to 2 weeks -tx- thumb spica
oral herpes simplex
- HSV1, MC 6 months- 5 yrs. - gingivitis- friable, bleeding gums -tx- self limiting
Osgood schlatters disease
- MC 8-15 -sx- Anterior knee pain with swelling of tibial tuberosity. increases gradually over time. worse when going upstairs -dx -lateral radiography is usually normal. may show fragmentation of tibial tubercle -tx- abstain from physcial activiity for as long as several monthes. RICE
diabetic retinopathy
- MC cause of new, permament vision loss/blindness in 23-74 Nonproliferative: venous dilation, microaneurysms (blot and dot hemorrhages, flame shaped hemorrhages, cotton wool spots, hard exudates) - not associated with vision loss and treated with laser therapy proliferative: neovasculization, vitreous hemorrhage - VEGF inhibitors, laser photocoagulation, tight glucose control
bacterial conjunctiviits
- MC staph/strep, h. flu, moraxella - purulent d/c, lid crusting, usuallly no visual changes (mild pain) - absence of ciliary injection - secondary bacterial keratitis can develop tx: erythmycin topical - if contact lens - (FQ or tobrex) - gonnoccocal (5d ceftriaxone IV)- unilateral - chlamydia (azithromycin)- follicular response, nontender preauricular adenopathy common - if rare pathogen suspected: grain stain and giemsa stain ( no organisms seen with chlaymida, intracellular gram-negative diplococci in gonorrhea) neonatal: day 1: AgNO3 day 2-5: gonococcal day 5-7: chlamydia day 7-11: HSV
Scolisis
- Right thoracic MC, Idiopathic Sclosis MC spinal deformity evaluated -sx- Right thoracic and left lumbar prminence with flank crease with forward bend -dx- Adams forward bend test -Single, standing AP Radiograph if >5 degrees on scoliometer -tx-10-15 angle- 6-12 month follow up. clinical+ possible x rays 15-20- AP 3-4 month follow up for large, 6-8 monthes for small Curves ≥20 degrees require orthopedic referral - difference of 5% between 2 measurements- treat with brace
osteomylistis
- Staph Arues #1!!! Lumbar spine is where is spreads hemtagenous. hip 1!!! -samonella= sickle cell**** -sx- inflammation over bone. increased ESR and WBC**** -dx- gold standard= bone aspiration, MRI, xray- periosteal reaction, sequestrum. -tx- IV abx 4-6 weeks= 4 months strep B= Nafcillin or oxacillin+ 3rd gen stap a more than 4 month= nafcillin or oxacillin Samonella= FQ or 3rd, MRSA resistant= Vanco -puncture wound= cipro
foreign bodies
- TEST VISUAL ACUITY FIRST - may be on cornea or under upper lid - local anesthetic (proparacaine) - fluorescein - remove with fine gauge needle (avoid wet cotton tip? - steel foreign bodies look for rust ring- may be removed with a rotating burr or the pt referred - polymycin-bacitracin or erythromycin - pain releieved with instillation of analgesic drops - do not send pts home with local analgesics
optic neuritis
- acute inflammatory demyelination of the optic nerve - MC young pts 20-40 - multiple sclerosis MC, meds (ethambutol for TB, chloramphenicol), autoimmune - loss of color vision, visual field defects (central scotoma/blind spot), loss of vision over a few days (usually unilateral) - associated with ocular pain that is worse with eye movement PE: Marcus Gunn pupil: relative afferent pupillary defect- when bright light is shone from the unaffected eye to the affected eye, pupils appear to dilate rather than constrict (delayed response of affected nerve) Fundoscopy: 2/3 normal (retrobulbar neuritis) or 1/3 with optic disc swelling/blurring (papillitis) - MRI! IV methylprednisolone followed by PO steroids - vision usually returns with tx
macular degeneration
- age related to d/t toxic effects of drugs (chloroquine or phenothiazine) - leading cause of irreversible central vision loss - increases after age 50, white, females, smoking - Drusen deposits in Bruch membrane - can also have wet - new abnormal vessels grow which leak and bleed= retinal scarring- rarer but more progressive - GRADUAL bilateral blurred or loss of central vision (including detailed and colored vision), scotomas (blind spots, shadows), metamorphopsia (wavy or distorted vision can be measured with Amsler grid) - micropsia (object seen by affected eye smaller than unaffected) - visual loss deteriorates quickly once neovascular degeneration - mottling, serous leaks, and hemorrahges - scarring develops in end-stage disease TX - no effective treatment - if detected early - laser therapy or intravitreal injections of monoclonal antibody drugs may slow progression - vitamins, antioxidants, zinc and copper, and omega-3 fatty acids may reduce progression
glaucoma
- any impediment to flow of aqueous humor through trabecular meshwork and canal of Schlemm will increase pressure in the anterior chamber
strabismus
- binocular fixation not present- should be by 2-3 months - may occur in one or both eyes - corneal light relfex test - cover-uncover test - possible diplopia, scotoma inward misalignment (esotropia) outward misaligment (exotropia) TX- eye exercsies (patch therapy) or surgery in severe cases - if left untreated after the age of 2- amblyopia will result
tx for hyphema
- blood in anterior chamber - place at 45 degrees to keep RBCs from staining cornea
hydroxycholorquine and sildenafil
- cause cause blindness - sildenafil mostly color changes
blepharitis
- chronic inflammation of the eyelids - burning and itching of the eyes - no change in vision - eyelids show scaling and crusting, in seborrheicd the scales are greasy
Osteoarthritis***
- chronic- articular cartilage damage and degeneration Obesity RF. MC in weightbearing joints -sx- evening joing stiffness-- pain worsens throughout day, hard bony joint -herb nodes (DIP joints!)- barn-PIP -dx- XRAY- osteophytes -tx- acetaminophen! in elderly with bleeding risks. NSAIDS more effective, CAPSIN (Pts who cannot tolerate orals) corticosteroid injections****
dacryostenosis
- common in the newborn after the first month of life and occurs when the duct does not open - obstruction usually resolves by 9 months TX: warm compresses and massage; surgical probe
etiology of cataracts
- congenital (rubella, CMV) - traumatic - systemic disease (diabetes) - medications (steroids, lovastatin) - senile (most common > 60)
keratitis
- corneal ulcler/inflammation - MC d/t bacteria, viruses, fungi, (acanthamoeba in contact lens wearers) - associated with rapid progression and sight threathening - exposure keratitis (bells palsy) - pain, photophobia, reduced vision, tearing - conjunctival injection/erythema, limbic flush (ciliary injection), corneal ulceration, purulent or watery discharge - Bacterial: hazy cornea, ulcer, stromal abscess, +/- hypopyon Tx: FQ, no patching HSV keratitis: dendritis lesions tx: trifluidine, vidarabine, acyclovir
Ankle sprain
- dislocation- posterior MC- anterior talofibular, calcanrofibular MC -sx- pop swelling, inability to weight bare -tx- RICE, NSAIDS
herpes zoster ophthalmicus
- due to infection with varicella-zoster - infects trigeminal nerve the ophthalmic branch - shingles noted on tip of nose think eye involvement - fluorescein stain to look for dendritic ulcers - refer!
angle-closure pearls
- elderly, hyperopes (far-sighted), Asians precipitating factors: mydriasis (pupillary dilation further closes the angle)- dim lights, anticholinergics, sympathomimmetics - eye feels hard to palpation - tonometry shows > 21 mm HG - "cupping" of optic nerve -
chemical burns
- every minute counts! - irrigation stated ASAP - alkali burns worse than acids (liquefactive necrosis), denatures proteins and collagen, causes thrombosis of vessels - ex: fertilizers, household cleaners, drain cleaners acid burns: coagulative necrosis (H+ precipitates protein barrier)- industrial cleaners, batteries tx: irrigation- LR or NS (LR is better b/c closer to eye PH) for 30 minutes or at least 2 liters - check pH and acuity after irrigation: irrigate until eye pH 7.0-7.3 x 30 minutes - broad spectrum abx and cyloplegic agent
otitis externa
- excess water or local trauma changes the normal acidic pH of the ear, causing bacterial overgrowth - pseudomonas MC, staph and strep - aspergillus (fungal) - 1-2 d of ear pain, pruritis in ear canal, auricular discharge, pressure/fullness (recent activity of swimming) - hearing usually preserved PE: pain on traction of the ear canal/tragus, external auditory canal erythema/edema/debris TX: - protect ear against moisture (drying agents include isopropyl alcohol and acetic acid) - ciprofloxacin/dexamethasone ( ofloxacin safe if associated TM perf) - aminoglycoside combo: neomycin/hydrocortisone otic ( not used in suspected TM perf)
central retinal artery occlusion
- eye emergency - poor prognosis even with treatment - causes: emboli, thrombosis, vasculitis - must be differentiated from giant cell arteritis (fever, HA, scalp tenderness, jaw claudication, visual loss) - sudden, painless, marked unilateral loss of vision - fundo: pallor of the retina, arteriolar narrowing, cherry red macula (red spot) - veins may show segmentation (box car apperance) - may see emboli 20% - no hemorrhage - usually preceded by amaurosis fugax TX: recumbent position and gentle ocular mssage may help reduce damage - vessel dilation and paracentesis - workup for athersclerosis and arrythmias - decrease IOP with acetolamide
Juvenile rheumatoid arthririts
- females over males -sx-- "Morning stiffness" more than 6 weeks for over 30 min. incidous onset systemic= fever spikes, polyathralgias, salmon piink maculopapular rash, weight loss. -pauciarticular= 4 or fewer joints -polyarticular- 5 or more joints, low grade fever, fatigue, rhuematoid nodes, anemia -dx- + RF, anti-CCP- systemic=ESR/CRP increased - pauarticular- ANA pos -tx- NSAIDS, steroids PT, OT. methotrexate
orbital floor "blowout" fractures
- fractures of the orbital floor ( maxillary, zygomatic, palatine) - decreased visual acuity - enophthalmos (sunken eye) - diplopia esp. with upward gaze (inferior rectus entrapment) - orbital emphysema (eyelid swelling with blowing the nose from connection to maxillary sinus)- may have exopthalmos - epistaxis, dyesthesias, hyperalgesia, anesthesia to anteriormedial cheek (d/t stretch of intraorbital nerve) - CT scan TX: initial: nasal decongestants (decreases pain), avoid blowing nose, prednisone (to reduce edema), abx ( unasyn or clinda); surgical repair. optho referall
chronic otitis media
- from repeated epsidoes of acute otitis media, trauma, or cholesteatoma - different organisms ( pseudomonas, s. aureus, proteus, anaerobes) - PERFORATED TM WITH CHRONIC EAR DISCHARGE with or without pain - TM and/or ossicular damage can lead to CONDUCTIVE HEARING LOSS TX: removal of infected debris, avoidance of water exposure, and topical abx drops - surgery (TM repair/reconstruction)
bacterial conjunctivitis labs and tx
- gram stain of eye TX - sulfonamide 10% ophthalmic solution - GC: IV ceftriaxone, topical erythromycin - chlamydia: oral tetracycline, doxy, axithromycin
chalazion
- granulomatous inflammation of a meibomian gland - chronic disease - painless, hard, non-tender swelling of upper or lower lid - can distort vision - tx: warm compresses, incision and curettage
dacryocystitis
- infection of lacrimal sac - obstruction of nasolacrimal system - acute: s. aureus, beta hemolytic strep, h. flu - infants and adults > 40 - pain, swelling, tenderness, redness in tear sac area - usually unilateral - may have purulent discharge - tx: remove obstruction, systemic abx ( clindamycin + 3rd gen. cephalosporin - dacrocystorhinoscopy
acute otitis media
- infection of middle ear, temporal bone and mastoid air cells - MC preceded by URI - STREP PNEUMO, H. FLU, M. CATT, STREP PYOGENES (same as bronchits and sinusitis) - peak age 6-18 months - URI causes eustachian tube edema leading to transudation of fluid and mucous in middle ear which is colonized by bacteria risk factors: young, eustachian tube dysfunction, day care, bottle use, parental smoking, symptoms: fever, otalgia, ear tugging in infants, conductive hearing loss, stuffiness - if TM perforation - rapid relief of pain and otorrhea (usually heals in 1-2 days) PE: bulging, erythematous TM with effusion and DECREASE TM MOBILITY on pneumatic otoscopy - loss of landmarks - if bullae on TM- suspect mycoplasma TX 1. amoxicillin x 10-14d DOC 2. augmention 2nd line 3 if PCN allergic - erythromycin, azithroxymycin, bactrim 4. myringtomy (drainage) if severe otalgia or mastoiditis 5. tympanostomy if recurrent or persistent for recurrent cases- iron def. anemia w/u, CT scan
mastoiditis
- inflammation of the mastoid air cells of the temporal bone - prolonged or inadequately treated AOM s/sx: deep ear pain (usually worse at night), mastoid tenderness, may develop cutaneous abscess complications: hearing loss, labyrinthitis, vertigo, CN VII paralysis tx: 1. IV abx with myringotomy (ampicillin), 2. followed by full course of oral abx 3. refractory = mastoidectomy
polymyosititis
- inflammatory disease of proximal limbs, neck, pharynx -sx- Progressive symmetrical proximal muscle weakness -dx- increased aldolase!!!, + anti-jo 1 Ab, +anti-srp ab -Dermatomyosis= Helotrope rash (blue discoloration on eye lids) Gottrons papules!!! (fingers)
entropion
- inward turning of the lower lid - seen in the elderly - eyelashes seen against the eyeball- can cause scarring - have redness and tearing - surgical tx
cataracts
- lens opacity, usually bilateral - visual loss, yellow discoloration center of lens - absent red reflex
lesions of the optic nerve
- lesions anterior to the optic chaism will affect only 1 eye - lesions at optic chiasm will affect both eyes partially (bitemporal hemianopsia) - posterior to optic chiasm left lesion (right sides of both visual fields)
hordeolum
- local abscess of the eyelid margin (external sebaceous gland) - staph aureus 90-95% - painful, warm, swollen, red lump on eyelid - warm compressed mainstay of tx (most eventually point and drain) - +/- topical abx ointment (erythomycin, bacitracin) if actively draining - I and D if no drainage within 48 hours
bacterial conjunctivtis
- more common in adults - S. pneumo, S. aureus, h. flu - transmit via direct contact, autoinoculation - chlamydia, gonorrhea (ocular emergency) - purulent discharge, mild loss visual acuity
viral conjunctivits
- more common in children, midsummer to early fall - adenovirus type 3, herpes - CONTAGIOUS, transmit by direct contact - clinical: URI, sore throat, fever, malaise common early - starts unilateral but becomes bilateral in 3-5 days - copious watery discharge, erythema, periauricular lymphadenopathy TX: sulfonamide ointment, cool compresses - follicullar along with chylamydia
Lunate fracture
- most serious fracture -avascular necrosis of lunate bones= kienbocks disease -tx- thumb spica
papilledema
- optic nerve swelling from increased ICP (classically bilateral) etiology: - idiopathic intracranial HTN (psuedotumor cerebri) - space- occupying lesions (tumor, abscess) - increased CSF production - cerebral edema, severe HTN exam: headache, nausea/vomiting, vision usually well preserved, may have enlarged blind spot or transient visual alterations diagnosis: swollen optic disc with blurred margins MRI or CT scan first to rule out mass effect- LP puncture TX: diuretics (acetazolamide which decreases aqeuous humor and CSF), treat cause
ectropion
- outward turning of the lower lid (basset hound) - common in the elderly - lower lid margin droops outward - may have excessive tearing, but eyes typically dry - surgical tx
corneal ulcers
- pain, photophbia, and tearing - risk factors include trauma, contact lens use, and poor lid apposition - exam will reveal circumcorneal injection and watery to purulent discharge - fluorescein staining reveals dense corneal infiltrate with overlying epithelilal defect - dendritic lesions indicates herpes keratitis - all should be refered - lesion should be stained and cultured to identify cause - avoid topical steroids b/c cause further tissue loss and increase risk of perforation
angle-closure
- painful eye and loss of vision PE: circumlimbal injection, steamy cornea, fixed mid-dilated pupil, decreased visual acuity, and tearing - anterior chamber narrows- IOP acutely elevated - nausea, vomiting and sweating are common TX: start IV carbonic anhydrase inhibitor (acetazoalmide), topical beta blocker and osmotic diuresis (mannitol) - do not give mydriatics - laser or surgical iridotomy
chalazion
- painless granuloma of the internal meibomian sebaceous gland - focal eyelid swelling - often these are larger, firmer, slower growing and less painful than syte - hard, nontender eyelid swelling on conjunctival surface of eyelid TX: eyelid hygiene, warm compresses. abx usually not necessary. injection of steroid or incision and curettage
open-angle
- people over 40 and more common in AA and in pts with a family history of glaucoma or diabetes - chronic, asymptomatic, and potentially blinding disease that affects 2% - increased IOP, defects in the peripheral visual field, and increased cup to disc ratios - asymptomatic until late in disase - loss of peripheral vision and halos around lights - elevated IOP without optic disc damage known as ocular hypertension- close monitoring required - optic nerve damage without increased IOP seen- subsequent monitoring typically reveals increasing IOP TX: optho - topical and/or systemic meds to decrease IOP by decrease aqeuous production (beta blockers, carbonic anhydrase inhibitors) and/or increasing outflow (prostaglandins, cholinergics, epi) - alpha agonists (brimonidine) provide both mechanisms
cataracts
- progressive increase in the proportion of insoluble protein - secondary to natrual aging process (senile) or d/t trauma, congential (torch), systemic disease ( DM), or meds (steroids, statins) - excess sun exposure - gradual dimunution of vision - possible double vision, excess glare, fixed spots, or reduced color perception - typically bilateral - translucent, yellow discoloration in lens Fundo: dark against a red background - once mature- retina no longer visible tx: intracapsular or extracapsular extractions with lens replacement
glaucoma meds
- prostaglandin analogs - beta blockers (timolol) - alpha agonists - carbonic anhydrase inhibitors - pilocarpine (also used for dry mouth)
Barotrauma
- rapid pressure changes, inability of ET to equilize pressure -scuba, airplane -tx- oral degongetants, auto insufflation
allergic conjunctivitis
- red eyes - may have viral sx (rhinorrhea, fever, malaise, pharyngitis) - cobblestone mucosa appearance to inner/upper eyelid, ITCHING, tearing, redness, stringy d/c, may have photophobia, visual loss - usually bilaterla - possible chemosis (conjunctival swelling) tx: topical antihistamines,
amblyopia
- reduced visual acuity not correctable by refractive means - MC caused by strabismus; uremia, or toxins such as alcohol, tobacco, lead,
retinal detachment
- separation of the retina from the pigmented epithelial layer, causing the detached tissue to appear as flapping in the vitreous humor - tears most commonly begins at the SUPERIOR TEMPORAL retinal area - spontanoulsy or d/t trauma; extreme myopia (nearsigthed); or inflammatory changes in the vitreous, retina, or choroid - acute onset of painless blurred or blackened vision that occurs over several minutes to hours and progresses to complete or partial monocular blindness - bilateral detachment 20% - curtain being drawn over the eye from top to bottom - may sense floaters or flashing lights at the beginning - IOP is normal or reduced PE: relative afferent pupillary defect (marcus gunn) fundo exam may reveal the ridges of the displaced retina in the vitreous humor TX: emergency consult regarding possible laser surgery or cryosrugery - SUPINE with the head turned to the side of the retinal detachment - prognosis is good: 80% recover without recurrence 15% retreatment 5% never attach
hordeolum
- staph infection of the meibomian gland (internal) or glands of zeis or moll (external) - a stye (external) - red, swollen, tender area on upper or lower lid - tx: warm compresses, abx ointment (E-mycin, bacitracin) - if no improvement in 2 days can I and D
drugs that increase glaucoma risk
- steroids and anticholinergics closed angle: steroids, anticholinergics, sympathomimetics, topiramate, antihistamines, antidepressants, phenothiazines
treatment for blepharitis
- supportive, lid scrubs ( baby shampoo) - antibiotics: oral (tetracycline), eye ( E-mycin, Bacitracin)
SLE
- sx- MALAR, DISCOID RASH. serositis= pericarditis, plueritis*** drug induced= procainamide, INH, Hydralazine -dx-sensitive= ANA (BEST). specific= anti-sm Abs, DS-DNA. -tx- regular exercise, sun protection, NSAIDS, MTX (gastritis), hydroxychloquine (diahrea, rash)
amaurosis fugax
- temporary monocular vision loss (lasting minutes) with complete recovery - d/t retinal emobli ior ischemia - EXTERNAL CAROTID ARTERY commonly involved
globe rupture
- the outer membrane of eye disrupted by blunt or penetrating trauma - EMERGENCY - ocular pain (maybe absent), diplopia PE - misshaped eye with prolapse of ocular tissue from sclera or corneal opening - markedly reduced visual acuity (maybe light perception only) - ENOPHTHALMOS (recession of the globe within the orbit), foreign body maybe present, may have exopthalmos - SEVERE CONJUNCTIVAL HEMORRHAGE ( 360 bulbar) - corneal/sclera: prolapse of the iris through the cornea - positive Seidels test ( parting of the fluorescein dye by a clear stream of aqueous humor from anterior chamber) - obscured red reflex - teardrop or irregularly shaped pupil - hyphema TX: rigid eye shield (protect eye from applied pressure, impaled object should be left undistrubed) immediate refer - IV ABX - avoid topical eye solutions
central retinal vein occlusion (CRVO)
- thrombus leads to fluid backup in retina - sudden monocular vision loss - risk factors: HTN, DM, glaucoma, hypercoaguable states PE: afferent pupillary defect, optic disc swelling, blood and thunder retina (dilated veins, hemorrhages, edema, and exudates) - vision typically resolved with time at least partially - workup for thrombosis - neovasculization treated with vascular endothelila growth factor inhibitors
Hip Dislocation
- trauma MC cause avascular necrosis= complication*, sciatic nerve injury , posterior MC -sx- hip pain with leg shortened internally and rotated -tx- orthopedic emergency!
ocular abx
- used for blepharitis, conjunctivits, stys, - gentamycin, tobramycin, erythromycin, besifloxacin
orbital cellulits
- usually secondary to sinusitis (ethmoid 90%) - s. pneumo, GABHS, h. flu, s. aures - may be caused by dental infections, bacteremia, dacrycystitsi, facial infections - MC in children (7-12) - DECREASED VISION, PAIN WITH OCULAR MOVEMENTS, PROPTOSIS, chemosis (swelling of bulbar conjunctiva), increased IOP, visual changes, eyelid edema, exopthalmos, erythema, discharge diagnose with CT scan - infection of fat and ocular muscles - IV abx (vanc, clinda, cefotaxime) until fever subsides then complete 2 to 3 weeks of oral abx - MC strep, h. flu, s. aureus - can lead to meningeal or cerebral infection ddx: preseptal cellulitis (infection of eyelid and periocular tissue) - associated with URI (no visual changes or pain with ocular movement)
spondylisis/spondylthesis
- young athlete MC -spondylisis- defect in pars interarticular from repetive hyperextension trauma MC L5/S1. seen on oblique films -spondylithesis- forward slipping of vertebrae on another. 10-15 y/o MC -tx- spondylisis- activity restriction, PT spondylisthesis- PT. high grade- surgery
Mastoiditis -Dx test
-CT
hearing impairment
-Conductive - Webber lateralized to AFFECTED ear. Rinne B > A -SensoriNeural -Webber lateralize to UNAFFECTED ear. Rinne A > B conductive-causes- external or middle earCerumen Impaction, URI, Acute otitis external, Otosclerosis (abnml new bone forms), Otitis media -tx- audiological testing -sensorineural- inner ear
Otitis Externa -1st line Tx
-Fluoroquinolone +/- steroid (Ciprodex)
ACL
-MC Injured knee ligament -sx- noncontacting pivoting injury, pop swelling and swelling with hemarthrosis -dx- lachmans test- most sensative
optic neuritis
-MS- MC -sx- loss of color vision, unilateral- ocular pain worse with eye movement -dx- marcus gunn pupil***- pupils dilate rather than constrict when light is shown -fundoscopy- optic disc swelling -tx- IV methyprednisolone with PO steroids
Mastoiditis -x3 Tx
-Myringotomy for drainage & culture -IV abx -Followed by oral abx
Chronic Otitis Media x4 MC pathogens
-Staph aureus -Pseudomonas aeruginosa -Proteus -Anaerobes
Acute Otitis Media x4 MC pathogens
-Strep pneumoniae -Staph pyogenes -H. influenzae -M. Catarrhalis
Otitis externa x3 MCC
-Water exposure -Trauma to canal -Exfoliative skin conditions (eczema or psoriasis)
Sjogren syndrome
-autoimmune system attacks exocrine glands -sx- dry eyes, dry mouth (xerostoma) enlarged parotid gland -dx- ANA, +RF, schirmers test (decreased tears production) -tx- artificial tears, Pilocarpine for xerostoma cevimeline (evoxac)
tibial plateau fractures
-axial loading/rotation/direct trauma (MC in children MVA- bumper) MC lateral plateau -sx- check peroneal nerve functions (foot drop) -tx- non displaced- conservative tx. displaced- ORIF
colles/smiths fracture
-colles- dorsal angulation,FOOSH wrist extension, EPL tendon rupture. tx- sugar tong -smiths fracture-ventral angulation, FOOSH wrist flexion
patellar fracture/ dislocation
-fractures- MC direct blow-dx- sunrises view X ray -dislocation- MC females, usually laterally, tx- closed reduction
Hip fracture
-high incident of avascular necrosis with femoral neck fractures, high incidence of DVT and PE -sx- hip pain with leg shortened, externally rotated, abducted -tx- ORIF
parotitis
-if viral- mumps, fever, anorexia fever -if bacterial- chewing argrivates pain of swelling of gland -dx- CT and MRI w/ gladodlinium -tx- symptomatically, local heat massage
lateral/medial epicondylitits
-lateral epicondylitits- inflammation of ECRB (extensor carpi radial brevis. gripping and forearm pronation -medial epicondylititis- pronator teres-flexor carpi radialis. worse with pulling activitis
Legg-pegg/ avascular necorsis
-most important and severe complication of DDH. -sx- 4-10. painless limping* dull achy throbbing pain at groin at end of day, lateral hips, buttocks. loss of rotation, abduction, anagenic limp -dx- MRI -tx-protected weight bearing. little benefit from bracing. Alendronate.
vertigo
-peripheral vertigo- labrinyth or verstibular nerve- BPV, Menieres, vestibular neuritits, labrithyisis, -tx- antihistamines, metoclopramide (antagonizes D2 receptors), anticolingergics- scopolamine - central vertigo- Vertical nystagmus, graual onset, migranes, CNS signs - tx- prophylaxis
Knee dislocations
-severe limb threatneing emergencies= Popliteal artery injuries!- 1/3 of patients- ATERIOGRAPHY+ tibial nerve injury -tx- immediate ortho consult
Skiers thumb/ boxers fracture
-skiers- UCL injury! instability of MCP joint* -sx- thumb far away from other digits - thumb spica -boxer- fracture of 5th metcarpal- always check for bite wounds* -tx- unlnar gutter splint
Humeral shaft fractures
-sx- FOOSH Must r/o radial nerve injury*** -tx- sugar tong splint
meniscal tear
-sx- US c/o locking, popping, giving way, effusion with activities. + mcmurrays sign- pop of click while tibia is externally and internally rotated -tx- NSAIDS
olecranon bursitis
-sx- abrupt "goose egg" swelling, limited ROM with flexion -tx- rest, NSAIDS
lumbosacral sprain/strain
-sx- back muscle spasms, no nuerological changes (no pain below knee) -tx- brief bed rest- 2 days
spinal stenosis
-sx- back pain, worsened with extension (walking) relieved with flexion -tx- lumbar epidural injections of steroids
Osteoid osteoma
-sx- benign tumor in children age 5 to 20, presents with increasing pain, worse at night and relieved by aspirin. spine, tarsal bone, phalanx, Trabecular ossification, osteolytic nidus
polymyalgia rhumatica
-sx- bilateral proximal joint stiffness, (shoulder and pelvic girdle pain and stiffness, a lack of skin findings) Closely related to Giant Cell arthritis!!! -dx- clinical -tx- cortiocosteroids (10-20 mg)
hyphema
-sx- bleeding anterior chamber, ENOPHTHALAMUS, tear drop pupil -dx- evaluate for global rupture injury- Positive Seidels test- parting of dye -tx- Rigid eye shield, restrict movement, bed elevate to 45 degrees, opthal. NO NSAIDS.
Nursemaids elbow
-sx- child presents with arm slightly flexed, refises to use arm -tx- reduction- pressure on radial head with supination and flexion
Cholestertoma
-sx- chronic negative middle ear pressure--- TM retracts medially. has potential to errode bone -dx- granular tissue seen with ottoscope -tx- surgical referal
retinopathy
-sx- copper/ silver knicking, atervenous nicking, cotton wool spots, retinal hemmorhages -dx- fundscopy -tx- optimize BP and glucose control
oral canidida
-sx- cottage cheese patches, can be scraped away to reveal erythemus mucosa -tx- Antifungal (Nystatin) - oral. Diflucan (last resort). treat moms nipple too!!!
AC joint disolcation
-sx- direct blow to adducted shoulders, pain with lifteing arn -dx- xrays taken with weights -tx- brief sling immobilization
Olecranon fractures
-sx- direct blow, inability to extend elbow -dx- all considered intrarticular and need reduction ulnar nerve dysfunction*
corneal abrasion
-sx- foreign body sensation, injection, photophobia. pain relieved at instillation of opthal analgesics drops -dx-1. visual acuity!!! slit lamp with flourscine -tx- topical anthestic (no rx!!!)+ patch for 24 hrs. topical abx (polymixicn/ bactericim), genta/ cipro for contacts. opthalamology follow up in 1-2 days. remove rust ring at 24 hrs
nystagmus
-sx- horizontal eye movement
septic arthritis
-sx- infection in joint cavity. staph areus MC -dx- athrocentesis (WBC 50,000, cloudy) -tx- -gram pos cocci- nafcillin - gram neg cocci- ceftriaxone - gram neg rods- ceftriaxone - no organism seen- naficillin
radial head fractures
-sx- lateral elbow pain, inability to fully extend elbow -dx- fat pad sign- posterior or increased anterior -tx- non displaced- sling long arm splint
Osteosarcoma
-sx- malignant bone tumors that present with pain and swelling. No improvement is noted with conservative therapy. METAPHYSIS -DX- Metaphysis, sunburst/Cloud-like bone formation, humerus, fibula, iliac bone. Surgery and chemotherapy - 50-50 chance of survival
Rheumatoid arthrititis
-sx- morning stiffness less than 1 hr, fever, weakness, muscle pain.. NO DIP -dx-RF 1st!!!! anti- CCP(95%)+ RF (75%) -tx- DMARDS 1st!!!, MTX (MONTIOR CBC diff. gastrisi MC SE)
Thoracic outlet syndrome
-sx- nerve compression ulnar side of hand, swelling, doscoloration of the arm with abduction of arm, + adson -dx- MRI -tx- pt
dupuytren contracture
-sx- nodes over distal palmar crease or proximal phalynx MCP!
Glaucoma
-sx- steamy cornea, fixed mid dialted pupil, tunnel vision loss -dx-increased intraocular pressure narrow anterior chamber -tx-acute closed- azcelomide (1st line), timlol (1st in open angle), pilocarpine, azcelomide (1st in angle closure), mannitol--- surgical irrtotomy---trabulectomy chronic open- prostagladin analogs
retinal vascular occulsion
-sx- sudden monocular vision loss -dx- fundscopy- blood and thunder appearance, retinal hemorrages -tx- no effective treatment
dental abcess
-sx- swelling at base of tooth, sharp gnawing pain -dx- xray for deeper abcesses -tx- drain and abx
laryngitis/mastoiditis
-sx- usually viral- rhino follows URI. hoarsenss -tx- Fluids, rest= if more than 3 weeks horesness evaluate for cancer- refer to ENT -mastoditis= CT, persistent adult- must R/O cancer, ENT referal tx- ampicillin
strabismus
-sx-"CROSS EYED", turns into amplytopia (must fix this lazy eye before 1 years) eso= inward. exo=outward -dx- cover/uncover -tx- patch good eye. under 3 monthes refer
slipped capital ephysis
-sx-ages 11-16, obese boy, limp with hip/thigh/knee pain. with limp, "Ice cream cone falling off" -dx- FROG leg LATERAL Pelvis= kliens lines -tx- pinning in situ= surgical
allergic rhinitis
-sx-boddy, shiner -dx- ige medated allergy test -tx- intranasal flucusalone/corticosteroids--- antihistamines
meniere disease
-sx-excessive fluid in middle ear -recurring vertigo min-hours -triad- low freq SNHL, fluctuating tinnitus, Episodic vertigo -tx- low sodium diet and diruetics---scoplamine, meclizine
polyarthritis nodosa
-sx-fever, hip, and shoulder muscle weakness.... renal hypertension, renal failure, fever, arthritis, neuropathy, livedo reticularis- pt will have Hep B, purapura -dx- - increased ESR -Angiography recommended (will show rosary sign) - CLASSIC is ANCA Negative! - mesenteric angiography will show microaneursism in small arteries -tx- prednisone and cyclophosphamide
Vertigo caused by problems with the inner ear or vestibular system, which is composed of the semicircular canals, the otolith (utricle and saccule), and the vestibular nerve is called "peripheral", "otologic" or "vestibular" vertigo.The most common cause is benign paroxysmal positional vertigo (BPPV), which accounts for 32% of all peripheral vertigo.Other causes include Ménière's disease (12%), superior canal dehiscence syndrome, labyrinthitis and visual vertigo.
...
what is normal audiometry measurement
0-20 decibels
hypertensive retinopathy
1. arterial narrowing: abnormal light reflexes on dilated tortuous arteriole shows up as colors - Copper wiring: moderate - Silver wiring: severe 2. AV nicking: venous compression @ arter-venous junction by increased arterial pressure. may lead to CRVO 3. flame shaped hemorrhages, cotton wool spots (soft exudates which are lighter than hard exudates) 4. papilledema (malignant HTN)
menieres dz classic triad
1. episodic vertigo 2. low frequency hearing loss 3. tinnitus
prostaglandin analogs
1st line class of treatment for chronic glaucoma
antihistamines
1st line treatment class for vertigo
tx of dental abscess
1st--ABs 2nd--root canal 3rd--tooth extraction
remove rust ring at
24 hours
vestibular system
3 semicircular canals originating in the vestibule responsible for balance
Viral infection of the conjunctiva is usu. caused by adenovirus type ___, __ or ____
3, 8 , 19
When does Glaucoma screening begin?
40 years old - asymptomatic prior to optic nerve damage and subsequent visual changes
pathogens of acute sinusitis
40% S. pneumoniae 30% H. influenzae 20% m. catarrhalis 10% other
open angle glaucoma
65+ y/o must be screened increased or normal IOP cut to disc ratio > 0.5 TONOMETRY > 21 optic disc cupping Tx: Lantaprost, BB, timolol, Brimodidine
normal IOP
8-21 mmHg
Sinusitis
80% of cases will improve within 2 weeks without antibiotic therapy. MCC is viral. Results from mucociliary clearance and sinus obstruction due to mucosal edema. Mucus accumulation becomes secondarily infected. Bacterial pathogens are similar to those of Ottis media (S pneumoniae, Other strep, Hflu, S aureus, Moraxella). May present with unilateral facial fullness, pressure, tenderness in cheek area. Pain may refer to upper incision or canines. Prudent yellow-green nasal drainage or expectoration. Fever, malaise halitosis, HA and cough. MC site is MAXILLARY for adults, FRONTAL for peds. Bacterial variant will persist more than 10 days. Viral variant will tend to be improving at 10 days. Tx with NSAIDs, oral or nasal decongestants. If symptoms persist for more than 10 days, ABX are indicated. 1st line = amoxicillin, macrolide, or tetracycline therapy if PCN resistance or allergy. Tx for 10 days.
acoustic neuroma
8th cranial nerve dx: MRI
Acute sinusitis
<4 weeks. Viral
Chronic sinusitis
> 12 weeks. Anosmia. CT scan. Glucocorticoids, antibiotics (weeks), nasal saline
What is the Tonometry pressure concerning for Open-Angle Glaucoma?
> 21 mmHG
open angle glaucoma
>40, chronic, asx, can cause blindness
A 30-year-old male presents to your office complaining of sinus and facial pain, congestion, and purulent nasal discharge for one month. He has been treated with two courses of different antibiotics by another provider, and does not feel any improvement in his symptoms. What diagnostic test is indicated?
A CT scan is the current preferred method for sinus imaging of chronic sinusitis. CT imaging has better visualization of mucosal thickening air-fluid levels and bone structures. Plain radiographs and CT scans are of limited use in acute sinusitis, because viral pathogens that cause sinus abnormalities are indistinguishable from bacterial causes.
is characterized by a pale retina, as well as a cherry red spot on the macula.
A central retinal artery occlusion
A 66-year-old female has a chief complaint of vision loss in her left eye. She denies pain and states that this occurred over the past few hours. Her past medical history includes hypertension, high cholesterol, and peripheral vascular disease. Upon funduscopic exam, you note marked hemorrhages in all quadrants and disc edema. The contralateral eye shows only mild hypertensive vascular changes. What is your diagnosis?
A central retinal vein occlusion is characterized by a "blood and thunder" fundus, with marked hemorrhages, tortuous vessels, and optic disc edema.
A 45-year-old male presents with a non-tender nodule protruding from his lower eyelid. There is some surrounding erythema to the conjunctiva, but no discharge is seen. He states that it has been there for one month. He has no visual problems. What is your diagnosis?
A chalazion is a sterile, chronic, and non-painful granulomatous nodule, caused by a previous acute infection in a meibomian gland. It can develop over a period of a few weeks. Treatment is intralesional steroids or surgical curettage.
Hyphema
A collection of red blood cells in the anterior chamber of the eye. Results from trauma to the ciliary body, iris, or anterior structures causes bleeding. May present after incurring trauma to the eye. Perform CT and US to exclude associated orbital fracture or foreign body. If no increase in IOP, limit activity for 72 hours. If increased IOP, topical oral ocular hypotensives, and cycloplegics (atropine).
A 45-year-old presents with a markedly tender nodule protruding from the edge of his upper eyelid. He states that this has been present for 12 hours. No discharge is seen. He denies visual problems. What is the most likely diagnosis?
A hordeolum (sty) is caused by an acute infection of the Zeis or Moll's glands of the eyelid. Symptoms include pain and tenderness. An "internal hordeolum" points to the inner conjunctiva of the lid and an "external hordeolum" points to the skin surface of the eyelid.
A 12 year old male presents with lesions on the palmar surface. They have been present for less than a week. Prior to the lesion appearing there was a small lesion that was assumed to be a bug bite. The lesion bleeds profusely with minimal provocation. What is the most likely diagnosis?
A pyogenic granuloma (PG) occurs at the site of minor trauma such as a bug bite or scratch. The PG grows rapidly forming a popular lesion with a collarette of scale. It will bleed profusely with minimal provocation. The only effective treatment is shave excision with curetting and ablation of the blood vessels that form the base of the PG.
A 35-year-old homeless male presents with a painful red right eye and decreased visual acuity, which occured over the past 48 hours. He doesn't recall any trauma, and prior to this his vision was good. His past history includes alcoholism and liver disease. On physical exam you notice a white opacity in the center of his right cornea. You are unable to do an ophthalmoscopic exam due to the opacity, and a fluorescein staining is strongly positive. What is the likely etiology of the white opacity?
A rapidly progressing central corneal ulcer must be considered first and treated aggressively. An ulcer will show fluorescein staining, due to a break in the corneal epithelium. Pseudomonas, strep pneumonia, herpes, and fungus must be considered as possible causes. An emergent ophthalmology consult can be sight saving.
Corneal Ulcer
A red eye with circumcorneal injection. Commonly a result of infection (bacterial, viral, fungal, or amoebas). Noninfectious causes inculde neurotrophic keratitis, exposure keratitis, severe dry eyes or allergic eye disease, and various ocular or systemic inflammatory disorder. May present with pain, photophobia, tearing, and reduced vision. PE reveals a red eye with mainly circumcorneal injection and purulent watery discarge.
A 24-year-old intoxicated male presents to the emergency department after being in a fight. He was punched in the nose, and now has mild deformity of the nose and some epistaxis. An x-ray reveals a fractured nasal bone. During his physical exam, what must you look for in order to prevent permanent destruction of his nasal septum?
A septal hematoma can cause ischemic necrosis of the nasal septal cartilage if not identified and drained. A deviated septum can be expected with a nasal bone fracture, and must be addressed by the otolaryngologist. Excessive epistaxis that does not resolve with direct pressure and anterior packing may indicate a posterior bleed.
dequervains tenosynovitis
APL and EPB -sx- pain along radial aspect of wrist -dx- finklestein test- pain with ulnar deviation or thumb extension -tx- thumb spica splint
A 26 year old male has dark urine 2 weeks after pharyngitis. UA shows red blood cell casts. What laboratory test can be drawn to support your suspicions?
ASO titer in patient with signs of post-streptococcal glomerulonephritis
central vertigo causes
AV malformation, tumor of brain stem or cerebellum, MS, vertebrobasilar migraine syndrome
Treatment for Open-angle glaucoma are many. Name the Topical Carbonic Anhydrase Inhibitors used for treatment:
Acetazolamide Dorzolamide
Describe some presentation symptoms of Acute Angle Closure Glaucoma
Aching, throbbing pain - severe "halos" around light Decreased visual acuity Injected conjunctiva* Cloudy/"steamy" cornea* Fixed, dilated pupil* HA/N/V
Intracranial benign tumor affecting CN VIII
Acoustic Neuroma
Slow growing benign tumor of the eight cranial nerve?
Acoustic neuroma/Schwannoma
Penicillin or cefuroxime PCN allergy: macrolides (erythromycin)
Acute Bacterial Pharyngitis treatment
Follows URI Purulent nasal discharge, facial pain, nasal obstruction Fever
Acute Bacterial Sinusitis clinical features
Viral URI that leads to eustachian tube dysfunction or blockage
Acute Otitis Media
Fever, ear pain, ear pressure, hearing impairment TM erythema
Acute Otitis Media clinical features
A 54-year-old male presents to you with a sudden onset of severe left eye pain and blurred vision. He states that he is nauseated and vomited twice. He denies any history of eye problems, other than having to wear glasses for reading. His only recent problem has been a mild upper respiratory infection, for which he is taking an over-the-counter decongestant. On physical exam, the vision in the affected eye is 20/200. His pupil is mid-sized and non-reactive to light, and the conjunctiva is markedly injected. What diagnosis must you consider first?
Acute angle closure is characterized by sudden onset of severe eye pain, blurred vision, nausea, vomiting, visual halos, and headache. Physical exam findings can include conjunctival injection, a rock hard ocular globe on palpation, a cloudy cornea, and a mid-position fixed pupil. Normal intraocular pressure is below 21mm Hg. Acute angle closure glaucoma can develop pressures of 60 to 80mm Hg.
Hordeolum
Acute development of a painful nodule or posture within a gland of the upper or lower lid. MCC by Staph, is not contagious. Internal - caused by inflammation or infection of the meibomian gland with pustular formation, situated deep to the palpebral margin. External (Sty) - caused by inflammation or infection of the glands of Moll and Zeis with pustular formation. Situated immediately adjacent to the palpebral margin. Presents with acute onset of pain and edema of the involved eye. Palpable, infuriated area in the involved eyelid, which has a central area of prudence with surrounding erythema. Tx with warm compress several times per day for 2 days. Topical ABX if infected. I&D may be required.
What is the DX? Acute vertigo associated with N/V tinnitus hearing loss in patient with no HX of vertigo.
Acute labyrinthitis (usually post infectious/viral)
What is the Dx? Acute deep ear pain erythematous bulging tympanic membrane middle ear fluid and hearing loss.
Acute otitis media
Sialadenitis
Acute pain and swelling of the parotid or submandibular gland. Ducal obstruction by mucus plus and salivary stasis leads to secondary infection, most commonly by Staph Aureus. May present with acute gland swelling, increased pain and swelling with meals, tenderness, and erythema of duct opening. Pus can be expressed from the duct. Occurs in the setting of dehydration or chronic illness. Dx with US or CT I&D is supportive variant develops. Tx with IV ABX with transition of orals. Less severe cases may be treated with orals alone. Stimulation of salivary flow with hydration, warm compress, sialogogues such as sour candies and gland massage. Treatment failure may indicate abscess formation, duct stricture, stone, or tumor.
How will Optic Neuritis present?
Acute vision loss (mono) Pain in affected eye Sluggish pupillary response
Mumps
Acute, self-limited, systemic viral illness characterized by the swelling of one or more of the salivary glands, typically the parotid glands May present with fever, headache, malaise with onset within 24 hours. May complain of ear pain, worse with chewing. May cause thyroiditis, pancreatitis (rare), or orchitis (50%) in postpubertal males, with 30% being bilateral. May also cause Oopheritis in postpubertal females. Associated with fever, nausea and vomiting, and low abdominal/pelvic pain. Will have a markedly enlarged parotid gland, submaxillary glands may be swollen and Stensons duct may be enlarged at the opening. Self limiting, supportive care, fluids, analgesics, ice packs or warm compresses to soothe swollen glandular areas.
Labyrinthitis
Acute, severe, continuous vertigo Cause is unknown. Pt may have had cold like symptoms that resolved around 1 week prior to onset of dizziness. Presents as acute onset of continuous vertigo lasting several days to a week. Hearing loss and tinnitus are present. Vertigo gradually improves, but hearing improvement varies. Tx with ABX for febrile patients with suspected bacterial infection. Vestibular suppressants (diazepam, meclizine) during acute phase.
Demographically speaking, in whom are cataracts *most common*?
Adults > 60 yrs old
You are asked to examine an 88-year-old female resident of a nursing home, who presents with a red eye. Her notes from the nursing home say that the patient has had this problem for six months, but now seems to be getting worse despite using daily artificial tears and occasional topical antibiotic drops. On physical exam you notice markedly injected conjunctiva to the right eye, with no discharge. The lower lid appears to be curled in toward the bulbar conjunctiva, with the eyelashes pointing inward. What is the name of this condition?
Aging causes a relaxation in the lower lid retractors, resulting in an entropion. This causes chronic irritation to the bulbar conjunctiva and corneal abrasions. Treatments include taping the lower lid to the cheek, botulinum toxin injection, or surgery.
A 45-year-old female presents with a sudden onset of vertigo, nausea, and vomiting. Upon physical exam, you note that she is holding on to the rails of the bed, and her pain gets worse when you attempt any movement of her head. Neurologic exam is grossly normal. Which combination of the following medications is indicated to treat the patient's symptoms?
All other combinations include an ototoxic medication: furosemide, gentamycin, aspirin, and cisplatin. Treatment of acute vertigo is more effective using a combination of vestibular suppressants (benzodiazepines), anti-emetics (prochlorperazine), and anticholinergics (diphenhydramine or scopolamine).
Your patient has symptoms consistent with perennial allergic rhinitis, and after performing a history and physical examination, you elect to perform an IgE-specific serum antibody test for both food and respiratory allergens. The results return and the patient does not have an IgE positive response to a single allergen tested, yet the patient's total serum IgE is elevated dramatically. What would be the most appropriate next step in the diagnosis and treatment of this patient?
Allergen-specific serum IgE testing is an easy and accurate method for determining the presence of atopic allergy, and with newer in vitro technology available, in vitro testing is at least equivalent to skin testing in efficacy. In vitro assays are safe, specific, cost-effective, and reproducible, and do not require the patient to be free of antihistamines and other medications that may interfere with skin testing. They are also easy and quick and are therefore preferred, especially in children and in anxious patients.
Allergic shiners Rhinorrhea, watery eyes, sneezing, nasal congestion Dry cough Pale mucosa Watery/clear discharge
Allergic Rhinitis clinical features
A patient presents to your office with a sudden onset of headache, right eye pain, decreased visual acuity, nausea and vomiting. His intraocular pressure is 47. Which of the following classes of medications are indicated for treatment of this condition?
Alpha agonists and Beta blockers Ophthalmic alpha-agonists (brimonidine) and beta blockers (timolol) decrease aqueous humor production, and decrease intraocular pressure. They facilitate aqueous flow through outflow tract and the canal of Schlemm.
A pt that complains of sudden loss of vision in one eye is experiencing what (term)?
Amaurosis Fugax
Which of the following diagnostic studies is indicated for a patient with amaurosis fugax?
Amaurosis fugax is a monocular vision loss that appears like a curtain passing over the eye, and comes from carotid artery disease. A CT of the head is indicated for lateralizing stroke symptoms. Intraocular pressure is taken for evaluation of chronic or acute glaucoma. A temporal artery biopsy is taken if giant cell arteritis is suspected. An ocular fluorescein angiogram is done to evaluate retinal disorders.
Topical abx for dacryocystitis?
Aminoglycosides (Gentamicin, Tobramycin) Fluoroquinolones (Cipro, Moxi, Oflox, Norflox) Macrolides (Erythromycin)
The American Academy of Pediatrics (AAP) recommends which of the following treatments for a two-year-old child with an acute otitis media who has a fever of 103.7˚F, had an ear infection two months ago, and in whom you suspect penicillin-resistant strep bacteria?
Amoxicillin-clavulanate 45 to 90 mg/kg, divided into BID dosing and administered for 10 days
An 18-year-old female presents with two weeks of severe sore throat and fatigue. Her exam shows an exudative tonsillitis. A mono-spot test is positive, and a rapid strep test is positive. Which of the following medications should be avoided?
Ampicillin should be avoided, because a high percentage of mononucleosis patients develop a fine, non-allergic maculopapular rash when given ampicillin class drugs. The remaining antibiotics are appropriate for treating group A strep. Prednisone is used to reduce the pain and inflammation associated with severe tonsillitis.
How is central loss vision tested?
Amsler Grid
This is an opthalmic emergency characterized by painful eye and loss of vision. Physical exam will reveal circumlimbal injection, steamy cornea, fixed mid-dilated pupil, decreased visual acuity and tearing.
Angle closure glaucoma
What're the 2 types of Glaucoma?
Angle-closure Open-Angle
Is the most common type of nosebleed an anterior or posterior bleed?
Anterior bleed
The source of most cases of epistaxis comes from what anatomic location?
Anterior nasal septum. 95 percent of epistaxis come from Kesselbach's plexus, which is a superficial, fragile group of arterioles and veins that are the most likely cause of nosebleeds. Five percent are posterior bleeds that originate along the sphenopalentine artery.
Which class of meds puts older pts at risk of angle-closure glaucoma?
Anti-ACh meds
Painful, round ulcers with yellow-gray centers and red halos Recurrent
Aphthous Ulcers clinical features
Topical corticosteroids
Aphthous Ulcers treatment
A mother presents with a 2-month-old infantwith a concern of bald spots in the child's scalp. Shestates that there were ulcerated areas present at birth that healedwithin a few days. What is the most likely diagnosis?
Aplasia cutis congenita is a rare condition that is present atbirth, and presents as asymptomatic ulcerations of the scalp. Theseulcerations heal with scarring in a matter of weeks. The cause isbelieved to be incomplete neural tube closure or cessation of skindevelopment of the embryo.
PAtient presents with a single or multiple painful, round ulcers with yellow gray centers and red halos. likely dx?
Apthous ulcers (canker sores, ulcerative stomatitis)
Critical: Retinal vessels
Artery to vein ratio is 2 to 3 without nicking or spasms
What is the most common pathogen in fungal otitis externa?
Aspergillus causes 90% of cases
What underlying disorders may be related to nasal polyps?
Asthma and ASA or NSAID allergy
Rheumatic fever
Autoimmune inflammatory process that develops as a sequela of streptococcal infection with extremely variable manifestations. The most severe complication is heart disease, usually occuring after multiple recurrences. May present with the following: Sore Throat (35-60%) Polyarthritis (75%) Carditis (30-60%, more common in children) Sydenham Chorea (25% of children, rare in adults) Erythema Marginatum (10% of children, rare in adults) Tx is primarily supportive at time of acute episode. Tx of primary infection is best prevention. IV immunoglobulin may help reduce risk of development of rheumatic heart disease.
What is the treatment for small tympanic membrane perforation?
Avoid water until healed in all types of rupture - oral antibiotics if caused by infection/AOM
Urinary Retention
Avoidance of oral antihistamines in patients with this condition.
Your 11 year old patient presents with acute onset of copious purulent dc from both eyes. They have a mild decrease in visual acuity and mild discomfort. The eys are "glued" shut upon awakening. Started 10 days ago. Likely dx?
BACTERIAL conjunctivitis
What is the most likely type of vertigo in a patient with vertigo who has a positive Dix Hallpike maneuver?
BPPV (Benign Paroxysmal positional vertigo)
A 48-year-old female complains of ear fullness, episodes of tinnitus, and vertigo. She also complains that her hearing is not as good as it used to be. She states that this has occurred sporadically over the past year. What is the most likely diagnosis?
BPPV is characterized by sudden vertigo, made worse with head position change, and accompanied by nausea and vomiting. Meniere syndrome is characterized by episodic severe vertigo, fluctuating sensorineural hearing loss, tinnitus, and ear "fullness." Pathologically, there is distention of the endolymphatic system throughout the inner ear, presumably due to dysfunction of the endolymphatic sac. Labyrinthitis is characterized by severe vertigo and hearing loss, and is likely a result of a viral inner ear infection. Vestibular neuronitis is also a result of a viral inner ear infection, with symptoms of severe vertigo, nausea, and vomiting, without hearing loss. Both labyrinthitis and vestibular neuronitis resolve in one to two weeks. Presbycusis is age related hearing loss.
Polymorphonuclear cells (PMNs)
Bacterial Conjunctivitis diagnostics
Acute ear pain hemotympanum hearing loss after flying?
Barotrauma
You are evaluating a patient who is complaining of facial drooping , and inability to close his eye. During the cranial nerve exam you notice he is unable to wrinkle his forehead. Based on this information what is the most likely diagnosis?
Bell's palsy affects cranial nerve VII, the facial paralysis conforms to the all branches of the peripheral nerve including the side of the face, eyelid and forehead muscles. An acute cerebrovascular accident would present only with a facial droop, the ability to close the eye and wrinkle the forehead would be preserved and there would likely be other focal weakness on physical exam. Horner's syndrome is miosis, ptosis and facial flushing and hyperhydrosis caused by abnormalities of the supercervical ganglion along the internal carotid artery.
What is a Pinguecula?
Benign, yellow growth that does not cross onto cornea
What're the tx options for open-angle glaucoma?
Beta-blockers (Timolol/Betaxolol) Prostaglandin Analogs Carbonic-Anhydrase Inhibitors (Acetazolamide) Laser Surgery
Viral conjunctivitis
Bilateral mucoserous discharge
Lesion of the optic chiasm will cause what visual symptoms?
Bitemporal heteronymous hemianopsia
Chronic inflammation of the eyelid margins
Blepharitis
Inflammation of the eyelids with no sign of palpable lumps...?
Blepharitis - Red, swollen eyelids
Swelling, misalignment of the eye Movement of globe restricted Double vision Subcutaneous emphysema Exophthalmos
Blow-Out Fracture clinical features
Direct trauma to the zygomatic prominence or the soft tissue around the orbit may cause which type of fx?
Blowout Fx
As a diver descends for a deep water dive, at about 10 feet of depth he begins to feel nausea, severe ear pain, and develops vertigo and vomiting. What is the most likely cause of his symptoms?
Boyle's law states that as a diver descends, the increasing external pressure causes an equal decrease in pressure in the middle ear, which must be equalized during the descent. If the middle ear pressure is not equalized, the tympanic membrane becomes severely retracted, due to the negative middle ear pressure. This can result in hemotympanum, hemorrhage, or tympanic membrane perforation. Ascent causes increased pressure in the middle ear as the external pressure is decreased. Equalization techniques must also be used to prevent a tympanic membrane perforation. Decompression sickness occurs on ascent, when nitrogen gas bubbles are forced into the middle ear, and vascular and lymphatic spaces.
Describe a Corneal Ulcer. What is a common cause?
Breakdown, necrosis & thinning of cornea. Herpes simplex keratitis
Name Alpha-agonists for OA Glaucoma tx
Brimonidine
A 25 yowm who wears soft contact lenses presents to the ER w a Corneal Abrasion x 4 hours after a fall. In addition to advising him not to wear contacts x 1 wk, which abx choice would appropriate? A- Bacitracin B- Mupirocin C- Tobramycin D- PCN
C- Tobramycin. Soft-contact lens wearers are at an increased risk for INFX w *Pseudomonas*, so abc-choice should cover for it. A Fluoroquinolone would also be appropriate.
sx of meniere's ds
CHRONIC and PROGRESSIVE: hearing loss, tinnitus, vertigo, N/V
Retinopathy in HIV pt is most likely caused by...?
CMV Toxoplasmosis
labyrinthitis
CN8, MC viral -sx-horizontal Nystagmus, continuous vertigo,+ hearing loss/tinnitus -tx- corticosteroids (methylipredinisone 22 days)
What diagnostic test can best confirm the diagnosis of mastoiditis?
CT scan
how to dx orbital cellulitis
CT scan
test of choice for mastoiditis
CT scan
test of choice to dx sinusitis
CT scan
what is the next step after visualizing papilledema on an ophthalmologic exam?
CT with contrast
dx of orbital cellulitis
CT, CBC, blood culture, drainage culture
What is first line tx for acute angle closer glaucoma?
Carbonic Anhydrase Inhibitors: Acetazolamide (Diamox) Methazolamide (Neptazane)
vertigo
Cardinal symptom of vestibular disease. "room is spinning" sensation. Presents with a sensation of motion without actual motion, or an exaggerated sense of motion. Peripheral variant - sudden onset, associated with tinnitus, hearing loss, and horizontal nystagmus. Central variant - Gradual onset, without audiometry symptoms, will have + Romberg. Dx with audiogram, electronystagmography, videonystagmography, MRI. Tx depents on etiology, meclizine may help.
Which of the following diagnostic studies is indicated for a patient with amaurosis fugax?
Carotid ultrasound
Opacity of the natural lens of the eye due to progressive increase in the proportion of insoluble protein
Cataract
Gradual diminution of vision Double vision, excess glare, fixed spots, reduced color perception Translucent, yellow discoloration of the lens
Cataract clinical features
"Clouding of the lens" is AKA . . .
Cataracts
Aphthus Ulcer
Cause is unknown, associated with HHV 6. Also referred to as ulcerative stomatitis. Part of the diagnostic criteria for SLE (lupus), seen in Crohn's, and affects woman more than men. Found on buccal and labia mucosa, sparing attached gingival and palpated mucosa. Single or multiple, recurring painful small round ulceration with yellow-gray fibrinoid center surrounded by a red halo. Tx with topical corticosteroids (triamcinolone 0.1%), topical diclofenac, mouthwashes containing amyloglucosidase and glucose oxidase. Short course of oral corticosteroids if necessary.
What is the potential problem with untreated orbital cellulitis?
Cavernous sinus thrombosis & Intracranial extension of orbital cellulitis. Can be life-threatening.
'fever over 38C, tender anterior cervical adenopathy, LACK OF COUGH and pharngotonsillar exudate' Presence of all 4 of these strongly suggest strep. What is this criteria called?
Centor criteria 3/4 rapid strep test sensitive > 90% 1/4 strep unlikely
Pharyngitis
Centor criteria. Penicillin
Sudden, painless, marked unilateral vision loss EMERGENCY
Central Retinal Artery Occlusion clinical features
Optic disc swelling 'blood and thunder' retina (dilation, hemorrhage, edema, exudates)
Central Retinal Vein Occlusion clinical features
Gradual onset Nystagmus NO auditory symptoms
Central Vertigo clinical features
is characterized by a sudden, painless vision loss. A cherry red spot is characteristic on the macula, along with pallor to the retina
Central retinal artery occlusion
_______ is vertigo due to a disease originating from the central nervous system (CNS). In clinical practice, it often includes lesions of cranial nerve VIII as well. Individuals with vertigo experience hallucinations of motion of their surroundings.
Central vertigo
Keflex
Cephalexin is a cephalosporin antibiotic used to treat certain infections caused by bacteria such as pneumonia and bone, ear, skin, and urinary tract infections. Antibiotics will not work for colds, flu, or other viral infections.
Painless, indurated lesions deep from palpebral margin Secondary to internal hordeolum
Chalazion
Sensory Hearing Loss
Chochlear deterioration due to loss of hair cells. Gradual, progressive high-frequency hearing loss with advancing age (presbycusis). Other causes include excess exposure, head trauma, systemic diseases. Usually not correctable but may be preventable. May be treated with corticosteroid therapy.
Perforated TM and chronic ear discharge +/- pain
Chronic Otitis Media clinical features
A 22-year old female presents to your office complaining of itchy red welts all over her body now fading. She is vacationing from Florida. She has no past medical history and her only medication is an oral contraceptive, but she did take an over-the-counter dipenhydramine four days ago on the flight from Florida to calm her nerves. The welts began after swimming in the ocean in New England three days ago, lasted a few hours, then disappeared spontaneously. They reoccurred Saturday morning again shortly after swimming, lasted a little longer, and again resolved. She relates that they were intensely itchy, red, and raised. She ate out at a restaurant and had seafood Saturday night, and thought that she might be allergic to the seafood, although she ate nothing new or unusual. From the history, which of the following is the likely cause of her urticaria?
Cold urticaria is a hypersensitivity to cold exposure (ie, wind, freezer compartments, water) resulting in histamine release. The hypersensitivity usually presents as localized redness, burning, pruritus, and urticaria in the exposed areas, or the response may progress to generalized systemic reaction, shock, and death. This condition may be familial or acquired. Familial cold urticaria is an autosomal dominant inflammatory disorder (including the Muckle-Wells syndrome), manifested as a burning sensation of the skin occurring about 30 minutes after exposure to cold. Acquired cold urticaria may be associated with medication (ie, griseofulvin) or with infection. Cold urticaria may occur secondarily to cryoglobulinemia or as a complication of syphilis. Most cases of acquired cold urticaria are idiopathic. For diagnosis, an ice cube is usually applied to the skin of the forearm for 4 to 5 minutes, then removed, and the area is observed for 10 minutes. As the skin rewarms, an urticarial wheal appears at the site that may be accompanied by itching. Second-generation antihistamines have been used as first-line treatment. Ebastine is also reported to safely and effectively prevent symptoms from acquired cold urticaria. Use of antileukotrienes in cold urticaria is anecdotal.
An 18-year-old female presents with a history of large open comedones and painful abscesses in both axillae. She has been treated by her primary care provider with oral antibiotics. A thorough physical exam may show which other affected sites?
Common areas of involvement in hydradenitis suppurtiva include the axillae, breasts, anogenital region, perineum, and scalp.
Barotrauma
Common risk factors include air travel, rapid altitude changes, and deep diving. Poor eustachian tube function decreases ability to equalize pressure. Most acute during airplane descent. Swallowing, yawning, or autoinflating ears during airplane descent helps. Slow descent while diving. Myringotomy for severe otalgia and hearing loss. Ventilating tubes for frequent episodes Avoid diving during episodes of URI, allergies, or TM perforation.
vincent's angina
Common, non-contagious infection of the gums with sudden onset. The main features are painful, bleeding gums, and ulceration of inter-dental papillae (the sections of gum between adjacent teeth). TRENCH MOUTH, Acute Necrotizing Ulcerative Gingivitis. Presents with severe gingival pain, Profuse gingival bleeding that requires little or no provocation, and Interdental papillae are ulcerated with necrotic slough. All three must be present to Dx. Tx with irrigation and debridement of infected areas. Oral ABX (metronidazole) for systemic involvement.
Gingival Hyperplasia
Commonly caused as a result of drug side effects of CCBs, Phenytoin (and many other anticonvulsants), and Cyclosporine.
Allergic Rhinitis
Condition is associated with pale or violaceous nasal turbinates. Exposure to airborne allergens activates humoral (B-cell) and cytotoxic (T-cell) responses. IgE causes release of inflammatory mediators (histamine, prostaglandins, kinins). Seasonal variant is associated with pollens and spores. Perennial variant is associated with dust, mites, pollution, and pet dander. May present with clear rhinorrhea, sneezing, tearing, conjunctival erythema, eye irritation, and pruritus. Accompanying symptoms may include cough, bronchospasm, and eczematous dermatitis. Yellow boggy masses of nasal polyps seen with chronic cases. Strong family history of atopy or allergies. Allergic Salute Dx with RAST - Radio allergosorbent test. Tx by reducing exposure referral to allergist for immunotherapy for resistant cases. Use of antihistamines, intranasal corticosteroids and saline, antileukotriene and anticholinergic agents.
What type of hearing loss will the Weber and Rinne tests assist in diagnosing?
Conductive
What type of hearing loss is experienced with cerumen impaction?
Conductive hearing loss
What type of hearing loss occurs with tympanic membrane rupture?
Conductive hearing loss
Which of the following will cause conductive hearing loss? A. Mumps B. Syphilis C. Multiple sclerosis D. Otitis media E. Medications
Conductive hearing loss is the result of blockage of sound waves from the external canal to the inner ear. Causes include cerumen, middle ear effusion, otitis media, and occiscle disruption. Multiple sclerosis causes VIIIth cranial nerve disruption and neural hearing loss. Mumps and syphilis can cause sensoryneural hearing loss.
Branchial Cleft Cyst
Congenital epithelial cysts, which arise on the lateral part of the neck from a failure of obliteration of the second branchial cleft in embryonic development, related to gill apparatus of fish. Commonly presents as a solitary, painless mass in the neck of a child or a young adult. A history of intermittent swelling and tenderness of the lesion during upper respiratory tract infection may exist. Discharge may be reported if the lesion is associated with a sinus tract. Tx with ABX if abscess if suspected. Definitive treatment is surgical excision.
A 35-year-old homeless male presents with a painful red right eye and decreased visual acuity, which occured over the past 48 hours. He doesn't recall any trauma, and prior to this his vision was good. His past history includes alcoholism and liver disease. On physical exam you notice a white opacity in the center of his right cornea. You are unable to do an ophthalmoscopic exam due to the opacity, and a fluorescein staining is strongly positive. What is the likely etiology of the white opacity?
Corneal Ulcer
Usu. caused by minor trauma such as from a fingernail, contact lens, eyelash or foreign body. Patient will present with pain and sensation of a foreign body and it can be accompanied by photophobia, tearing, injection and blepharospam.
Corneal abrasion
Patient presens to your clinic with pain, photophobia an tearing. Examination reveals circumcorneal injection and watery to purulent discharge. Fluorescein staining will reveal a dense corneal infiltrate with overlying epithelial defect. Dx? (corneal abrasian, blehpariits, corneal ulcer)
Corneal ulcer
What is inflammation of nasolacrimal duct?
Dacryoadenitis
An obstruction/INFX of the Lacrimal sac is AKA . . .
Dacryocystitis
Inflammation of the lacrimal gland caused by obstruction
Dacryocystitis
Obstruction of the lacrimal system
Dacryostenosis
How does a pt present when having orbital cellulitis
Decreased ROM Pain with eye movement Proptosis (Forward eye protrusion)
What does shingles in the eye look like w fluorescein stain?
Dendritic (branching) ulcers
A 28-year-old male presents with a rashon his hands that is unresponsive to topical steroids. On physicalexam you notice periocular violaceous erythema and edema. He also exhibitssignificant proximal muscle weakness. What is the most likely diagnosis?
Dermatomyositis is an autoimmune disease that targets the skinand skeletal muscle. Skin lesions usually consist of a periorbitalheliotrope rash, which can have associated edema. There can alsobe flat topped violaceous papules (Gottron papules) located on theneck, shoulders, and knuckles. Periungual erythema with telangiectasiasmay also occur. Possible muscular symptoms include muscle tenderness,muscle atrophy, and progressive proximal muscle weakness.
A 16-year-old male was hit on the left side of his face by a line drive baseball. Marked swelling is noted externally to the left eye. There was no loss of consciousness. Upon physical exam, he complains of diplopia during extraocular motion testing. Enophthalmos is noted, as well as decreased sensation of the left cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary sinus, and a fracture of the orbit. Based on this information, what is the most likely diagnosis?
Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve. A Le Fort I fracture describes a transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum. A Le Fort II fracture describes a pyramidal through the central maxilla and hard palate. Movement of the hard palate and nose occurs, but not the eyes. A Le Fort III fracture describes a craniofacial disjunction, wherein the entire face is separated from the skull due to fractures of the frontozygomatic suture line, across the orbit and through the base of the nose, and ethmoids. The entire face shifts, with the globes held in place only by the optic nerve.
benign paroxysmal positional vertigo
Dix-Hallpike to Dx Epleys maneuver to Tx lasts seconds to minutes otoliths are stuck in semicircular canals tx: meclizine
drusen deposits
Drusen are tiny yellow or white deposits in a layer of the retina called Bruchs membrane. They are the most common early sign of dry age-related macular degeneration.
While you are doing a funduscopic exam on an 80-year-old female with progressive vision loss, you notice drusen formations on her retinas. What is the most likely diagnosis?
Drusen are yellow colored collagen deposits in Bruch's membrane of the retina. They can be diffuse, discrete, or confluent. Retinal pigment changes and atrophy are see in "dry" macular degeneration. "Wet" macular degeneration demonstrates choroidal neovascularization, or serous retinal pigment hemorrhages and retinal detachments.
centor criteria
Dx and Tx GAS: fever cervical adenopathy lack of cough tonsillar exudate 2+ need culture and 3+ strep likely
Conductive Hearing Loss
Dysfunction of external of middle ear impairing passage of vibrations to inner ear. Obstruction (cerumen), mass loading (effusion), stiffness (otosclerosis), discontinuity (ossicular disruption). Correctable with medical or surgical therapy. May be treated with amplification devices if not medically correctable.
Retinal artery occlusion
ER!
closed angle glaucoma
ER! loss of vision, pain, circumlimbal injection, steamy cornea, fix dilated pupil, decreased visual acuity, N/V, diaphoresis, HALOS
A 12-year-old male begins to sneeze, and develops itchy, watery eyes about 15 minutes after being exposed to a cat. There is no respiratory difficulty. What phase of allergic response is he in?
EXPLANATION: The humeral or early phase occurs in the first 15 minutes of being exposed to an allergen. The symptoms are caused by release of histamine. The cellular phase is the late phase, and occurs after four to six hours of allergen exposure. Seasonal allergic rhinitis occurs in a regular pattern each year, corresponding to pollen exposure. Perennial rhinitis occurs year round, and may be more linked with indoor allergen exposures.
Lid everts secondary to trauma, infection, palsy of the facial nerve
Ectropion
A 65-year-old female presents with a red irritation in her right eye. She states that this has been occurring intermittently for about two years. She also states that her eyelids are "droopy," and that she needs plastic surgery. On physical exam you notice a diffusely injected conjunctiva and an outwardly tilted lower eyelid. What is the most likely diagnosis for the abnormal physical finding?
Ectropion Ageing causes a relaxation of the obicularis oris muscle, and will cause the lower eyelid to sag outwardly. This prevents the lower lid from protecting the eye, and frequently results in exposure conjunctivitis and keratitis. Treatment is surgical.
Sore throat, fever, drooling Children: tripod or sniffing posture to improve air exchange 'Thumb sign' on lateral xrays
Epiglottitis clinical features
Most common cause of Mononucleosis?
Epstein-Barr Virus (EBV)
Acoustic Neuroma
Evaluate for this intracranial mass in patients with unilateral or asymmetric sensorineural hearing loss. Benign lesion which arise within the internal auditory canal and eventually grow to compress the pons, resulting in hydrocephalus. Presents with unilateral hearing loss, deteriorating speech, disequilibrium. Dx with enhanced MRI. Tx with observation, microsurgical excision, stereotactic radiotharpy. Bevacizumab for treatment of tumors in patients with neurofibromatosis type 2.
A 21 year old female presents with a solitary firm right cervical node for the last 2 months. What is the most appropriate next step?
Excisional biopsy and pathology to rule out Hodgkin lymphoma
Diagnosis/ENT/Ophthalmology A 56 year-old female presents complaining of intense left eye pain associated with unilateral headache, nausea, and colored rings around lights. On examination you note decreased visual acuity, a pupil that is fixed and mid-dilated, and ciliary flushing. Which of the following is the most likely diagnosis? A. Acute glaucoma B. Migraine C. Episcleritis D. Acute uveitis
Explanations (c) A. Acute glaucoma is an ocular emergency that presents as an acutely painful eye and elevated intraocular pressure. Patients typically complain of acute eye pain associated with unilateral headache, nausea/vomiting, cloudy vision, and colored rings around lights. On exam the pupil is fixed and mid dilated with prominent ciliary flush. (u) B. Migraine headaches have associated unilateral headache and nausea however there would be no pupillary changes. (u) C. Episcleritis is an inflammation of the thin layer of connective tissue between the conjunctiva and sclera. Episcleritis resembles conjunctivitis but is a more localized process and discharge is absent. (u) D. Acute uveitis is frequently due to systemic disorders associated HLA-B27-related conditions ankylosing spondylitis, reactive arthritis, psoriasis, ulcerative colitis, and Crohn's disease. The pupil is usually small, inflammatory cells and flare within the aqueous are present.
Diagnosis/ENT/Ophthalmology A patient presents with a nontender, painless, nodule involving a meibomian gland. Which of the following is the most likely diagnosis? A. Chalazion B. Dacryocystitis C. Entropion D. Hordeolum
Explanations (c) A. Chalazion is characterized by a hard, nontender swelling on the upper or lower lid with redness and swelling of the adjacent conjunctiva and is due to granulomatous inflammation of a meibomian gland. (u) B. Dacryocystitis is an infection of the lacrimal sac due to obstruction of the nasolacrimal system. (u) C. Entropion is an outward turning of the lower lid. (u) D. A hordeolum is a bacterial inflammation of the base of the eyelash.
Clinical Intervention/ENT/Ophthalmology There is considerable debate about the use of tympanostomy tubes in the management of recurrent otitis media in children. Tympanostomy tube placement has been proven to Answers A. improve hearing. B. prevent mastoiditis. C. prevent recurrence of effusion. D. prevent delayed language development.
Explanations (c) A. Hearing is improved with tympanostomy tubes by eliminating middle ear effusion when the tubes are functioning properly. (u) B. Mastoiditis is prevented by early treatment of otitis media with antibiotics. (u) C. Effusion can occur even with tympanostomy tubes in place. (u) D. Tympanostomy tubes have not been proven to prevent delayed language development.
Diagnosis/ENT/Ophthalmology A patient presents with eye pain and blurred vision. Snellen testing reveals vision of 20/200 in the affected eye and 20/20 in the unaffected eye. Fluorescein staining reveals the presence of a dendritic ulcer. Which of the following is the most likely diagnosis? A. Viral keratitis B. Fungal corneal ulcer C. Acanthamoeba keratitis D. Bacterial corneal ulcer
Explanations (c) A. Herpes Simplex virus is a common cause of dendritic ulceration noted on fluorescein staining. (u) B. Fungal corneal ulcers have an indolent course with intraocular infection being common but fluorescein staining is negative for a dendritic pattern. (u) C. Acanthamoeba keratitis has a waxing and waning course over several months and has no fluorescein staining in a dendritic pattern. (u) D. Bacterial corneal ulcers can progress aggressively resulting in corneal perforation. Fluorescein staining does not occur in a dendritic pattern.
Diagnosis/ENT/Ophthalmology Which of the following is a staphylococcal infection characterized by a localized red swollen and acutely tender abscess of the upper or lower eyelid? A. Hordeolum B. Uveitis C. Chalazion D. Dacryocystitis
Explanations (c) A. Hordeolum (stye) is a staphylococcal infection characterized by a localized red swollen and acutely tender abscess of the upper or lower eyelid. (u) B. Uveitis is an intraocular inflammation involving the uveal tract. (u) C. Chalazion is a granulomatous inflammation of the meibomian gland. (u) D. Dacryocystitis is an infection of the lacrimal sac due to obstruction of the nasolacrimal system.
History & Physical/ENT/Ophthalmology When performing a Weber test on a patient with impacted cerumen in the right canal, the sound should be A. referred to the right ear. B. referred to the left ear. C. equal in both ears. D. louder with air conduction.
Explanations (c) A. In unilateral conductive hearing loss, the sound is referred to the impaired ear. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. Bone conduction as noted with the Rinne test is louder than air with conductive hearing loss.
Clinical Therapeutics/ENT/Ophthalmology Which of the following may precipitate acute angle-closure glaucoma? A. metoclopramide B. timolol C. glyburide D. acetazolamide
Explanations (c) A. Metoclopramide and other drugs with high anticholinergic effects may precipitate acute angle-closure glaucoma from pupillary dilation. (u) B. Timolol, a beta-antagonist, is used in the treatment of acute angle-closure glaucoma. (u) C. Glyburide has no relationship to glaucoma. (u) D. Acetazolamide, a carbonic anhydrase inhibitor, may suppress the production of aqueous humor by 40-60% and is used in the emergency treatment of glaucoma.
Clinical Intervention/ENT/Ophthalmology In patents with diabetic retinopathy, what clinical intervention is most successful in preserving vision? A. Panretinal laser photocoagulation B. Iridectomy C. Radial keratotomy D. Vitrectomy
Explanations (c) A. Panretinal laser photocoagulation is indicated for preservation of vision in patients with diabetic retinopathy. (h) B. Iridectomy is of no value in preserving the retina and iridectomy is harmful in this situation due to the trauma it causes to the eye. (h) C. Radial keratotomy is indicated to correct myopia. This surgery destroys normal eye architecture and has no benefit in diabetic retinopathy. (h) D. Vitrectomy is indicated for treatment of retinal tears and not to preserve an intact retina.
History & Physical/ENT/Ophthalmology Whispered voice test on a patient reveals decreased hearing in the left ear. Which of the following would be most consistent with conductive hearing loss in the left ear? A. Sounds best heard in the left ear on Weber test. B. Air conduction longer than bone conduction in the left ear on Rinne test. C. Sound best heard in the right ear on Weber test. D. Bone conduction longer than air conduction in the right ear.
Explanations (c) A. Sound best heard in the ear with decreased hearing on Weber test (in this case, the left ear) is indicative of conductive hearing loss. (u) B. With conductive hearing loss, bone conduction should be heard as long as or longer than air conduction of sound in the effected ear. Air conduction lasting longer than bone conduction of sound would indicate sensorineural hearing loss. (u) C. Sound best heard in the ear with unaffected hearing on Weber test (in this case, the right ear) is indicative of sensorineural hearing loss. (u) D. With conductive hearing loss, bone conduction should be heard as long as or longer than air conduction of sound in the effected ear. The right ear showed normal hearing on physical exam.
Scientific Concepts/ENT/Ophthalmology Dental caries are caused by which of the following organisms? A. Streptococcus mutans B. Streptococcus pyogenes C. Staphylococcus epidermidis D. Staphylococcus aureus
Explanations (c) A. Streptococcus mutans is the principle organism that helps to demineralize the enamel. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.
Diagnosis/ENT/Ophthalmology A 45 year-old smoker presents with a sore mouth and increasing difficulty eating for two weeks. Physical examination reveals a 1 cm white lesion on the buccal mucosa that cannot be rubbed off. Which of the following is the most likely diagnosis? A. Oral cancer B. Oral candidiasis C. Aphthous ulcer D. Necrotizing ulcerative gingivitis
Explanations (c) A. The presence of leukoplakia in a smoker over the age of 40 should be biopsied to rule out the presence of oral cancer. (u) B. Oral candidiasis presents with white patches. Unlike leukoplakia, the patches easily rub off. (u) C. While aphthous ulcers are commonly found on the buccal mucosa, they are usually 1 to 2 mm round ulcerative lesions. (u) D. Necrotizing ulcerative gingivitis is common in young adults under stress. Clinically, it presents with painful acute gingival inflammation and necrosis.
Clinical Therapeutics/ENT/Ophthalmology A 23 year-old sexually active female presents with a 4 day history of painless bilateral eye exudates which she describes as copious. Visual acuity is 20/20, generalized conjunctival inflammation with sparing of the cornea is noted on physical examination. Gram stain of the exudate reveals gram negative diplococci. Appropriate management of this case is A. ceftriaxone (Rocephin). B. polymyxin ophthalmic drops (Aerosporin). C. ciprofloxacin (Cipro). D. doxycycline (Doryx).
Explanations (c) A. With sparing of the cornea, as in this case, a single 1 gram IM dose of ceftriaxone is sufficient treatment for ophthalmic gonorrhea. If the cornea is involved, 5 days of IM ceftriaxone would be required. (u) B. Polymixin is ineffective against gonococcus. (u) C. Oral ciprofloxacin is not used in cases of gonococcal conjunctivitis. (u) D. Doxycycline is ineffective against gonococcus.
Diagnostic Studies/ENT/Ophthalmology A 32 year-old carpenter complains of right eye irritation all day after driving a metal stake into the ground with his hammer. He states that "something flew into my eye." Visual acuity is 20/20. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact. There is minimal right corneal injection. No foreign body is noted with lid eversion. Fluorescein stain reveals a tiny pinpoint uptake in the area of the corneal injection. Which of the following is the most appropriate diagnostic test at this stage? Answers A. MRI B. X-ray orbits C. Applanation tonometry D. Fluorescein angiography
Explanations (h) A. MRI should never be used when there is suspicion of an iron-containing intraocular foreign body. (c) B. Orbital x-rays or CT scan will be most helpful in identifying an intraocular metallic foreign body. (u) C. Tonometry is used to evaluate intraocular pressure, but not the presence of intraocular foreign bodies. (u) D. Fluorescein angiography is used to evaluate vessels of the eye, not intraocular foreign bodies.
Clinical Intervention/ENT/Ophthalmology A 16 year-old male involved in a fight sustained a laceration to his right upper eyelid. He is unable to open his eye, and a possible laceration of the globe is suspected. Which of the following is the next step? A. Use a slit lamp to determine the extent of the injury. B. Use fluorescein strips to determine the extent of injury. C. Apply a metal eye shield and refer to an ophthalmologist. D. Apply antibiotic ointment to the lid and recheck in 24 hours.
Explanations (h) A. See C for explanation. (h) B. See C for explanation. (c) C. Protect the eye from any pressure with a rigid metal eye shield and refer for immediate ophthalmologic consultation. Avoid unnecessary actions that would delay treatment or cause further injury. (h) D. See C for explanation.
Diagnostic Studies/ENT/Ophthalmology Which of the following is most helpful in the diagnosis of a retropharyngeal abscess? A. CBC with differential B. fever and a muffled voice on examination C. CT of the neck with contrast D. history of a recent throat infection
Explanations (u) A. A CBC with differential would identify an infection but not specifically a retropharyngeal abscess. (u) B. The presence of fever and a muffled voice on physical exam is not specific for a retropharyngeal abscess. (c) C. CT of the neck is considered the "gold standard" for the diagnosis of a retropharyngeal abscess. (u) D. A recent throat infection is not specific for a retropharyngeal abscess.
Diagnostic Studies/ENT/Ophthalmology Which of the following diagnostic studies would be most helpful in diagnosing a retropharyngeal abscess? A. CBC B. Neck CT scan C. Rapid strep screen D. Heterophile antibody
Explanations (u) A. A CBC would be an important test, but it is not definitive for peritonsillar abscess. (c) B. A neck CT scan would identify a peritonsillar abscess. (u) C. A rapid strep screen may have been performed prior to placement on antibiotics, but does not provide a definitive diagnosis for a peritonsillar abscess. (u) D. A heterophile antibody is not indicated in the diagnosis of a retropharyngeal abscess.
History & Physical/ENT/Ophthalmology Which of the following are normal findings in a Weber test? Answers A. The tympanic membrane is movable with pneumatic otoscopy. B. The tympanic membrane is pearly gray with a sharp cone of light with apex at the umbo. C. Sound is heard equally in both ears when a vibrating tuning fork is placed on the mid forehead. D. Air conduction is greater than bone conduction when a vibrating tuning fork is moved from the mastoid bone to close to the ear canal.
Explanations (u) A. A movable tympanic membrane indicates there is no effusion, and is not the Weber test. (u) B. The tympanic membrane is evaluated by direct observation with an otoscope, and is not the Weber test. (c) C. A normal Weber test means there is no lateralization of sound perception when a vibrating tuning fork is placed on the mid forehead. (u) D. A normal Rinne test means that tuning fork vibration is heard longer through the air than the bone.
Clinical Therapeutics/ENT/Ophthalmology A 13 year-old presents with pain in his right ear and loss of hearing since yesterday. He has never had an episode like this before. On exam vital signs are T- 38°C P- 70/minute R- 18/minute BP- 90/60 mmHg. Neck is supple, without lymphadenopathy. Right tympanic membrane is not visible; the canal is swollen, with small amount of exudate noted. There is tenderness of the external ear, especially with gentle traction of the tragus. Left tympanic membrane is normal, and the canal is clear. Oropharynx is normal. Which of the following is the most appropriate topical treatment for this patient? Answers A. Acetic acid solution B. Erythromycin solution C. Cortisporin otic suspension D. Gentamycin drops
Explanations (u) A. Acetic acid solution may be used, but the burning sensation associated with it reduces patient compliance. It is usually used in combination with a topical antimicrobial. (u) B. Erythromycin solution is not used to treat otitis externa. (c) C. Cortisporin otic suspension is a combination antimicrobial (Neomycin and Polymyxin B) and steroid (hydrocortisone) that is effective to use in the treatment of otitis externa. In addition, the suspension is safe to use in suspected cases of tympanic perforation. (u) D. Gentamycin drops are not used in the treatment of otitis externa.
Diagnosis/ENT/Ophthalmology A 52 year-old female presents with complaints of intermittent episodes of dizziness, tinnitus, and hearing loss in the right ear for 6 months. She describes the dizziness as the "room spinning around her," with the episodes typically lasting for 2 to 4 hours. Physical examination reveals horizontal nystagmus and right ear hearing loss, but the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis? A. Acute labyrinthitis B. Positional vertigo C. Acoustic neuroma D. Ménière's syndrome
Explanations (u) A. Acute labyrinthitis typically presents with an acute onset of continuous vertigo that lasts several days to a week and is associated with nausea and vomiting. It does not have any associated auditory or neurologic symptoms. (u) B. Positional vertigo occurs following changes in head positioning with very brief, less than 1 minute, episodes. Nystagmus occurs following the position change. (u) C. Acoustic neuroma typically presents with hearing loss and tinnitus. The neuroma grows slowly and central compensatory mechanisms can prevent or minimize the vertigo. Vertigo, when present, is continuous and not episodic. (c) D. Ménière's syndrome usually presents with episodes of vertigo that last from 1 to 8 hours, sensorineural hearing loss and tinnitus.
Clinical Therapeutics/ENT/Ophthalmology The best course of action for a patient with a bothersome inflamed pingueculae (pingueculitis) is A. antibiotic drops. B. excision. C. Visine drops. D. no treatment.
Explanations (u) A. Antibiotic drops have no benefit with pingueculitis. (h) B. Excision is indicated for a pterygium that is threatening vision. (u) C. Visine drops will not do anything, but artificial tears may be beneficial. (c) D. With pingueculitis, no treatment is necessary; a short course of NSAID drops or steroids may help.
Clinical Therapeutics/ENT/Ophthalmology A 19 year-old college student complains of a sore throat for over a week, with fever and general malaise. On exam T-38°C P-70/minute R-20/minute BP-110/76 mmHg. The patient is alert and oriented x 3. The skin is warm, dry, and without rash. The TMs have a normal light reflex and the canals are clear. The oropharynx is inflamed, with bilaterally enlarged tonsils, and a small amount of exudate. The neck is supple, with anterior cervical adenopathy. The lungs are clear. The heart has a regular rhythm without murmurs. The abdomen is soft, nontender and a spleen tip is palpable. The labs reveal a negative rapid strep screen and positive Monospot. The WBC count is 9,000/microliter with a differential of 40% atypical lymphocytes, 35% lymphocytes, 5% monocytes, 10% eosinophils, and 10% neutrophils. Which of the following is the most appropriate treatment? Answers A. Penicillin B. Erythromycin C. Acetaminophen D. Acyclovir
Explanations (u) A. Antibiotics are not indicated in the treatment infectious mononucleosis, or Ebstein-Barr virus infections. (u) B. See A for explanation. (c) C. Aspirin or acetaminophen may be used to treat fever and pain associated with infectious mononucleosis, or EBV infection. (u) D. Acyclovir is not approved for use in treatment of EBV, although it is active against the EBV in vitro and in vivo. It may be used in certain patients with AIDS, but has not been shown to affect the outcome of EBV in these patients.
Clinical Therapeutics/ENT/Ophthalmology A 19 year-old college student complains of a sore throat for over a week, with fever and general malaise. On exam T- 38 degrees C, P-70/minute, RR-20/minute, BP-110/76 mmHg. The skin is warm, dry, and without rash. The TMs have a normal light reflex and the canals are clear. The oropharynx is inflamed, with bilaterally enlarged tonsils, and a small amount of exudate. The neck is supple, with anterior cervical adenopathy. The abdomen is soft, nontender and a spleen tip is palpable. The labs reveal a negative rapid strep screen and positive heterophil antibody. The WBC count is 9,000/microliter with a differential of 40% atypical lymphocytes, 35% lymphocytes, 5% monocytes, 10% eosinophils, and 10% neutrophils. Which of the following is the most appropriate treatment? A. Penicillin B. Erythromycin C. Acetaminophen D. Acyclovir
Explanations (u) A. Antibiotics are not indicated in the treatment infectous mononucleosis, or Ebstein-Barr virus (EBV) infections. (u) B. See A for explanation. (c) C. Acetaminophen may be used to treat fever and pain associated with infectious mononucleosis, or EBV infection. (u) D. Acyclovir is not approved for use in treatment of EBV, although it is active against the EBV in vitro and in vivo. It may be used in certain patients with AIDS, but has not been shown to affect the outcome of EBV in these patients.
Clinical Therapeutics/ENT/Ophthalmology A 2 year-old female presents with purulent nasal discharge bilaterally with fever and cough for several days. Her 80 mom had taken her out of daycare for a similar occurrence 2 months ago, that was treated with Amoxicillin. Exam further reveals halitosis and periorbital edema. Treatment should be initiated with which of the following? A. Antihistamines B. Ribavirin (Rebetol) C. Intranasal corticosteroids D. Amoxicillin-clavulanate (Augmentin)
Explanations (u) A. Antihistamines and intranasal corticosteroids have not been adequately studied in children to prove they make a difference in treating recurrent sinusitis. (u) B. Ribavirin is approved for the treatment of RSV infection. (u) C. See A for explanation. (c) D. High dose amoxicillin-clavulanate is the treatment of choice for resistant bacterial sinusitis, especially in children presenting with risk factors (daycare attendance, previous antibiotic treatment 1-3 months prior, age younger than 2 years).
Clinical Therapeutics/ENT/Ophthalmology A 12 year-old presents with complaint of both eyes "watering." He also complains of sinus congestion and sneezing for two weeks. On exam vital signs are T-38°C, P- 80/minute, and RR-20/minute. The eyes reveal mild conjunctival injection bilaterally, clear watery discharge, and no matting. Pupils are equal, round, and reactive to light and accommodation. The extraocular movements are intact. The funduscopic exam shows normal disc and vessels. The TMs are normal and the canals are clear. The nasal mucosa is boggy, with clear rhinorrhea. Which of the following is the most helpful pharmacologic agent? Answers A. Artificial tears B. Tobramycin drops C. Erythromycin ointment D. Naphazoline (Naphcon-A) drops
Explanations (u) A. Artificial tears are used for dry eyes. (u) B. Tobramycin drops and erythromycin ointment are used to treat bacterial infections. (u) C. See B for explanation. (c) D. Naphazoline is a topical antihistamine that relieves symptoms of allergic conjunctivitis.
Clinical Therapeutics/ENT/Ophthalmology A 20 year-old woman presents with a 3-day history of sneezing, watery nasal discharge, and a nonproductive cough. Her throat was sore for the first 2 days, and she now complains of fatigue and difficulty breathing because of her "stuffy nose." Which of the following is most likely to improve this patient's status? Answers A. Ascorbic acid B. Amoxicillin C. Pseudoephedrine D. Chlorpheniramine
Explanations (u) A. Ascorbic acid is of no proven benefit in the treatment of viral URI. (u) B. The use of antibiotics is inappropriate for viral infections. (c) C. A decongestant will relieve the nasal congestion and stuffy nose symptoms. (a) D. An antihistamine may relieve the sneezing, but it may thicken secretions, making them difficult to clear.
Clinical Therapeutics/ENT/Ophthalmology A 22 year-old woman presents with sneezing, runny nose, postnasal drip, and nasal congestion for the last week. She says this happens every spring. She is not allergic to any medications. Which of the following is the most appropriate pharmacologic treatment for this patient? A. Azithromycin (Zithromax) B. Phenylephrine (Neo-synephrine) C. Nedocromil D. Pseudoephedrine
Explanations (u) A. Azithromycin is used to treat bacterial infections not allergic disorders. (u) B. Neo-synephrine is not indicated in the treatment of allergic rhinitis. (c) C. Nedocromil inhibits mast cell degranulation and is an effective treatment for allergic rhinitis. It may take 2-6 weeks for full therapeutic effect. (u) D. Pseudoephedrine is a decongestant that may relieve the nasal congestion, but has no effect on the allergic response.
Diagnosis/ENT/Ophthalmology A patient is evaluated in the office with a red eye. The patient awoke with redness and a watery discharge from the eye. The eyelids were not matted together. Examination reveals a palpable preauricular node. Which of the following is the most likely diagnosis? A. bacterial conjunctivitis B. viral conjunctivitis C. allergic conjunctivitis D. gonococcal conjunctivitis
Explanations (u) A. Bacterial conjunctivitis is associated with purulent, not watery eye discharge. (c) B. Viral conjunctivitis is associated with copious watery discharge and preauricular adenopathy. (u) C. Allergic conjunctivitis is associated with symptoms limited to the conjunctiva with hyperemia and edema. (u) D. Gonococcal conjunctivitis is associated with copious purulent discharge and no preauricular adenopatthy.
Health Maintenance/ENT/Ophthalmology Which of the following is the leading cause of permanent visual loss in a patient over the age of 75? A. Blepharitis B. Cataracts C. Central retinal artery occlusion D. Macular degeneration
Explanations (u) A. Blepharitis is a chronic bilateral inflammatory condition of the lid margins. (u) B. Cataracts are the clouding of the lens sufficient to reduce vision. Most develop slowly as a result of aging, leading to gradual impairment of vision. (u) C. Central retinal artery occlusion presents as a rare cause of sudden profound monocular visual loss. (c) D. Age-related macular degeneration is the leading cause of permanent visual loss in the older population. The exact cause is unknown, but the prevalence increases with each decade over age 50 years.
Clinical Intervention/ENT/Ophthalmology A 13 year-old boy with leukemia presents with epistaxis for 2 hours. The bleeding site appears to be from Kiesselbach's area. The most appropriate intervention is A. electrocautery of the bleeding site. B. silver nitrate application. C. posterior nasal packing. D. intranasal petrolatum gauze.
Explanations (u) A. Cautery is not used because the edges of the cauterized area may begin to bleed. (u) B. Silver nitrate is not used in children because it increases the risk for nasal septal perforation. (u) C. Posterior nasal packing is indicated for posterior bleeds in the inferior meatus. (c) D. Petrolatum gauze will provide pressure to the bleeding point while the cause of bleeding is corrected.
Diagnosis/ENT/Ophthalmology A 59 year-old male complains of "flashing lights behind my eye" followed by sudden loss of vision, stating that it was "like a curtain across my eye." He denies trauma. He takes Glucophage for his diabetes mellitus and atenolol for his hypertension. He has no other complaints. On funduscopic exam, the retina appears to be out of focus. Which of the following is the most likely diagnosis? Answers A. Central retinal vein occlusion B. Retinal artery occlusion C. Retinal detachment D. Hyphema
Explanations (u) A. Central retinal vein occlusion causes painless, variable loss of vision. Exam shows retinal hemorrhages in all quadrants and edema of the optic disk. (u) B. Retinal artery occlusion presents with sudden, painless loss of vision. Exam shows pale retina with normal macula, seen as a cherry-red spot. (c) C. Patients with retinal detachment frequently complain of flashes of light or floaters that occur during traction on the retina as it detaches. This is followed by loss of vision. In small detachments, the retina may appear out of focus, but with larger detachments, a retinal fold may be identified. (u) D. Hyphema is usually associated with trauma, and is a collection of blood in the anterior chamber.
History & Physical/ENT/Ophthalmology Which of the following findings is most consistent with cataracts? A. conjunctival injection B. poorly visualized optic disc C. central visual field loss D. arcus senilis
Explanations (u) A. Conjunctival injection is associated with conjunctivitis and other inflammatory conditions of the eye. (c) B. Cataracts are caused by opacification of the crystalline lens, and this decreases the amount of light that enters the eye. It is difficult to see through the lens from either direction, and thus, the optic disc is poorly visualized on examination. (u) C. Central field loss is associated with macular degeneration. (u) D. While arcus senilis may be seen in geriatric patients and is not associated with cataracts.
History & Physical/ENT/Ophthalmology Which of the following is described as a harmless triangular nodule in the bulbar conjunctiva on either side of the iris? A. Corneal arcus B. Hordeolum C. Pinguecula D. Xanthelasma
Explanations (u) A. Corneal arcus is an extremely common, bilateral, benign peripheral corneal degeneration, associated hyperlipidemia. (u) B. Hordeolum is characterized by a localized red, swollen, acutely tender area on the upper or lower lid. (c) C. Pinguecula is a yellow elevated conjunctival nodule, more commonly on the nasal side, in the area of the palpebral fissure. (u) D. Xanthelasma appear as yellow plaques that occur on the anterior surface of the eyelid, usually bilaterally near the inner angle of the eye.
Scientific Concepts/ENT/Ophthalmology Closure of the eyelids is mediated by which cranial nerve? A. cranial nerve III B. cranial nerve V C. cranial nerve VII D. cranial nerve IX
Explanations (u) A. Cranial nerve III is involved in extraocular movement and controls opening of the eyelids but has no control over closing the eyelids. (u) B. Cranial nerve V controls the motor function of the temporal and masseter muscles and facial sensation. It has no control over eyelid closure. (c) C. Cranial nerve VII controls the motor function of the facial muscles not controlled by cranial nerve V (forehead, eyebrows, mouth, and lips) including closing of the eyelids. (u) D. Cranial nerve IX controls swallowing and the voice.
Clinical Intervention/ENT/Ophthalmology An 18 year-old college student took her goggles off in the chemistry lab while she was washing her glassware from an experiment she had just completed. She thinks the beaker had contained sodium hydroxide, and it splashed into her right eye. She rinsed her eye out for about five minutes in the lab. Which of the following is the most appropriate first step? Answers A. Check visual acuity B. Flush the eye with two liters saline C. Check for corneal damage with fluorescein D. Instill a topical anesthetic to facilitate examination
Explanations (u) A. Delaying irrigation of the eye to assess vision or corneal damage is inappropriate as damage to the eye may occur during the delay. (c) B. Any chemical injury to the eye may result in severe injury and loss of sight, and is a true emergency. The eye should be irrigated copiously with at least two liters of saline, and pH checked to determine when the chemical has been cleared. (u) C. See A for explanation. (u) D. Topical anesthetic may be used to facilitate irrigation with a Morgan lens, but see A for explanation.
Clinical Therapeutics/ENT/Ophthalmology A 34 year-old female presents with recurrent bouts of dizziness, tinnitus, and hearing loss. She states that the episodes are incapacitating and cause her to become nauseous and vomit. The attacks last about one hour and the symptoms disappear after a few days. The last two episodes were treated with meclizine (Antivert) and prochlorperazine (Compazine) at the emergency room. Audiologic testing reveals low-tone frequency hearing loss. Which of the following is the most appropriate long-term management for this patient? A. Epley maneuver B. Diuretics and low-sodium diet C. Broad-spectrum antibiotics and Ibuprofen D. Scopolamine transdermal patch
Explanations (u) A. Epley maneuver is used to treat benign paroxysmal positional vertigo. (c) B. Diuretics and a low sodium diet will decreases the endolymphatic pressure in the semicircular canals, which is believed to be elevated in Meniere's disease, and help relieve symptoms. (u) C. Broad-spectrum antibiotics and ibuprofen are used to treat otitis media, not Meniere's disease. (u) D. A scopolamine patch is useful for treatment of a single episode, but not long-term management.
Scientific Concepts/ENT/Ophthalmology Small grayish vesicles and punched-out ulcers in the posterior pharynx in a child with pharyngitis is representative of which organism? A. Epstein-Barr virus B. Group C Streptococcus C. Coxsackievirus D. Gonorrhea
Explanations (u) A. Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate. (u) B. Group C Streptococcus presents with a red pharynx and enlarged tonsils with a yellow, blood tinged exudates (c) C. Coxsackievirus presents with small grayish vesicles and punched-out ulcers in the posterior pharynx. (u) D. Neisseria gonorrhea of the pharynx may be asymptomatic
History & Physical/ENT/Ophthalmology Which of the following would indicate an optic nerve lesion? A. Excessive conjunctival edema B. Ptosis C. Inability to gaze laterally D. Afferent pupillary defect
Explanations (u) A. Excessive edema of the conjunctiva is a feature of chemosis. (u) B. Ptosis is not indicative of an optic nerve lesion. (u) C. Inability to gaze laterally would be due to paralysis of the lateral rectus muscle controlled by cranial nerve VI. (c) D. Pupil size, controlled centrally by the Edinger-Westphal nucleus in the midbrain, is primarily based on the afferent light stimulus transmitted via the optic nerve.
Diagnostic Studies/ENT/Ophthalmology During a baseball game, a 22 year-old college student is hit in the right eye by a baseball. He complains of blurry vision in that eye. On physical exam, the physician assistant notes proptosis of the right eye, and limitation of movement in all directions. On CT scan, which of the following is most likely to be seen? A. Fracture of the medial orbital wall B. Prolapse of orbital soft tissue C. Hematoma of the orbit D. Orbital emphysema
Explanations (u) A. Fracture of the medial orbital wall is associated with diplopia from medial rectus impingement, orbital emphysema and epistaxis. (u) B. Prolapse of orbital soft tissue, including inferior rectus muscle, inferior oblique muscle, orbital fat, and connective tissue results in enophthalmos, ptosis, diplopia, anesthesia of the ipsilateral cheek and upper lip, and limitation of upward gaze and is seen with fractures of the orbital floor. (c) C. Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma. (u) D. Orbital emphysema is seen with fractures of the medial orbital wall or floor of the orbit into the maxillary and ethmoid sinuses respectively. It will not lead to proptosis.
Clinical Intervention/ENT/Ophthalmology A 66 year-old male presents with epistaxis of two hours duration. He has been unable to stop the bleeding at home. He has a history of hypertension and cardiovascular disease. On exam the vital signs are T-38°C, P-74/minute, RR-20/minute, and BP-180/110 mmHg. Bleeding is noted from the right nare; the left is essentially clear with normal nasal mucosa. After applying pressure for 15 minutes, a bilateral anterior pack is placed. You note persistent bleeding, with blood in the posterior oropharynx. Of the following, the most appropriate treatment is to remove the packing and Answers A. replace with Gelfoam packing. B. cauterize Kiesselbach's plexus. C. insert a posterior balloon pack. D. apply topical solution of lidocaine and epinephrine
Explanations (u) A. Gelfoam packing, cauterization of Kiesselbach's plexus, and topical lidocaine and epinephrine are helpful in treating an anterior bleed, but not in a posterior bleed. (u) B. See A for explanation. (c) C. A posterior balloon packing is used to treat posterior epistaxis. These patients must be admitted to the hospital and prompt consultation with an otolaryngologist is indicated. (u) D. See A for explanation.
Clinical Therapeutics/ENT/Ophthalmology An 18 year-old patient is diagnosed with bacterial conjunctivitis. Gram stain reveals gram-negative intracellular diplococci. Which of the following is the most appropriate treatment of this infection? A. Gentamicin B. Penicillin C. Bactrim D. Ceftriaxone
Explanations (u) A. Gentamicin is used in the treatment of gram negative rods and does not provide coverage of Neisseria gonorrhoeae. (u) B. Penicillin does provide coverage for some Neisseria species but is not considered the treatment of choice for Neisseria gonorrhoeae because of increased resistance. (u) C. Bactrim is used to treat Chlamydia trachoma not Neisseria gonorrhoeae. (c) D. Neisseria gonorrhoeae is confirmed by the Gram stain findings of intracellular gram-negative diplococci. The treatment of choice for Neisseria gonorrhoeae is ceftriaxone.
Health Maintenance/ENT/Ophthalmology A patient with type 2 diabetes mellitus presents for a yearly eye exam. Ophthalmoscopic exam reveals neovascularization. Which of the following is the most likely complication related to this finding? A. Glaucoma B. Cataracts C. Vitreous hemorrhage D. Optic neuritis
Explanations (u) A. Glaucoma occurs in about 6% of diabetics. Neovascularization of the iris can cause closed angle glaucoma. (u) B. Cataracts can occur secondary to diabetes, but are not caused by proliferative retinopathy. (c) C. Proliferative retinopathy, as evidenced by neovascularization, is associated with an increased risk of vitreous hemorrhage. (u) D. Optic neuritis is strongly associated with demyelinating disease, like multiple sclerosis.
Clinical Therapeutics/ENT/Ophthalmology A 35 year-old patient has recurrent seasonal rhinitis and a history of mild asthma. Which of the following should be included for first-line management? A. Immunotherapy B. Decongestants C. Corticosteroid inhalers D. Cromolyn sodium (Intal)
Explanations (u) A. Immunotherapy (desensitization) is indicated as a last resort in patients who fail to either respond to pharmaceutical management or face prolonged exposure to known allergens. (u) B. Decongestants have a limited role in helping to decrease edema, and are generally ineffective in relieving allergic symptoms. (c) C. Regular use of corticosteroid nasal spray and oral inhalers prior to the allergy season is among the best means of preventing allergies. (u) D. Cromolyn sodium has been found to be moderately effective for some patients with allergic symptoms, but it is not usually first-line management.
Scientific Concepts/ENT/Ophthalmology A 53 year-old woman complains that she has not been able to smell for several weeks. Prior to an upper respiratory infection 3 weeks ago, her sense of smell was "just fine." The most likely cause of the anosmia is Answers A. intranasal obstruction. B. destruction of the olfactory neuroepithelium. C. thickened mucus covering the olfactory cilia. D. depletion of the G-protein in the ciliary membrane.
Explanations (u) A. Intranasal obstruction is common with acute bacterial or viral infections, but anosmia resolves when the obstruction resolves. (c) B. The olfactory epithelium is destroyed by viral infections and chronic rhinitis. (u) C. Thickened mucus does not inhibit odorants from reaching the neuroepithelium. (u) D. G-protein is not depleted in viral URIs.
Diagnosis/ENT/Ophthalmology A 23 year-old graduate student presents with sudden onset of severe dizziness, with nausea and vomiting for the past couple of hours. She denies hearing loss or tinnitus. She has had a recent cold. Which of the following is the most likely diagnosis? A. Meniere's disease B. vestibular neuronitis C. benign positional vertigo D. vertebrobasilar insufficiency
Explanations (u) A. Meniere's disease is associated with hearing loss, tinnitus, and vertigo that lasts from seconds to hours. (c) B. Vestibular neuronitis or labyrinthitis presents with vertigo, nausea, and vomiting, but not hearing loss or tinnitus. It is related to viral URIs, and develops over several hours, with symptoms worse in the first day, with gradual recovery over several days. (u) C. Benign positional vertigo occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant. (u) D. Vertebrobasilar insufficiency is usually accompanied by brain stem findings, such as diplopia, dysarthria, or dysphagia, and is not common in this age group.
Diagnosis/ENT/Ophthalmology A 64 year-old woman complains of headache and left eye pain for about a day. She says it started yesterday as a dull ache and now is throbbing. She also complains of nausea and vomiting, which she attributes to the popcorn she ate at the movie theater yesterday afternoon. On exam, the left pupil is mid-dilated and nonreactive. The cornea is hazy. A ciliary flush is noted. Which of the following is the most likely diagnosis? Answers A. Migraine headache B. Temporal arteritis C. Acute glaucoma D. Retinal artery occlusion
Explanations (u) A. Migraine headache does not present with eye findings. (u) B. Temporal arteritis presents with headache and systemic symptoms of fever, myalgias, anorexia, and tenderness over the temporal artery. (c) C. Acute glaucoma often presents with abdominal complaints that may delay diagnosis. Findings of ciliary flush, mid-dilated and nonreactive pupil, and hazy cornea in a patient with severe eye pain are consistent with acute angle closure glaucoma. (u) D. Retinal artery occlusion presents with sudden, painless, severe loss of vision. There are no systemic symptoms.
Diagnosis/ENT/Ophthalmology A 23 year-old graduate student presents with sudden onset of severe dizziness, with nausea and vomiting for the past couple of hours. She denies hearing loss or tinnitus. She has had a recent cold. Which of the following is the most likely diagnosis? Answers A. Ménière's disease B. Vestibular neuronitis C. Benign positional vertigo D. Vertebrobasilar insufficiency
Explanations (u) A. Ménière's disease is associated with hearing loss, tinnitus, and vertigo that lasts from seconds to hours. (c) B. Vestibular neuronitis or labyrinthitis presents with vertigo, nausea, and vomiting, but not hearing loss or tinnitus. It is related to viral URIs, and develops over several hours, with symptoms worse in the first day, with gradual recovery over several days. (u) C. Benign positional vertigo occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant. (u) D. Vertebrobasilar insufficiency is usually accompanied by brain stem findings, such as diplopia, dysarthria, or dysphagia, and is not common in this age group.
Clinical Intervention/ENT/Ophthalmology A 57 year-old male was working on his farm, when some manure was slung hitting his left eye. He presents several 61 days after with a red, tearing, painful eye. Fluorescein stain reveals uptake over the cornea looking like a shallow crater. Which of the following interventions would be harmful? A. Ophthalmic antibiotics B. Pressure patch C. Examination for visual acuity D. Copious irrigation
Explanations (u) A. Ophthalmic antibiotics and copious irrigation are indicated when treating a patient with a suspected corneal ulcer due to an infectious cause. (c) B. Patching of the eye after abrasion associated with organic material contamination is contraindicated due to increased risk of fungal infection. (u) C. Examination for assessment of visual acuity should be performed. (u) D. See A for explanation.
Diagnostic Studies/ENT/Ophthalmology In a patient with amaurosis fugax what is the most appropriate initial diagnostic study? A. Ophthalmoscopy B. Schiotz tonometry C. MR angiography D. Carotid ultrasound
Explanations (u) A. Ophthalmoscopy provides visualization of retina but does not help elucidate the source of the plaque. (u) B. Schiotz tonometry is used to measure intraocular pressure. (u) C. MR angiography is a useful test to identify retinal vascular anatomy but is not the first choice in the search for causes of amaurosis fugax. (c) D. The most common cause of amaurosis fugax is an atherosclerotic plaque in the carotid artery which can be identified with ultrasound.
Clinical Intervention/ENT/Ophthalmology A 20 year-old presents 30 minutes after being struck by a hockey puck in the mouth. On physical examination a central incisor is missing from its socket. The patient has the tooth wrapped in tissue paper and the root appears intact. Which of the following is the most appropriate next step in the treatment of this patient? A. Administration of IM penicillin B. No treatment is warranted C. Place tooth in saline and refer to plastic surgery for reimplantation D. Immediately reimplant the tooth and refer to an oral surgeon
Explanations (u) A. Penicillin is not indicated for treatment of an avulsed tooth. (h) B. Reimplantation is warranted as this is a permanent tooth with root intact. Primary teeth are never reimplanted. (u) C. See D for explanation. (c) D. Avulsed permanent teeth should be cleansed, transported in Hanks solution or saline and reimplanted by an oral surgeon within one hour.
Diagnosis/ENT/Ophthalmology A 2 year-old child is brought to the office because of a cough and a fever of 102 degrees F for 2 days. The physician assistant notes the presence of hoarseness, a barking cough, and stridor. The ears and nose exam are unremarkable. Auscultation of the chest reveals decreased breath sounds without crackles or expiratory wheezes. Which of the following would be the initial diagnostic impression? A. pneumonia B. bronchiolitis C. croup D. asthma
Explanations (u) A. Pneumonia would not produce the stridor noted on physical exam. Pneumonia would more than likely produce crackles, also not noted in this patient. (u) B. Bronchiolitis would produce inspiratory wheezes which are absent in this patient. (c) C. Hoarseness, inspiratory stridor, and a barking cough are classic signs of croup, all of which are noted in this patient. (u) D. Asthma would not normally present with fever and stridor.
Diagnostic Studies/ENT/Ophthalmology A 2 month-old infant presents for a routine health maintenance visit. The mother has been concerned about the infant's hearing since birth. Physical examination reveals no apparent response to a sudden loud sound. Which of the following is the most appropriate diagnostic evaluation? A. audiometry B. tympanometry C. acoustic reflectometry D. auditory-evoked potentials
Explanations (u) A. Pure tone audiometry can be used to screen for hearing deficits in children over the age of 3 years. (u) B. Tympanometry is used to identify an effusion as the cause of hearing loss, but in infants over the age of months. (u) C. Acoustic reflectometry measures the spectral gradient of the tympanic membrane, but is not used clinically due to concerns about its reliability. (c) D. Brainstem auditory-evoked potentials evaluate the sensory pathway and identify the site of any anatomical disruption. The test does not require any active response from the patient and is useful in the evaluation of suspected hearing loss in an infant.
Clinical Intervention/ENT/Ophthalmology Which of the following is a potential complication of a traumatic hyphema? A. retinal detachment B. glaucoma C. cataract formation D. chronic conjunctivitis
Explanations (u) A. Retinal detachment may occur from trauma but not from a hyphema. (c) B. If the trabecular network becomes obstructed from the hyphema then glaucoma may occur. (u) C. Cataracts may be caused by increasing age (most commonly), toxins, systemic disease, smoking, and hereditary, but not by hyphemas. (u) D. Chronic conjunctivitis is not known to be associated with hyphemas.
Health Maintenance/ENT/Ophthalmology Which of the following is the most common cause of adult blindness in the USA? Answers A. Hypertension B. Diabetes mellitus C. Macular degeneration D. Retinal artery occlusion
Explanations (u) A. See B for explanation. (c) B. Diabetes is the leading cause of blindness in the US, and is usually due to diabetic retinopathy. Up to 15% of type 1 diabetics and up to 7% of type 2 diabetics become legally blind. (u) C. See B for explanation. (u) D. See B for explanation.
Health Maintenance/ENT/Ophthalmology Which of the following is the most common cause of blindness in adults under the age of 70 years in the USA? A. hypertension B. diabetes mellitus C. macular degeneration D. retinal artery occlusion
Explanations (u) A. See B for explanation. (c) B. Diabetic retinopathy is the leading cause of blindness in adults under the age of 70 in the US. (u) C. See B for explanation. (u) D. See B for explanation.
Diagnostic Studies/ENT/Ophthalmology A 45 year-old male complains of loss of hearing in his left ear. He also complains of ringing in the ear, and has had occasional dizziness. On exam, there is unilateral left- sided sensorineural hearing loss and a diminished corneal reflex. Neuro exam is otherwise normal. TMs are normal, and canals are clear. Neck is supple, without adenopathy. Oropharynx is normal. Of the following, the best diagnostic study to identify the cause of this patient's complaints is Answers A. auditory brainstem evoked response. B. gadolinium-enhanced MRI. C. acoustic reflex testing. D. vestibular testing.
Explanations (u) A. See B for explanation. (c) B. MRI has replaced auditory brainstem evoked response and acoustic reflex testing in the evaluation of patients for acoustic neuromas. (u) C. See B for explanation. (u) D. Vestibular testing is not a useful screening test for acoustic neuromas.
Clinical Intervention/ENT/Ophthalmology A 28 year-old HIV positive male presents complaining of fever, dysphagia, odynophagia, and trismus for the past 2 days. Physical examination reveals an ill-appearing male with a temperature of 101.3 degrees F, poor dentition, "woody" edema in the sublingual area and neck, tongue displaced posteriorly, and drooling. The immediate managment of this patient includes which of the following? A. CT of the neck B. intubation C. start IV penicillin D. incision and drainage of the abscess
Explanations (u) A. See B for explanation. (c) B. This person presents with the classic signs and symptoms of Ludwig's angina. He is unable to handle his secretions and the displacement of his tongue suggests impending airway obstruction. Intubation to secure his airway is the most immediate concern. CT of the neck for diagnosis, starting IV antibiotics, and incision and drainage are actions that need to be taken after securing the airway. (u) C. See B for explanation. (u) D. See B for explanation.
Clinical Intervention/ENT/Ophthalmology A 17 year-old male is accidentally struck in the right eye while playing football and is immediately transported to the hospital. In the emergency room, he complains of severe pain behind the eye as well as double vision. On examination, he has exophthalmos, cannot move his right eye upward and blood is noted in the anterior chamber. Which of the following is the most appropriate course of action at this time? A. Apply ice packs and cold compresses B. Immediately refer the patient to an ophthalmologist C. Attempt to keep the patient calm and order a skull x-ray D. Administer a dose of intramuscular broad-spectrum antibiotic
Explanations (u) A. See B for explanation. (c) B. This scenario describes a "blow-out" fracture of the orbit with hyphema and, because of the signs and symptoms presented, warrants an immediate consult by an ophthalmologist. (u) C. See B for explanation. (u) D. See B for explanation.
History & Physical/ENT/Ophthalmology In infants, the eyes should move in parallel without deviation by the age of A. 2 weeks. B. 3 months. C. 6 months. D. 1 year.
Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months. (u) D. See C for explanation.
History & Physical/ENT/Ophthalmology Hairy leukoplakia has the greatest prevalence of distribution on the 51 A. palate. B. floor of the mouth. C. lateral tongue. D. gingiva.
Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. The lateral border of the tongue is where hairy leukoplakia is commonly seen. (u) D. See C for explanation.
Scientific Concepts/ENT/Ophthalmology What is the most common location of anterior nasal epistaxis? A. Middle turbinate B. Posterior ethmoid artery C. Kiesselbach's triangle D. Inferior turbinate
Explanations (u) A. See D for explanation. (u) B. See D for explanation. (c) C. 90% of all cases of anterior epistaxis originate from Kiesselbach's triangle. (u) D. The inferior turbinate is the most common location for posterior epistaxis.
Diagnosis/ENT/Ophthalmology An 18 year-old sexually active female was seen in the student health clinic 1 week ago for a sore throat. A streptococcal antigen test was positive, and she was given a prescription for oral penicillin. After 3 days, she stopped her medication because she felt better. She now presents with a severe sore throat. On physical examination, she has a temperature of 102.6° F (39.2° C), marked pharyngeal erythema, medial deviation of the soft palate on the left, tender left anterior cervical adenopathy, and a "hot potato" voice. The rest of her history and physical examination are unremarkable. Which of the following is the most likely diagnosis? A. Recurrent streptococcal pharyngitis B. Infectious mononucleosis C. Gonococcal pharyngitis D. Peritonsillar abscess
Explanations (u) A. This presentation suggests a complication of an incompletely treated streptococcal pharyngitis rather than recurrent disease. (u) B. Infectious mononucleosis may present with severe sore throat, fever, and cervical adenopathy in this age group, but would not cause deviation of the soft palate or the muffled voice. (u) C. Gonococcal pharyngitis usually follows a more indolent course than this patient's presentation. (c) D. The soft palate deviation and a muffled voice are classic signs of peritonsillar abscess.
Diagnosis/ENT/Ophthalmology A 4 year-old boy presents with purulent, foul-smelling nasal discharge for three days. He has not had any other symptoms of respiratory illness, cough, wheeze, or fever. His activity level and appetite has been normal. On exam, he is afebrile. TM's have normal light reflex, canals are clear. Left nare is clear; there is considerable amount of purulent exudate from the right nare, and a bright reflection of light is noticed. Oropharynx is without inflammation or exudate. Neck is supple, without lymphadenopathy. Which of the following is the most likely diagnosis? A. viral URI B. acute sinusitis C. allergic rhinitis D. nasal foreign body
Explanations (u) A. Viral URI does not present with foul-smelling nasal discharge. (u) B. Acute sinusitis may present with purulent nasal discharge, but the observation of a bright light reflection suggests a foreign body. (u) C. Allergic rhinitis is seasonal, associated with sneezing and other allergy-related symptoms. (c) D. Nasal foreign body is suggested by unilateral nasal obstruction or discharge.
Diagnosis/ENT/Ophthalmology A 4 year-old boy presents with purulent, foul-smelling nasal discharge for three days. He has not had any other symptoms of respiratory illness, cough, wheeze, or fever. His activity level and appetite has been normal. On exam, he is afebrile. TM's have normal light reflex, canals are clear. Left nare is clear; there is considerable amount of purulent exudate from the right nare, and a bright reflection of light is noticed. Oropharynx is without inflammation or exudate. Neck is supple, without lymphadenopathy. Lungs are clear, with equal breath sounds and no wheezing. Heart has regular rhythm without murmurs. Which of the following is the most likely diagnosis? Answers A. Viral URI B. Acute sinusitis C. Allergic rhinitis D. Nasal foreign body
Explanations (u) A. Viral URI does not present with foul-smelling nasal discharge. (u) B. Acute sinusitis may present with purulent nasal discharge, but the observation of a bright light reflection suggests a foreign body. (u) C. Allergic rhinitis is seasonal, associated with sneezing and other allergy-related symptoms. (c) D. Nasal foreign body is suggested by unilateral nasal obstruction or discharge .
Health Maintenance/ENT/Ophthalmology Which of the following is considered a risk factor for retinopathy of prematurity? A. maternal rubella infection B. maternal alcohol abuse C. perinatal oxygen therapy D. family history of retinal detachment
Explanations (u) A. While maternal rubella infection is a risk factor for ocular disease in the newborn, it is not a specific risk for retinopathy of prematurity. (u) B. Maternal alcohol abuse is associated with the development of fetal alcohol syndrome, which includes craniofacial abnormalities, but does not include increased risk for retinopathy of prematurity. (c) C. Risk factors for retinopathy of prematurity include perinatal oxygen therapy, low birth weight, prematurity, and sepsis. (u) D. If retinopathy of prematurity is not treated, retinal detachment may occur causing blindness. A family history of retinal detachment is not considered a risk factor for the development of retinopathy of prematurity.
14
Extra-ocular movements
What're the s/sx of angle-closure glaucoma?
Extreme pain, blurred vision, N/V, HA. elevated intraocular pressure w tonometry (>22mmHg)
Pinguecula
Eye condition caused by chronic actinic exposure, repeated trauma, and dry and windy conditions. May present with elevated, yellowish, fleshy, conjunctiva mass found on the sclera adjacent to the cornea. Painless inflammation may occur. Tx - none necessary, may be respected if cosmetically undesirable or chronically inflamed.
Bacterial Conjunctivitis
Eye condition characterized by acute onset of copious, prudent discharge from BOTH eyes. May present with mild decrease in visual acuity and mild discomfort. Eyes may be "glued" shut upon waking. Common pathogens are strep pneumo, Staph aureus, Haemophilus aegyptius, and Mirabella. Transmitted via direct contact or famines, autoinoculation from one eye to other is typical. Infection is usually self limited. Rare pathogens via sexual contact or vaginal delivery and may result in permanent visual impairment if not treated. Tx is ABX for specific pathogen topically, for rare pathogens TX topical plus systemic ABX.
Blowout Fracture
Eye condition commonly caused by trauma from fist or ball, effecting the floor of the orbit, trapping orbital structures. May present with swelling and misalignment of the eyes, movement restriction, specifically the inability to look up due to entrapment of the infraorbital nerve and musculature. Double vision is common and subcutaneous emphysema and exophthalmos are present. Prompt referral to ophthalmologist, keep pt from sneezing or coughing, use of nasal decongestants, ice packs and cold compresses as well as ABX during transport to ophthalmology.
Amblyopia
Eye condition of reduced visual acuity not correctable by refractive means. Most commonly caused by Strabismus, but may caused by Uremia, or toxins such as alcohol, tobacco, lead, or other toxic substances.
Presence of the Centor criteria are suggestive of group A strep pharyngitis. List the criteria.
Fever - Absence of cough - Tonsillar exudates - Tender cervical lymphadenopathy
A 5-year-old child with no known drug allergies is diagnosed in your clinic with bilateral acute otitis media. Which of the following is the drug of choice?
First choice antibiotic treatment for acute otitis media includes a 10-day course of amoxicillin (80 to 90 mg/kg/day in two divided doses) or a combination of erythromycin (50 mg/kg/day) and a sulfonamide (150 mg/kg/day). Reasons for amoxicillin therapy include spectrum of activity including both susceptible and intermediate resistant S pneumoniae, safety, cost, and tolerability.
If an abrasion is suspected, what diagnostic test will aid?
Fluorescein stain.
Corneal Abrasion
Fluorescein staining
Which topical antibiotics are not ototoxic and may be used with a tympanic membrane perforation?
Fluoroquinolones
dysfunction of eustachian tube
Follows URI -sx- ear fullness, popping -dx- fluid behind TM -tx- decongestants pseudophedrine, phenylepherine, oxymetazoline nasal spray
A patient presents with a cerumen impaction. Which of the following is true when performing the Rinne- Weber test?
For conductive hearing loss, the Weber will lateralize to the affected ear and bone conduction will be greater than air conduction. Conductive hear loss prevents sound from entering the inner ear due to obstruction in the external auditor canal and middle ear. Examples would be cerumen impaction and otitis media. Sensory neural hearing loss affects the inner ear and cranial nerve VIII. Weber will lateralize to the unaffected ear (normal ear) and Rinne will reveal Air conduction > Bone conduction.
What PE is essential for suspected foreign body?
Full inspection of lids, conjunctiva and cornea. Slit lamp
16 - TURN OFF LIGHTS
Fundoscopic exam - have them focus on a spot on the wall in front of them - their Right eye, my right hand, my right eye - their Left eye, my left hand, my left eye
Fever, tender anterior cervical adenopathy, pharyngotonsillar exudate
GABHS Criteria
Tender temporal artery Fever, malaise Elevated ESR EMERGENCY
Giant Cell Arteritis clinical features
Causes of monocular vision loss
Giant cell arteritis Retinal artery occlusion Multiple sclerosis
In a patient whom you suspect has giant cell arteritis, which of the following medication and dosage combinations is indicated?
Giant cell arteritis (GCA) or temporal arteritis is a large vessel vasculitis that can cause ischemic optic neuropathy and blindness. The first line treatment of high dose prednisone 60 mg/day for one month is sight saving. The lower dose of prednisone 20mg per day is effective in treating polymyalgia rheumatic (PMR). Methylprednisolone dose-pack is a very low dose of steroid and would be ineffective in treating GCA. Infliximab is a tumor necrosis factor inhibitor used for treating ankylosing spondylitis, rheumatoid arthritis and crohn's disease.
What diagnostic tool may be used to aid in diagnosing acute angle closure glaucoma
Gonioscopy - measures iridocorneal angle
dx of closed angle glaucoma
Gonioscopy is the gold standard
Diptheria
Gradual onset of sore throat and fever with a grey, white patchy psuedomembrane development in the throat which may obstruct the airway or cause a "barking" cough similar to that in croup. May include markedly swollen cervical lymph nodes that may impede swallowing or breathing, "BULLS NECK". May involve cutaneous eruptions. Caused by Corynebacterium. Fatal in 5-10% of cases, up to 20% in young children and those over 40 years old. Antibiotic treatment is not shown to effect course of disease, but is indicated to reduce transmission to others. Metronidazole, Penicillin G, or Erythromycin
A 10-year-old male who plays soccer presentswith annularly configured dermal papules that are skin colored andshiny, and are located on his shins. His mother states that the lesionsstarted as nodules, and have since enlarged. There is no scale presentand they are asymptomatic. No one else in his home has similar findings.What is the most likely diagnosis?
Granuloma annulare (GA) is a self-limited condition that mayappear as solitary lesions or in a more generalized distribution.They begin as small, shiny skin colored dermal papules that enlargeover time with central clearing. There are no epidermal manifestations.GA commonly occurs over bony surfaces, such as the shins or dorsaof the hands. It is frequently misdiagnosed as tinea corporis; however,the absence of epidermal scaling helps rule out this diagnosis.
griseofulvin
Griseofulvin is used to treat skin infections such as jock itch, athlete's foot, and ringworm; and fungal infections of the scalp, fingernails, and toenails.
apthous ulcer
HPV6 -sx-several ulcers round, yellow greyish centers and red halos -tx- topical corticosteroids then predisone taper 1 week, prevention= cimetidine -mouth wash- chlohirixidne
herpetic gingivostomatitis
HSV-1 lesions on gingiva & mucocutaneous border of lip; seen in children 6mo-5 years causes burning followed by small vesicles that rupture & form scabs; treated with acyclovir & magic mouthwash
herpetic pharyngotonsillitis
HSV-1 vesicles--> ulcerative lesions on the posterior pharyngeal mucosa; seen in adults
Most common organism causing epiglottitis in children?
Haemophilus influenzae
Closed angle
Halo, headache, vomiting, fixed pupil
How long can a patient with an external hematoma of the ear wait to see the ENT?
He should be seen ASAP, goal < 7 days
Head and Face Inspection
Head is norm-o-cephalic, there are no lesions or areas of erythema, ecchymosis or swelling
tinnitus
Hearing ones own heartbeat is characteristic of the pulsatile version of this ear disorder. Perception of abnormal ear or head noises. May indicate sensory hearing loss. Intermittent, mild, high pitched episodes common in normal-hearing individuals. May present with sensory hearing loss with Weber and Rinne. Avoid exposure to excessive noise or ototoxic agents (aminoglycosides). Oral antidepressants may help (nortriptyline).
First step in removing foreign body?
Heavy irrigation
Common cause of Cauliflower ear (recurrent damage to cartilage)?
Hematoma of the external ear
A 10 year old male presents with bright red, well-demarcated petechiae and palpable purpura located on bilateral lower extremities. He also complains of abdominal pain and mild joint pain. His mother report the child had an upper respiratory infection about a week ago. Punch biopsy shows IgA immunoreactivity around post-capillary venules. What is the most likely diagnosis?
Henoch Schonlein purpura (HSP) is commonly described as palpable purpura. It is precipitated by an upper respiratory infection and can also be associated with abdominal pain and joint pain.
A 45-year-old female presents with a rashthat started on her ankles two days ago and is spreading up herleg. The lesions are asymptomatic; however, she has abdominal painand joint pain. The lesions are palpable and non-blanchable whencompressed. What is the most likely diagnosis?
Henoch-Schonlein Purpura (HSP) is a hypersensitivity vasculitisthat occurs most frequently after an infection with group A streptococcus.This rash consists of the classic palpable purpura, and can be accompaniedby abdominal pain that is worse after meals secondary, bowel ischemia,bloody diarrhea, and arthritis.
A patient presents complaining of a painful rash on his lips. What is the causative pathogen for the rash shown in the image?
Herpes simplex type 1 causes an orolabial and gingival vesicular rash. Herpes simplex type 2 causes genital lesions and is sexually transmitted. Herpes zoster or shingles causes a dermatomal, unilateral, and painful vesicular rash. Staphylococcus aureus and beta hemolytic streptococci cause bacterial skin infections.
An 18-year-old female presents with a history of draining abscesses in the axilla and groin, with large, open comedones. Currently, she has multiple scars in the axillae. What is the most likely diagnosis?
Hidradenitis suppurtiva affects females more than males, and may show a family history of nodulocystic acne and/or hidradenitis suppurtiva. Skin lesions are usually tender nodules and abscesses that may spontaneously drain. Open comedones, including double comedones, are common. Eventually, sinus tracts may form. Nodulocystic acne consists of nodules and cysts, ranging in size from 1 to 4 cm in diameter. These lesions are distributed on the face, back, and chest. Acanthosis nigricans is described as a velvety, hyperpigmented plaque distributed around the neck, in the axillae, and in the groin. MRSA can have several different presentations, ranging from erythrasma to the presence of papules and pustules. Comedones are not associated with MRSA.
Viral Conjunctivitis
Highly contagious eye condition, transmitted via direct contact with contralateral eye or with other persons. Can be transmitted in swimming pools and is most common in midsummer to early fall. Characterized by acute onset of unilateral or bilateral erythema of the conjunctiva, copious water discharge, and ipsilateral tender preauricular lymphadenopathy. TX is eye lavage with normal saline BID for 7-14 days. Vasoconstrictor-antihistamines may help. Warm compress to reduce discomfort.
A 66-year-old male patient complains of pain and swelling in his left foot intermittently over the past year. He denies any current symptoms. On examination you note the following findings. His left foot is unremarkable. Laboratory finding include an elevated uric acid. What is the most likely diagnosis?
His uric acid level is elevated, which further supports a diagnosis of gout. It is suspected that the intermittent left-foot swelling is related to acute flares of gout, which usually affects the first MCP joint. Choices (A), (C), (D), and (E) are not associated with elevated uric acid level or tophi. The patient may have osteoarthritis, but this does not explain the high uric acid level and the tophi on exam.
What is the name of the sign of a Shingles lesion on the tip of the nose?
Hutchinson Sign If you see this, make sure you do a through exam of the eye!!
Risk factors for thyroid cancer?
Hx of radiation exposure - HX of goiter - female gender - Asian
Hemorrhage into the anterior chamber of the eye is AKA. . .
Hyphema
tx of Peritonsillar abscess
I&D AB + steroids needle aspiration = gold standard, dx and tx tonsillectomy (10%)--if airway obstructed or marked asx recurrent strep
salter harris fracture
I- epiphysis. S= Seperation II- epiphsis + metaphyseal plate. A=Across. fx through metaphysis. MC!!! III- fracture through epipysis into articular surface.Lower= epipysis. IV- fracture through distal metaphysis, epiphysis, epipysiseal plate.T= THrough V- impaction of epiphyseal plate. ER= Everythings ruined
What is the tx for Strep pharyngitis?
IM pencillin in patient compliance is in doubt. Othewise an oral penicillin or cefoxime can be used. macrolides in the case of penicillin allergy
Retinal vein occlusion
INSIDIOUS ONSET 2 types: branch retinal vein occlusion (BRVO) central retinal vein occlusion (CRVO)
tx of mastoiditis
IV ABs (ceftriaxone) -if doesnt respond: myringotomy, a small incision in the tympanic membrane (eardrum), or the insertion of a tympanostomy tube into the eardrum -if still doesn't respond: mastoidectomy
What's the tx for G/C Bacterial Conjunctivitis?
IV Rocefin (ceftriaxoe) Topical erythromycin
You have hospitalized your patient who had presented with a peritonsillar abscess. What antibiotics would be appropriate choices for empiric therapy?
IV ampicillin/sulbactam or clindamycin
ciprofloxacin
IV antibiotic given to treat malignant otitis externa
azithromycin
IV antibiotic treatment for neonatal chlamydia conjunctivitis
ceftriaxone
IV antibiotic treatment for neonatal gonorrhea conjunctivitis
cefazolin
IV antibiotic used to treat mastoiditis
mastoiditis is a complication OM and can present with spiking fever and post auricular pain, erythema and fluctuant painful mass. What is the treatment?
IV antibiotics and myringotomy, followed by full course of oral antibiotic if ineffective, mastoidectomy
what is the treatment for mastoiditis?
IV antibiotics, possible mastoidectomy
treatment for closed angle glaucoma
IV carbonic anhydrase inhibitor, topical beta blocker, and osmotic diuresis. this is an emergency
GC conjunctivitis
IV ceftriaxone topical erythromycin
dexamethasone
IV corticosteroid used to treat epiglottitis
methylprednisone
IV corticosteroid used to treat optic neuritis caused by MS
Tx Orbital Cellulitis?
IV- Vancomycin + Ceftriaxone, Cefotaxime, Ampicillin-Sulbactam or Piperacillin-tazobactam So, Vanco + Anti-pseudomonas beta-lactam.
What is one of the main concerns when dealing with a hyphema?
If trauma was so intense as to cause a hyphema, be concerned about trauma elsewhere (Cervical, skull fracture, blow out fracture, etc)
A 33 year old male presents with chronic sinusitis. Cultures find fungal pathology. What underlying disorders should be considered?
Immunocompromise - Uncontrolled diabetes - Neutropenia - Glucocorticosteroid use - Nosocomial infection
If retinopathy is due to Toxoplasmosis of CMV retinitis, what must you also consider?
Immunocompromised state, HIV
What is the appropriate first line treatment of lyme disease in a non-pregnant adult female with erythema migrans and no other symptoms of lyme disease and no known drug allergies?
In patients over the age of 9 exhibiting skin or joint manifestations of lyme disease, the first line treatment is Doxycycline 100 mg bid. Patients less than 9 or those who are allergic to Doxycycline should be treated with amoxicillin. Erythromycin is fourth line treatment for all age groups. Ceftriaxone is first line for patients with nervous system involvement. (Wolff & Johnson, pg 691)
A Blowout fracture may result in entrapment of which muscle? Damage to the ______ nerve would cause paresthesia where?
Inferior rectus muscle - child cannot look upward. Infraorbital verve cause paresthesias in gums, upper lip and cheek.
retinitis pigmentosa
Inherited autosomal dominant Present with nightblindness in childhood May note pigmentation on retina Progressive visual loss begins in 2nd decade (Tunnel vision) Blindness often by age 40-50.
FB in eye
Injury to the eye which requires eyelids to be carefully exerted, stained with fluorescein, and observed with a Wood's lamp. Removal attempt with moistened, cotton-tipped swab. Patching may be beneficial if large, but limited to 24 hours with next day reexamination. Rust ring on cornea may be seen with metal objects, remove with rotating burr, or refer pt to ophthalmologist.
Open Angle Glaucoma
Insidious progressive bilateral loss of peripheral vision (Tunnel Vision). Gradual progressive "CUPPING" and pallor of optic disc with loss of vision progressing from decreased peripheral fields to complete blindness. IOP elevation is due to reduced or obstructed drainage of aqueous fluid. If left untreated may result in complete blindness by at 60-65. Primary - Bilateral presentation , with increased prevalence in 1st degree relatives and blacks. Secondary - Results from uveitis, ocular trauma, and all forms of CORTICOSTEROID USE. Cup:Disc radio > 0.5, or 0.2 or more asymmetry between both eyes. Initially paracentral visual field constriction. Central vision remains intact until late. Reproducible abnormalities in at least two of the following: optic disc, visual field, IOP. Tx with laser trabeculoplasty is often primary tx, consider surgical trabeculectomy if trabeculoplasty fails. Prostaglandin analogs are first line. BB, topical and/or oralcarbonic anhydrase inhibitors.
11
Inspect - external eyelids (eyes closed)
10 - EYES
Inspect - external eyelids (eyes open)
23 - NECK
Inspect - neck
21 - New speculum on otoscope
Inspect - nose and nares
1 - HEAD
Inspect - scalp and head
22 - MOUTH
Inspect (with a light) - lips - buccal mucosa (ulcers) - posterior pharynx (uvula) - under the tongue*****
Inflammation and infection of the meibomian gland
Internal Hordeolum
Throbbing pain, small pupil, normal pressure and perilimbic injection(Redness around iris), think...?
Iritis
A 16-year-old female has tried topical clindamycin and tretinoin. In addition, she recently finished a six-month course of doxycycline 100 mg bid. She has not noticed much improvement in her acne. The patient continues to complain of large, painful lesions, as well as numerous comedonal lesions. What is the next appropriate step in treatment?
Isotretinoin is indicated for nodulocystic acne, as well as acne that is resistant to topical treatments and oral antibiotics. Clotrimazole is an antifungal medication that is indicated for the treatment of cutaneous candidiasis and tinea. Keflex is a first generation Cephalosporin. It is not a first line treatment for acne. Elidel is indicated as a second line treatment for atopic dermatitis in patients over two years of age. It does not treat acne.
What're the s/sx of Bacterial Conjunctivitis?
Itching Purulent d/c Mild loss of visual acuity erythema, tearing Pt may wake up w a "crust" over the eye in the AM.
Epistaxis
Keisselbach plexus
What anatomical location is the most common site of anterior epistaxis?
Kiesslebach's Plexus or Little's Area is the most common site of anterior nosebleeds
Location of most anterior nose bleeds?
Kiesslebach's plexus
What should be done to remove a live insect from an ear?
Kill insect first with mineral oil or viscous lidocaine before attempting removal
cataract
LEADING CAUSE OF BLINDNESS IN THE WORLD causes: trauma, sun, steroids, congenital in kids
Patient presents with acute SEVERE vertigo that last days to weeks and hearing loss. The vertigo progessively improves over a few weeks but the hearing loss may or may not resolve. Likely dx?
Labrynithitis
Vertigo and hearing loss after acute otitis media with a normal otoscopic exam is the most likely what diagnosis?
Labyrinthitis
Acute vertigo + hearing loss hearing loss for several days
Labyrinthitis clinical features
A 12-year-old female presents with a complaint of dry flaking skin that becomes fissured and painful. Her skin has always had dark plate-like scales. What is the most likely finding in the patient's history?
Lamellar ichthyosis is a condition in which a baby is born with a collodion membrane. Within a few weeks, this membrane is shed and replaced by large gray scales. These plate-like scales persist with no improvement over time. Painful fissures on the hands and feet are common.
Hoarseness of voice, cough Follows URI
Laryngitis clinical features
Tx for Open-angle Glaucoma: Name Prostaglandins used
Latanoprost Bimatoprost
prostaglandin analogs
Latanoprost (Xalatan) Bimatoprost (Lumigan) Travoprost - CHANGES IRIS COLOR PERMANENTLY
Macular Degeneration
Leading cause of permanent visual loss in developed countries. Eye disorder that may be age related or secondary to toxic effects of medications (chloroquine or phenothiazine). Related to increased age, white race, female gender, family hx, and smoking, but exact cause unknown. Drusen deposits (discrete yellow deposits) are found on Burch's membrane, leading to degenerative changes, loss of nutritional supply, atrophy and neovascularization. Insidious onset, with chief clinical feature of gradual loss of central vision without pain or ocular erythema. WAVY OR DISTORTED VISION can be measured with Ambler Grid. Mottling, serious leaks, hemorrhages commonly develop on retina. Tx - no effective Tx. Laser therapy (reduces drusen) or intravitreal injections of monoclonal antibody drugs may slow progression of age related variant, but will not stop it.
Lesion of the RIGHT optic tract will cause what visual symptoms?
Left homonymous hemianopsia
Oral Herpes Simplex
Lesions most commonly occur on the gingival and mucocutaneous junction of the lip. Condition is common, mild, and self-resolving in most adults. May be severe in the immunocompramised. May present initially with burning around the lips, followed by small vehicles that rupture and scab. Lesions are found on the gingival, mucocutaneous junction of the lip, tongue, buccal mucosa and soft palate. Tx with antiviral therapy may shorten course and reduce pain afterwards.
Menieres disease
Less commonly known as endolymphic hydrops. Distention of endolymphatic compartment of the inner ear. Precise cause is unknown, however, two known sources are SYPHILIS and head trauma. May present with episodic vertigo (spells last 20 minutes to several hours), with fluctuating low-frequency sensorineural hearing loss, tinnitus, and unilateral aural pressure. Tx with low sodium diet and diuretics, congenital anomalies, otosclerosis, neoplasms, vasculitis.
A mother presents with her 6-year-old childwho has a rash on his arm. The rash has remained unchanged despitethe use of topical steroids for one month. The lesion is asymptomatic.What is the most likely diagnosis?
Lichen striatus is a benign rash consisting of linearly configured,shiny, and flat lesions that occur on any skin surface. This rashoccurs suddenly and resolves on its own in several weeks. The etiologyis unknown.
Ectropion
Lid everts, often secondary to age, trauma, infection or palsy of the facial nerve. TX - surgical repair if condition causes trauma, excessive tearing, exposure keratitis, or cosmetic distress.
Entropion
Lid inverts, often secondary to scar tissue or spasm of the orbicularis oculi muscle. Also frequently in older individuals due to degeneration of lid fascia. TX - surgical repair if condition causes trauma, excessive tearing, exposure keratitis, or cosmetic distress.
What is the Dx? A patient with pharyngitis is given amoxicillin and develops a macular-papular rash.
Likely mononucleosis (not bacterial)
What is the Dx? Bacterial infection/cellulitis of the floor of the mouth (stems from root of the teeth) potentially life threatening.
Ludwig's angina
epistaxis
MC = anterior. kiesslebach's plexus posterior = woodruff's plexus. sphenopalatine artery.
herniated disc
MC herniated disk L4-L5, L5-S1 L4- weak ankle dorsiflexion, loss of knee jerk L5- lateral, weak big toe extension S1- weak plantar flexion, loss of ankle jerk -dx- straight leg raise, mri
supracondylar fractures
MC in children 5-10 yr -sx- swelling tenderness @ elbow, + anterior fat pad in children -tx- non displaced splint. displaced- ORIF
Pantellofemoral syndrome
MC in runners -sx- knee pain behind or around patella -dx- apprehension sign- examiners appliers pressure medial- lateral patella with pain -tx- PT, stregnthening
macular degeneration (dry vs wet)
MC of vision loss in elderly sx- central vision loss. rapid vision loss dry- yellow deposits -dx-dry- YELLOW DEPOSITS- DURSEN wet- flourescin angiogrpahy -tx- dry- amsler grid -wet- bevacizumab
Reactive arthritis****
MC- chlaymydia -sx- cant see, cant pee, cant climb a tree. conjunctivitis, urethritis, arthritis. Keratoderma blennorrhagica (hyperkeratotic lesions on palms/soles) -dx- HLA-27 (Alkalosing spondylitis, bamboo spine too), synovial fluid- neg bacterial culture***, WBC 1,000-8,000 -tx- NSAIDS
Sialadenitis
MC- staph aureus. MC viral- MUMPS -sx- pus can be massaged by opening of duct -dx- failure to improve-U/S or CT -tx- sialogues....naficillin 405 g Q IV and measures to salivary flow if worsening sialogues
retinal detachment
MC= rhegmatogenous sx- extreme mytopia (far away objects appear blurry), curtain over vision*** Flashers and floaters -dx- Schaffer sign- clumping of pigment afferent pupillary defect--- contrlateral pupil doesnt constrict when light shown in fundscopy- regous retina- flapping**** -tx- EMERGENCY! remain supine, detach from temporal... turn head towards attachment side. optha
retinopathy
MCC = Diabetic retinopathy other causes: HIV, CMV, toxoplasma
acute otitis media
MCC = STREP PNEUMO H. flu, M. cat, strep pyogenes, staph aureus RSV = viral Dx: INSUFFLATION
pharyngitis
MCC = group A Beta hemolytic strep = strep pyogenes Dx: throat culture, ASO TITERS consider C&G infection Tx: PCN
Retinopathy
MCC is Diabetes, with others being HTN, pre-eclampsia/eclampsia, blood dyscriasis, HIV Leading cause of blindness in the US. Proliferative - neovascularization, vitreous hemorrhage. Nonproliferative - venous dilation, retinal hemorrhage, retinal edema, hard exudates, microanuerysms. Treat underlying condition, control BP, glucose. Laser photocoagulation or vitrectomy may be used. Severe dz is permanent.
thyroglossal duct cyst
MIDLINE moves with protrusion of tongue
femoral condyle fractures
MOI- axial loading peroneal nerves injuries (check 1st web space)-popliteal injury -tx- immediate ortho consult
What is the best imaging modality for acoustic neuroma?
MRI
dx of mastoiditis
MRI or CT clinical based on sx
dx of labyrinthitis
MRI to r/o other cause LP if meningitis suspected audiogram
Monteggia/ Galeazzi fracture
MUGR monteggia- proximal ulnar shaft fx with anterior radial head dislocation , usually direct blow to forearm -sx- radial nerve injury- paralysis to -tx- ORIF galeazzi- mid distal radial head dislocation -tx- unstable! needs ORIF
Tx of Bacterial conjunctivitis?
Macrolides (Erythromycin) Sulfa (Sulfacetamide) Fluoro (Cipro, Oflaxacin) Polymixin (Cortisportin, Polytrim)
What is the disease condition that involves gradual central vision loss?
Macular Degeneration
Irreversible central vision loss
Macular Degeneration is the leading cause of...
This disorder of the eye may be age related or secondary to the toxic effects of drugs such as chloroquine or phenothiazine.* It is the leading cause of irreversible central visual loss.*
Macular degeneration
What is the concern with Dacryoadenitis?
May lead to Dacryocistitis and periorbital cellulitis
Which of the following conditions is a cause for central vertigo?
Meniere syndrome, labyrinthitis, vestibular neuronitis, and perilymphatic fistula are causes of peripheral vertigo. Acoustic neuroma, or eight cranial nerve schwannomas, are among the most common intracranial tumors, and a cause for central vertigo.
What is the most common cause of head and neck malignancy?
Metastasis to the lymph nodes of the neck
Tx of Optic Neuritis?
Methylprednisolone (Solu-medrol) IV, Neurology evaluation
A 6-year-old female presents with small erythematous papules grouped around the mouth. The mother reports that she tried to treat with over-the-counter hydrocortisone 1% cream. The condition has worsened. What is the best step in management of this condition?
Metronidazole 0.75% gel bid is a first line treatment for perioral dermatitis. Topical steroids, such as hydrocortisone valerate cream, will actually worsen perioral dermatitis and create a granulomatous condition. Oral antibiotics, like Keflex 500 mg bid, are frequently used to treat perioral dermatitis. However, Keflex is not indicated for perioral dermatitis. Clotrimazole is an antifungal cream that is not used in perioral dermatitis.
What is the Dx? Pharyngitis with diffuse cervical lymphadenopathy and fever.
Mononucleosis
Orbital Cellulitis
More common in children than adults with the median age at 7-12 years. Has several possible causes, including MCly sinusitis, dental infections, facial infections, infection of the glove or eyelid, and infection of the lacrimal system, less often due to trauma. Common pathogens are Staph pneumoniae, Staph aureus, Hflu, and gram negative bacteria. In adults it occurs secondary to acute or chronic sinusitis and has many possible causative agents. A MRSA increase has been noted with this condition. May present with Fever, proptosis, eyelid edema, exophthalmos, prudent discharge, restricted EOMs and conjunctivitis. Exam will reveal fever, decreased ROM in eye and sluggish papillary response.. CBC, blood cultures, drainage cultures required. Sinus CT to determine extent. Condition requires emergent treatment with broad spectrum IV ABX until pathogen is identified. Surgical drainage for abscess formation.
A 60-year-old male complains of right scapularpain that is sharp for the last two days. He reports that the painwas preceded by tenderness and a tingling sensation. What is themost likely diagnosis?
More than 2/3 of cases of the herpes zoster virus occurs in patients over the age of 50. A herpes zoster virus flare occurs unilaterally in a dermatomal distribution. The prodromal stage can consist of neuritic pain or paresthesias prior to eruption of the rash in two to three weeks. The rash consists of vesicles that eventually crust and heal. The pain of herpes zoster can continue for months or years after the rash has resolved.
Parotitis
Most common cause is Staph aureus and is strongly linked to Mumps as a defining characteristic. Is also a complication of Sjogrens disease and anorexia nervosa. May be infectious, Autoimmune, or due to blockage. Asymmetrical swelling of the face.
Adenovirus type 3, 8, or 19
Most common cause of Viral Conjunctivitis
Laryngitis
Most common cause of hoarseness. Most common cause is viral, Moraxella and Hflu may be isolated. May present with hoarseness that is persistent after resolution of a URI. Avoid vigorous use of voice to prevent formation of vocal fold hemorrhage, polyps or cysts. Tx with erythromycin, Cefuroxime, augmentin reduce severity. Oral or intramuscular corticosteroids may be used to speed recovery if vocal hemorrhage is absent.
Presbycusis
Most common cause of sensorineural hearing loss
Thyroid Cancer
Most common form is Papillary (Best, 80%), Follicular (14%), Medullar (3%), Anaplastic (worst, 2%). Woman are more commonly affected than men and the usual presentation is a single nodule, however only 5% of nodules are malignant. Associated with childhood neck or head irradiation or exposure to readioactive isotopes or iodine with peak occurence 20-25 years later. 1/3 of medullary type are associated with multiple endocrine neoplasia type 2 (MEN2), 1/3 familial, 1/3 sporadic. May present with a painless neck swelling and have a single, palpable, nontender, firm nodule. May also have hoarseness, neck discomfort, or dysphagia. Nodule may enlarge, gland may be stony and hard. Medullary causes flushing, diarrhea, fatigue, cushings syndrome; anaplastic has signs of pressure or invasion (recurrent laryngeal nerve plasy) Dx with TSH, serum thyroglobulin is often elevated, Bx, US, MRI, PET, CT, CXR Tx with surgical resection an near total thyroidectomy are indicated, followed by radiation for anaplastic disease. Monitor for postoperative hypocalcemia. T4 HRT, Radioactive iodine ablation for residual disease.
Oral Candidiasis
Most common in individuals with local or systemic immunosuppression (corticosteroids, chemotherapy, antibiotics). May present with fluctuating throat or mouth discomfort. Erythema of the oral cavity or oropharynx with fluffy, whiter, CURD-LIKE patches overlying erythematous mucosa. White areas are EASILY SCRAPED OFF and bleed. Dx clinically, may use wet prep KOH. Biopsy. HIV testing recommended if no predisposing factors present. Tx with antifungal therapy (topical or systemic). Half-strength hydrogen peroxide or .12% chlorhexidine mouth rinses. Insure oral hygiene in denture wearers, diabetics, and the immunosuppressed.
S Pneumoniae
Most common pathogen of Acute Otitis Media
HSV 6
Most common pathogen of Apthous Ulcers
S pneumoniae
Most common pathogen of Bacterial Conjunctivitis
Seborrhea
Most common pathogen of Blepharitis
P aeruginosa
Most common pathogen of Chronic Otitis Media
S aureus
Most common pathogen of Dacryocystitis
S aureus
Most common pathogen of Hordeolum
Viral
Most common pathogen of Laryngitis
Epistaxis
Most common site is anterior, kiesslebach's plexus. Posterior site at woodruff's plexus. sphenopalatine artery. Predisposing factors include trauma, rhinitis, supplemental O2 use, septum deviation, HTN, hereditary telangiectasia (Oiler-Weber-Rend), nasal cocaine, anticoagulants, or coagulopathies. Bleeding is most common in the anterior septum where a confluence of veins forms a superficial venous plexus. Posterior bleeds are associated with atherosclerotic disease and HTN. Most cases respond to direct pressure within 15 minutes. Pt should sit, leaning forward. May need nasal tampon, cauterization or surgicel patch. May use topical vasoconstrictors (phenylephrine, 4% cocaine, oxymetazoline).
Mononucleosis
Most commonly caused by Epstein-Barr Virus (HHV4) and transmitted via saliva. KISSING DISEASE, associated with burkitt's lymphoma, nasopharyngeal carcinoma, pediatric leiomyomas, collagen vascular disease, and other disorders. Presents with fever and sore throat, may have exudative pharyngitis, tonsilitis, gingivitis, and soft palate petechiae. Severe infections exhibit malaise, anorexia and myalgias. Typically have painless posterior cervical node lymphadenopathy. May include splenomegaly (50%), a maculopapular or petechial rash (15%). Administration of amoxicillin incrases incidence of rash to 90%. Hemolytic anemia and thrombocytopenia may develop. Dx with heterophile antibody and screen tests. Will show FALSE POSITIVE SYPHILIS TEST (VDRL) or RPR in 10% of patients. Tx is based on symptoms, use nonaspirin NSAIDs and antipyretics. Antivirals will decrease viral shedding but will not affect course of illness.
Jane, a 21-year-old female, was seen in the office 10 days ago and was diagnosed with perennial allergic rhinitis and sent home with instructions for increased fluids, decongestants, and nasal steroids. She returns today with worsened symptoms of malaise, low-grade fever, nasal discharge, cough that is worse at night, mouth breathing, early morning unilateral pain over sinuses, and congestion. Physical examination reveals thick purulent nasal discharge, postnasal discharge visible in the posterior pharynx, periorbital swelling, and tenderness of sinuses upon palpation. She is 36-weeks pregnant and allergic to penicillin. Of the following, what is the most appropriate antibiotic?
Most patients with a diagnosis of acute rhinosinusitis based on clinical grounds improve without antibiotic therapy. The preferred initial approach in patients with mild to moderate symptoms of short duration is therapy aimed at facilitating sinus drainage, such as oral and topical decongestants, nasal saline lavage, and—in patients with a history of chronic sinusitis or allergies—nasal glucocorticoids. Adult patients who do not improve after seven days, children who do not improve after 10 to 14 days, and patients with more severe symptoms (regardless of duration) should be treated with antibiotics. Empirical therapy should consist of the narrowest-spectrum agent active against the most common bacterial pathogens, including S. pneumoniae and H. influenzae—e.g., amoxicillin. But amoxicillin is contraindicated in patients with urticarial reactions to penicillins, and quinolones are similarly contraindicated in pregnancy. trimethoprim-sulfamethoxazole is contraindicated in the third trimester of pregnancy. The best choice is clindamycin.
What is the tx for TM perforation?
Most will resolve on their own, however, surgical repair of TM as well as the ossicular chain may be necessary water/moisture to the ear should be avoided to prevent a secondary infection
What should you think of when you hear Optic Neuritis?
Multiple Sclerosis
Optic Neuritis
Multiple sclerosis will develop within 15 yars of the first episode in 50% of patients with this eye condition. Strongly associated with demyelnating diseases (MS, Acute disseminated encephalomyelitis), sarcoidosis, viral infections, and autoimmune disorders. Presents with unilateral vision loss developing over a few days. Pain is exacerbated by eye movements. Visual field loss is usually central scotoma. Marked color vision loss. Optic disc swelling (papillitis) with flame-shaped peri-papillary hemorrhages. Visual acuity usually improves by 95% in 2-3 weeks. Tx with IV methylprednisalone will accelerate visual recovery if cause is due to demyelinating disorder. Poor prognosis when associated with sarcoidosis, zoster, lupus, and may require prolonged corticosteroid therapy.
What is the Dx? Immigrant presents with fever and bilateral parotid swelling.
Mumps
What is the most common cause of acute non-suppurative sialadenitis in childhood?
Mumps
Treatment for chronic otitis media?
Myringotomy with T- Tube insertion
sx of pharyngitis
NEVER have a cough, lymphadenopahty, pharyngeal exudate
Barotrauma:
NO GTTS in RUPTURED EAR DRUM Tx: anti-inflammatories, decongestants
Pale, boggy masses on the nasal mucosa Chronic congestion Decreased sense of smell
Nasal Polyps clinical features
Topical corticosteroids Surgery
Nasal Polyps treatment
A child presents with foul smelling unilateral purulent nasal discharge. Most likely Dx?
Nasal foreign body
This bacteria causes bacterial conjunctivitis and patients will usu. present with unilateral copius purulent dc.
Neisseria
Copious purulent discharge, unilateral (bacterial conjunctivitis)
Neisseria gonorrhea bacterial conjunctivitis
A patient with persistent pharyngitis, negative throat culture and a history of multiple sexual encounters is likely to have infection with what organism?
Neisseria gonorrhoeae
Bilateral acoustic neuroma only occurs with which disorder?
Neurofibromatosis type II
Auricles, Tragus, Mastoid inspection and palpation
No lesions or tenderness of the auricles, tragus are non-tender, no discoloration, swelling or tenderness of the mastoid
Hot Thyroid Nodule
Not associated with thyroid cancer
A pt with a cup to disc ratio > 0.5 is diagnostic for..?
Nothing. Cup:Disc ratio > 0.5 is suspect of Open-angle glaucoma
Commonly associated with water exposure, trauma (ear cleaning or scratching) or exfoliative skin conditions (psoriasis, eczema)
OE
Patient presents with ear pain esp w/ movement of the tragus or auricle. They have redness and swelling of the ear canal and purulent exudate.What is the likely dx?
OE
A patient with chronic sinusitis has large nasal growths which resemble peeled seedless grapes. What is the most likely cause of her chronic sinusitis?
Obstruction from nasal polyps
Neural Hearing Loss
Occurs with lesions of the eighth cranial nerve, auditory nuclei, ascending tracts, or auditory cortex due to acoustic neuroma, multiple sclerosis, or auditory neuropathy. Corticosteroid therapy my be helpful.
Cataracts
Opacity of lens that may be partial or complete. LEADING CAUSE OF BLINDNESS IN THE WORLD May develop secondary to age, trauma, sun, steroids, and may be congenital in kids. Insidious onset of vision loss in persons generally >60yo May present with complaints of progressive vision loss, fixed spots, decreased color vision, or double vision. On exam, translucent yellow discoloration to the lens, on fundoscopic exam appearance of black spot on red background. Surgical extraction and lens replacement.
Cataract
Opacity of lens. UV light. Absent red reflex
This is a chronic, asymptomatic and potentially blinding dz that effects 2% of the population. causes defects in the peripheral visual field and increased cup to disc ratios. Patients typically aysmptomatic until late in disease.
Open angle glaucoma
Asymptomatic, potentially blinding Loss of peripheral vision Intraocular pressure elevated
Open-Angle Glaucoma clinical features
A patient presents to your office with a sudden onset of headache, right eye pain, decrease visual acuity, nausea and vomiting. His intraocular pressure is 47. Which of the following classes of medications are indicated for treatment of this condition? A. Alpha agonists and antihistamines B. Alpha agonists and Beta blockers C. Mydriatics D. Cycloplegics E. Angiotensin converting enzyme inhibitors
Ophthalmic alpha-agonists (brimonidine) and beta blockers (timolol) decrease aqueous humor production, and decrease intraocular pressure. They facilitate aqueous flow through outflow tract and the canal of Schlemm. Other acute treatments include prostaglandin analogs(latanoprost) and carbonic anhydrase inhibitors(acetazolamide). Mydriatics, cycloplegics(tropicamide) and antihistamines( diphenhydramine) can precipitate angle closure glaucoma in patients at risk. Angiotensin converting enzyme inhibitors are used for treating systemic hypertension.
A 45-year-old male presents to your office complaining of severe unilateral eye pain with some photophobia for one day. He denies any history of trauma. On examination and with staining, you notice a dendritic lesion to the cornea, and an otherwise normal examination. Which of the following medications would be contraindicated in this patient?
Ophthalmic corticosteroids in cases of suspected herpes simplex keratitis are contraindicated.
Papilledema
Optic disc swelling due to raised IOP. Usually bilateral, causing enlargement of the blind spot without visual acuity loss. Acute cases will result in profound loss of visual acuity. Tx with cerebrospinal fluid shunt or optic nerve sheath fenestration for those with progressive visual loss not controlled by medical therapy. Recommend weight loss when appropriate and acetazolamide.
characterized by painful visual loss and a swollen optic disc.
Optic neuritis
Acute monocular vision loss may be due to (3)?
Optic neuritis Retinal artery occlusion Giant cell arteritis
Glaucoma
Optic neuritis. Increased ocular pressure may or may not occur. No screening.
A 60-year-old male presents with complaints of irritation and a white plaque on his tongue. He denies pain. During physical exam you are unable to remove the white plaque from the mucosa with a tongue depressor. What is the most likely diagnosis, represented as follows?
Oral leukoplakia cannot be removed from the mucosa using a tongue depressor like oral thrush can. Lichen planus can mimic candidiasis, squamous cell carcinoma, or hyperkeratosis, and requires a biopsy to diagnose. Glossitis is a generalized inflammation, and loss of papillae of the tongue is caused by vitamin deficiencies, medication reactions, auto immune reactions, or psoriasis. Geographic tongue is an asymptomatic serpiginous area of atrophy and erythema of the anterior tongue. The condition is self-limiting.
Hospitalization Broad spectrum antibiotics Nafcillin, metronidazole
Orbital Cellulitis treatment
What is infected in Orbital Cellulitis?
Orbital muscles and fat (Periorbital cellulitis would involve only skin around the eye, but Orbital cellulitis involved muscles and fat behind the eye. It is life-threatening)
A 63-year-old male presents with an asymptomaticlesion in his mouth that was discovered by his dentist at a check-up.It is ill marginated with pigment ranging from medium brown to black.Parts of the lesion are raised. What is the next appropriate stepin management?
Oropharyngeal melanoma is characterized by varying pigment occurringin an irregularly shaped lesion. Although this is a rarely occurringmelanoma, a biopsy should be done and any pigmented oral lesionshould be excised. Areas which are raised within the lesion usuallyindicate sites of invasion.
Acute Otitis Media
Otalgia in the setting of an upper respiratory tract infection. Bacterial infection of mucosa-lined air spaces of the temporal bone. Often results from eustachian tube obstruction caused by viral URI. Fluid accumulation becomes infected by bacteria (strep pneumo, Hflu, Strep pyogenes). May present with otalgia, aural pressure, decreased hearing, mastoid tenderness, fever, erythema and decreased TM mobility with occasional bullae. Rupture more likely with outward bulging of TM due to severe empyema. Decrease in pain after rupture and onset of otorrhea. Swelling over mastoid or associated cranial neuropathy requires urgent care. Tx with tympanocentesis for recurrent cases after multiple courses of ABX. Myringotomy for severe otalgia or complicated cases. Insertion of tubes if prophylaxis fails. Amoxicillin is 1st line. Erythromycin plus sulfonamide may be used. Augmentin for resistant cases. Prophylaxis for recurrent cases is sulfa or amoxicillin daily for 1-3 months.
7
Otoscopic exam - pull external ear back - tilt head away - look in both ears
What causes retinopathy of prematurity?
Oxygen hitting the eyes (from O2 mask)
hordeolum
PAINFUL nodule or pustule w/in a gland in upper/lower eyelid tx: warm compress, topical AB if needed, I&D if not resolved
clinical features of retinal vessel occlusion
PAINLESS blindness or visual fiel defect usually UNILATERALLY
clinical features of open angle glaucoma
PAINLESS gradual history of occasional tunnel vision that is bilateral
what is a chalazion
PAINLESS indurated lesion deep from palpebral margin.
What's the tx for Shingles?
PO acyclovir Topical Steroids (if posterior uveitis is present)
herpes simplex eye infection tx
PO acyclovir, famicyclovir, valacyclovir topical antivirals (trifluridine) ophthalmology consult
chalmydial conjunctivitis
PO tetracycline, doxycycline, or azithromycin
Which PO ABX would be appropriate for Blepharitis? Which topical ABX?
PO- Tetracycline Topical- E-mycin or Bacitracin
13
PUPILS 1. Symmetry 2. Reactive to light
Epiglottitis
Painful swallowing out of proportion with oropharyngeal findings. Most common cause is viral due to Hflu vaccination. More common now in adults, was more common previously in children. May present with rapidly developing sore throat and odynophagia, swollen erythematous epiglottis and a muffled "HOT POTATO" voice. Xray shows THUMB PRINT sign on lateral view. Immediately protect airway in children, most adults do not require intubation. Indications for intubation include Dyspnea, rapidly advancing sore throat, endolaryngeal abscess on CT. Continuous pulse oximetry if patient is not incubated. Tx with IV ABX (ceftizoxime or Cefuroxime), dexamethasone, and airway observation. May eventually transition to oral medications.
Tx of Chalazion?
Painless Warm compress If persistent, refer to Opthalm
Cholesteatoma
Painless otorrhea. Retraction pockets. CT scan
Retinal Detachment
Painless vision loss. Curtain pulled down
4
Palpate - TMJ - have them open and close mouth
6
Palpate - external ears - mastoid process
3
Palpate - facial bones and sinuses - any tenderness/pain?
2
Palpate - scalp and head - any tenderness/pain?
25
Palpate lymph nodes - anterior cervical - posterior cervical - supraclavicular
20
Palpate nose
24
Palpate thyroid - stand behind patient - tilt head forward and down - palpate as they swallow
Most common type of thyroid cancer?
Papillary
This condition is defined as an increase in ICP. May be causes by malignant HTN, hemorrhagic strokes, acute subdrual hematoma and pseudotumor cerebri.
Papilledema
What virus causes mumps?
Paramyxovirus
Which salivary gland is most often affected with sialadenitis?
Parotid gland
19 - Nose
Patency - breathe IN through each nostril - with other one closed (hand)
A patient presents with sore throat. She is drooling, unable to speak and exam finds deviation of her uvula. Should you send her home with oral antibiotics?
Patient must be hospitalized with peri-tonsillar abscess - Needs airway monitored and I&D of abscess
Retinal artery occlusion
Patient presents with sudden monocular vision loss. Ophthalmologic emergency with poor prognosis, even if immediately treated. Commonly caused by embroil, thrombosis phenomenon, or vasculitides. Primarily effecting central or branch of retinal artery. Migraine, contraceptives, vasculitis, and thrombophilia should be considered in young patients. Presents with sudden, profound, painless, marked unilateral (monocular) vision loss. Explore carotid and cardiac sources of emboli Fundoscopy shows areteriolar narrowing (BOX CAR SEGMENTATION), separation of arterial flow, retinal edema, and perifoveal atrophy (CHERRY RED SPOT). Ganglionic death leads to optic atrophy and a pale retina. Emergent referral to ophthalmology with anterior chamber paracentesis and vessel dilation attempted. If seen within hours or onset, lay patient prone, ocular massage, high concentrations of inhaled O2, IV acetazolamide. Management of atherosclerotic disease to reduce risk.
What is the treatment for open angle glaucoma?
Patient should be referred to optho for close monitoring and chronic treatment Treatment consists of topical and/or systemic medications to decrease the IOP (BBs, acetazolamide, prostaglandin-like-medications, cholinergic mediactions, epinephrine, brimonidine) etc)
Patients who suffer with acne rosacea can relate a history of which outcome?
Patients who suffer with acne rosacea can relate a history of their condition worsening with exposure to hot temperatures, spicy foods, or alcoholic beverages. This is in response to increased reactivity of capillaries. Acne that worsens with the onset of menses is characteristic of acne vulgaris, not acne rosacea. Acne rosacea may resolve spontaneously; however, it is usually present in some form for a lifetime. Exposure to high temperatures, such as those in a steam room, can worsen acne rosacea.
A 54-year-old male patient presents to your office complaining of pain to the left eye with nausea, vomiting, and a headache after being brushed in the eye with his grandchild's stuffed animal. On examination the conjunctiva is not injected, and the cornea has a steamy appearance. You cannot visualize the retina. The pupil is fixed and 4 mm. When you stain the eye you are unable to see any lesions or scratches. You suspect:
Patients with acute glaucoma usually seek treatment immediately because of extreme pain and blurred vision, though there are subacute cases. The blurred vision is associated with halos around lights. Nausea and abdominal pain may occur. The eye is red, the cornea steamy, and the pupil moderately dilated and nonreactive to light. Intraocular pressure is usually over 50 mm Hg, producing a hard eye on palpation.
A 3-year-old male is brought to your office with a red, tearing right eye. The mother stated that the child was playing in another room with his 4-year-old brother. All she heard was the child beginning to cry. Upon physical exam, the child is intermittently crying, and his right eye is red and tearing. The child is continually rubbing the eye. The anterior chamber is clear and the pupil is equal and reactive. What is your next step in evaluating this patient?
Perform a fluorescein stain A corneal abrasion must be ruled out in a child with a red eye.
Sudden onset N/V Tinnitus, hearing loss, nystagmus
Peripheral Vertigo clinical features
Is Meniere's disease a peripheral or central cause of vertigo?
Peripheral vertigo
What is the visual loss progression in glaucoma? (Periphery to central or central to periphery?)
Periphery to central
Sore throat, pain with swallowing Deviation of soft palate/uvula Muffled 'hot potato' voice
Peritonsillar Abscess clinical features
What is the DX? Severe sore throat fever drooling muffled/hot potato voice uvula deviation.
Peritonsillar abscess
A patient presents with epistaxis from the right nares, along with direct pressure to the nares and elevation of the head. Which of the following is an appropriate initial treatment?
Phenylephrine is a topical decongestant, and acts as a vasoconstrictor to aid in stopping minor anterior septal epistaxis. Triamcinolone and momentasone are nasal steroids used for allergic rhinitis. Cromolyn sodium is a mast cell stabilizer, and azelastine is a topical H1 selective antihistamine, used for allergic rhinitis.
Medications that commonly cause gingival hyperplasia?
Phenytoin - Calcium Channel Blockers - Cyclosporine
Elevated, yellowish, fleshy conjunctival mass found on the sclera adjacent to the cornea
Pinguecula
Critical: Lymph nodes
Pre-auricular, Post-auricular, occipital, tonsillar, submandibular, submental, anterior cervical, deep cervical, posterior cervical, supraclavicular: No lymphadenopathy
Peritonsillar Abscess
Presentation includes a muffled "hot potato" voice. Caused by an infection that penetrates the tonsillar capsule and surrounding tissue. May present with sore throat, odynophagia, truisms, medial deviation of the soft palate and poeritonsillary fold, and a muffled voice. Dx with aspiration and culture of site. TX with needle aspiration, I&D, or tonsillectomy. Use of a single dose of IV amoxicillin of clindamycin in ER cases, may use oral ABX for less severe cases.
When should abrasion/ulcers NOT by covered with a pressure patching?
Pressure patching may cause further deformation of the cornea. Contact lens abrasions should NOT be patched, and should be treated with topical abx c/ pseudomonas coverage (Tobramycin, oflaxacin, cipro)
What pathogen is responsible for malignant otitis externa?
Pseudomonas
This is a slowly growing thickening of the bulbar conjunctiva that can be unilateral or bilateral. There will be a highly vascular triangular mass growing from the nasal side towards the cornea that enroaches on the cornea and interfers with vision.
Ptergyium
Highly vascular, triangular mass growing from the nasal side to the cornea
Pterygium
A 65-year-old male presents to you with a growth on the inner aspect of his left eye. He states that it has been getting slightly larger. On physical exam, you note a fleshy triangle shaped protrusion on the inner bulbar conjunctiva, touching the limbic border. Which of the following is the correct diagnosis?
Pterygium is a complication of exposure to ultraviolet light and wind. It consists of hyaline and elastin tissue. If it encroaches on the cornea, surgical removal is indicated.
12
Pull lower eyelids down - inspect conjuctivae/sclerae
How can you differentiate dacryoadentitis and dacryocystitis?
Purulent discharge, significant redness, pain, swelling, decreased feeding, failure to thrive would be seen in dacryocystitis.
How should you treat a corneal ulcer?
REFER TO OPTHALMOLOGIST stain lesion and culture
Tx for retinal vein occlusion?
Ranibizumab IV steroids Thrombolytics Surgical intervention
Tx for Wet Mac Degen?
Ranibizumab, laser tx
Acute Angle Closure Glaucoma
Rapid onset of severe eye pain with profound visual loss and "HALOS AROUND LIGHTS". Ophthalmic emergency presenting with painful eye with loss of vision, affecting people <40 years old and more commonly in African Americans or those with +family hx. Exam reveals circumlimbal injection (red eye), STEAMY CORNEA, fix mid-dilated pupil, and decreased visual acuity. IOP >50mmHg resulting in HARD EYE. Primary type occurs with closure of pre-existing narrow anterior chamber angle. Secondary type occurs in anterior uveitis, lens dislocation, or topiramate therapy. Narrow anterior chamber with acutely elevated intraocular pressure. May be accompanied by nausea, vomiting, and diaphoresis. Immediate referral to ophthalmology. Tx for primary is iridoplasty or anterior chamber paracentesis is effective if pharm therapies cause no response at initial presentation. Reduce IOP with single 500mg dose of IV acetazolamide then osmotic diuretics. Topical pilocarpine to reverse angle after IOP is decreased. Definitive Tx is iridectomy or iridotomy. Untreated dz will result in severe and permanent visual loss in 2-5 days.
A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following diagnostic studies should be performed as a result of this finding?
Rapid plasma reagin (RPR) Congenital cataracts may result from transmission of maternal infections such as herpes simplex virus, cytomegalovirus, toxoplasmosis, or syphilis and require further evaluation for potential systemic infection
17
Red reflex - B/L - "I see your red reflex."
What's the tx for angle-closure glaucoma?
Refer to an ophthalmologist! IV Acetazolamide (Diamox), once the pressure falls, topical pilocarpine 2%
What is the treatment for angle-closure glaucoma
Refer to optho immediately. Start IV acetazolamide, and topic timolol and osmototic diuresis (mannitol) - mydriatics should NOT be administered to patients optimal treatemnt is via laser or surgical iridotomy
Chalazion
Relatively painless, infuriated lesion deep from the palpebral margin, often secondary to chronic inflammation of meibomian gland or an internal hordeolum. Characterized by insidious onset with minimal irritation, may become pruritic and cause erythema of the involved lid. May present with complaints of a hard, non-tender, swelling of the upper or lower lid with adjacent conjunctival erythema and swelling. Large type may impress the cornea and cause distorted vision. TX with warm compress and referral to ophthalmology for elective excision if not resolved.
Tx for Allergic Conjunctivitis?
Remove offending agent Start with topicals: - Cromolyn, Olopatadine Oral Anti-histamines - Loratadine, Cetirizine, Fexofenadine, Diphenhydramine
Tympanic Membrane Perforation
Results from impact injury or explosive acoustic trauma. Persistent condition may result from secondary infections. May present with an audible whistle sound. May show prudent discharge if infection is present. Most cases heal spontaneously. Water exposure should be avoided (earplugs while swimming or bathing), until healed. Avoid ototoxic ear drops. Systemic antibiotics may be used if infection is present.
Inflammation of the nasal mucosa
Rhinitis
Lesion of RIGHT side of the RIGHT optic nerve will cause what visual symptoms?
Right nasal hemianopsia
9 - If hearing trouble
Rinne Test - Strike tuning fork - place on mastoid - after can't hear any more, place in front of ear - Do you still hear it? (Yes = nml) - It will be softer in the affected side **SENSORINEURAL hearing loss
Rotator cuff injury
SITS- Supraspinatus MC -sx- anterior deltoid pain, weakness, atrophy, Passive ROM greater than active ROM*** +hawkins, drop arm, neers test -tx- tendonitits- shoulder pendulum/ wall climbing exercises
EWING SARCOMA
SX- malignant bone tumors that present with pain and swelling. No improvement is noted with conservative therapy. MID SHAFT, SYSTEMIC -DX- Onion skin! -tx- local incision, chemo, radiation
Nasal Polyps
Samter's Triad is characterized by asthma, aspirin sensitivity, and this physical exam finding. Commonly seen in association with allergic rhinitis. Consider cystic fibrosis when seen in children. Presents with pale, edematous mucosa-covered masses. Diminished sense of smell and nasal obstruction. Surgical removal if medical management fails. Nasal corticosteroids for 1-3 months, short course of oral corticosteroids. Prevent with allergen avoidance, aspirin avoidance in those with this and asthma.
What is blepharitis associated with?
Seborrhea* Rosacea* Staph colonization
A 62 year old male presents with a concern regarding the numerous brown, warty looking papules on his back. They are asymptomatic but sometimes get caught on clothing which can cause irritation and bleeding. What is the most likely diagnosis?
Seborrheic Keratoses are described as brown, warty looking papules that have a "stuck on" appearance. They are more common in patients over 50 years old.
Blepharitis
Seborrheic, warm compress, baby shampoo
When would Neisseria Gonorrhea be considered?
Secretions, redness and pain are greater than expected *Newborns
Central Causes of Vertigo
Seizure Multiple sclerosis Wernicke Encephalopathy Chiaki malformation Cerebellar ataxia syndromes
What type of hearing loss is associated with Meniere's disease?
Sensorineural hearing loss
What type of hearing loss is associated with aging (presbycusis)?
Sensorineural hearing loss
Retinal Detachment
Separation of retina from pigmented epithelial layer, usually beginning at the superior temporal retina. May occur spontaneously or as a result of trauma. Central vision remains intact until macular involvement. May present with "CURTAIN DRAWN OVER EYES" from top to bottom. May complain of flashes of light or floaters early on. Fundoscopic exam may reveal rugous retina flapping in vitreous humor. Emergency consult with ophthalmology. Patient should remain supine with head turned towards effected side. 80% will not recur, 15% will need TX, 5% will no reattach. Methods used are laser, silicone, expansional gas, and vitrectomy, determined by underlying cause.
A 42-year-old male with a past medical history of renal failure and diabetes type II presents with facial swelling and pain. He states that it has been getting worse since it started five days ago. He also states that the side of his cheek became acutely swollen and painful five days ago when he was eating. His physical exam reveals a markedly swollen left submandibular space, with a firm and tender 1.5 cm nodule, palpable near the mandible, on the left side. When pressed, pus is seen coming out of the submandibular salivary duct. What is the most likely diagnosis?
Sialadenitis
A 45 year old male presents with progressive enlargement of his right submandibular gland over the last week. What is the most likely diagnosis?
Sialolithiasis
Pterygium
Slow growing, thickened part of the bulbar conjunctiva. May be unilateral or bilateral. Presents as highly vascularized triangular mass growing from the nasal side towards the cornea, occasionally encroaching on the cornea and interferes with vision. Tx with excision if vision is impaired. Recurrence is common.
Taking vitamin C, E, zinc, and beta carotene, and stopping smoking, have a preventative effect on the progression of which of the following diseases?
Smoking cessation and taking supplements, including vitamin C, E, zinc, and beta carotene, have shown an eight percent decrease in progression of late stage macular degeneration. Smokers or previous smokers should not take beta carotene, due to its link with lung cancer in smokers.
Taking vitamin C, E, zinc, and beta carotene, and stopping smoking, have a preventative effect on the progression of which of the following diseases? A. Macular degeneration B. Retinal detachment C. Central retinal artery occlusion D. Diabetic retinopathy E. Central retinal vein occlusion
Smoking cessation and taking supplements, including vitamin C, E, zinc, and beta carotene, have shown an eight percent decrease in progression of late stage macular degeneration. Smokers or previous smokers should not take beta carotene, due to its link with lung cancer in smokers.
A 25 year old female presents with multiple irregular brown macules on her upper back. They are asymptomatic. She has worked as a lifeguard for the past 7 years. She reports a couple of blistering sunburns and admits to maintaining a "healthy tan". What is the most likely diagnosis?
Solar lentigines are a result of skin damage from the sun. Unlike ephiledes, they do not fade once exposure to the sun has stopped. There is no risk of malignancy associated with solar lentigines.
Most common type of oral cancer?
Squamous cell (90%)
A 68 year old male drinker presents with 3 months of hoarseness. What condition must be considered?
Squamous cell carcinoma
Orbital Cellulitis
Staph & Strep. Pain with movement. EOM paralysis. CT scan.
The 4 most common pathogens responsible for Bacterial Conjunctivitis?
Staph A Strep pneu H flu M Catarrhalis
Most common organism causing painful eyelid nodule?
Staph Aureus
Most common pathogen causing sialadenitis?
Staph aureus
What're the common causes of Blepharitis?
Staph spp Viral INFX Seborrheic
What is the most common pathogen associated with sialadenitis? Which empiric antibiotic class should be used?
Staph. Aureus - Cephalosporins are first line
What most commonly causes orbital cellulitis?
Staph/Strep
Treatment for nasal polyps?
Steroids or surgical removal
3 most common bacterial organisms causing sinusitis?
Strep Pneumo #1 - H. Influenzae #2 - M. Catarrhalis #3
3 most common organisms causing AOM (Acute Otitis Media)?
Strep Pneumo #1 - H. Influenzae #2 - M. Catarrhalis #3
What are the common chronic pathogens causing dacryocystitis?
Strep pneumo H flu Pseudomonas Strep Viridans
Otitis media
Strep, moraxella, haemophilus. Tugging of ear. Immobility of TM. Bulging TM. Amoxicillin
In what area does a retinal tear most commonly begin?
Superior temporal retinal area
Tx for Dry Mac Degen?
Supportive, supplements
What's the tx for Cataracts?
Surgery!
How do you treat an entropion or an ectropion?
Surgical repair if the condition causes trauma (triachiasis), excessiv tearings, exposure keratitis or cosmetic distress
Treatment for cholesteatoma?
Surgical/possible stapedectomy with prosthesis placement
Second step in removing foreign body?
Swab attempt After that, opthalmologist.
What is papilledema?
Swelling of optic disk, may represent ICP. (Tumor, edema)
Otitis Externa
Swimming and Qtips. Otorrhea. Pain with tragus/pinna movement
Cranial Nerve 5 and 7 motor
Symmetric motor function of cranial nerve 5 and 7
Any impediment to the flow of aqeuous humor through the trabecular meshwork and canal of schlemm will increase pressure in the anterior chamber in Glaucoma. T or F
T
The prognosis for retinal detachment is good. 80% will recover w/o recurrence, 15% will require treatment and 5% will never reattach. T or F
T
Critical: Tympanic membrane
TM is pearly gray and translucent, light reflex is in anterior inferior quadrant, landmarks are undistorted
Which of the following concerning changes in nevi can be associated with melanoma?
The ABCDE's of moles are asymmetry, border irregularity, color change or irregularity, diameter >5mm, and evolving (changing in some way). These are all signs that the mole should be evaluated for possible dysplastic or malignant changes.
A 12 year old female found a tick on her leg after a camping trip. The tick was removed without incident. According to CDC recommendations, what is the appropriate testing for Lyme disease?
The CDC recommends first using ELISA to test for Lyme disease. If this is positive, then a Western Blot should be performed as confirmation. Acute and convalescent titers should be tested as only 20-30% of patients have a positive response in the acute phase. That percentage rises to 70-80% in the convalescent phase.
Since the introduction of the Haemophilus influenza B vaccine, which of the following diseases is in decline for the pediatric population, but is being seen more in adults?
The H. influenza B vaccine has significantly decreased the incidence of epiglotitis in children, leaving the adult population with a higher incidence of epiglotitis. The course of the illness in adults is not as severe as in the pediatric population. Influenza B is a seasonal virus, and requires yearly immunizations.
Which extra ocular muscles may become entrapped in a blowout fx? Which s/sx will the pt have in this case?
The Inferior Rectus and/or Inferior Oblique muscles This may cause an inability to gaze upwards, as well as double-vision, and possible subQ emphysema and/or exophthalmos
Viral Conjunctivitis caused by H. zoster is indicative of which nerve?
The Ophthalmic branch of the Trigeminal nerve. Shingles in the eye can be vision-threatening!!
A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following is the most appropriate management for this patient? A. Cataract surgery within the next 6 weeks B. Cataract surgery within the next year C. Observation every 3 months D. Observation every 6 months
The answer is A. EXPLANATION: Congenital cataracts that are large and affect visual acuity (e.g., central) must be surgically corrected within the first two months of life (A) to avoid the development of deprivation amblyopia. Observation (C, D, and E) or delayed surgery (B) may result in permanent deprivation amblyopia.
A patient presents with epistaxis from the right nares, along with direct pressure to the nares and elevation of the head. Which of the following is an appropriate initial treatment? A. Phenylephrine spray and anterior packing B. Triamcinolone spray and anterior packing C. Azelastine spray and anterior packing D. Momentasone spray and anterior packing
The answer is A. EXPLANATION: Phenylephrine is a topical decongestant, and acts as a vasoconstrictor to aid in stopping minor anterior septal epistaxis. Triamcinolone and momentasone are nasal steroids used for allergic rhinitis. Cromolyn sodium is a mast cell stabilizer, and azelastine is a topical H1 selective antihistamine, used for allergic rhinitis.
A 23-year-old male presents to the clinic complaining of left anterior neck pain that developed over the past week following recovery from an acute upper respiratory infection. On physical exam a tender mass is felt anterior to the left sternocleidomastoid muscle from the mandible inferiorly to the level of the cricoid cartilage. Which of the following is the most likely diagnosis? A. Branchial cleft cyst B. Dermoid cyst C. Peritonsillar abcess D. Salivary gland tumor
The answer is A. EXPLANATION: The development of a neck mass in a young adult following URI is consistent with branchial cleft cyst (A) and thyroglossal duct cyst (E). The location of this mass away from the midline and anterior to the SCM is most consistent with branchial cleft cyst (A). The location of the mass and history are inconsistent with dermoid cysts (B), which are typically midline, peritonsillar abcesses (C), which would be located in the retropharyngeal space, and salivary gland tumors (D), which would be located in the parotid, submandibular, or submental salivary regions.
A 43-year-old female presents to the outpatient clinic complaining of itching and irritation of her right eye. She denies decreased vision or photophobia. On physical exam the patient's eye has the following appearance: Which of the following is the most appropriate management for this patient's condition? A. Daily lid cleansing and application of bacitracin ophthalmic ointment 500 units/g B. Doxycycline 100 mg by mouth once daily C. Incision and drainage D. Referral to an ophthalmologist
The answer is A. EXPLANATION: The patient's symptoms of itching and irritation of the lid margin with an inflamed eyelid and eyelash scaling is consistent with mild anterior blepharitis, which is initially treated with cleansing and the potential addition of a topical antistaphlococcal antibiotic (A). Answers (C) and (E) are appropriate treatments for a hordeolum. Doxycycline once daily (B) can be used as a long-term treatment for posterior blepharitis. The condition doesn't warrant referral (D).
As a diver descends for a deep water dive, at about 10 feet of depth he begins to feel nausea, severe ear pain, and develops vertigo and vomiting. What is the most likely cause of his symptoms? A. Decompression sickness B. Decreasing pressure in the middle ear C. Benign paroxysmal positional vertigo D. Increasing pressure in the middle ear E. Equalization of pressure between the middle ear and eustachian tube
The answer is B. EXPLANATION: Boyle's law states that as a diver descends, the increasing external pressure causes an equal decrease in pressure in the middle ear, which must be equalized during the descent. If the middle ear pressure is not equalized, the tympanic membrane becomes severely retracted, due to the negative middle ear pressure. This can result in hemotympanum, hemorrhage, or tympanic membrane perforation. Ascent causes increased pressure in the middle ear as the external pressure is decreased. Equalization techniques must also be used to prevent a tympanic membrane perforation. Decompression sickness occurs on ascent, when nitrogen gas bubbles are forced into the middle ear, and vascular and lymphatic spaces.
A 60-year-old male presents with complaints of irritation and a white plaque on his tongue. He denies pain. During physical exam you are unable to remove the white plaque from the mucosa with a tongue depressor. What is the most likely diagnosis, represented as follows? A. Oral thrush B. Leukoplakia C. Geographic tongue D. Glossitis E. Lichen planus
The answer is B. EXPLANATION: Oral leukoplakia cannot be removed from the mucosa using a tongue depressor like oral thrush can. Lichen planus can mimic candidiasis, squamous cell carcinoma, or hyperkeratosis, and requires a biopsy to diagnose. Glossitis is a generalized inflammation, and loss of papillae of the tongue is caused by vitamin deficiencies, medication reactions, auto immune reactions, or psoriasis. Geographic tongue is an asymptomatic serpiginous area of atrophy and erythema of the anterior tongue. The condition is self-limiting.
A 65-year-old male presents to you with complaints of decreasing hearing, along with difficulty discerning words when in conversations in noisy environments, such as restaurants. His only medication is simvastatin for hyperlipidemia. The following is his audiogram. He has bilateral decreased high frequency hearing loss, and decreased speech recognition. What is the most likely diagnosis? A. Vestibular schwannoma B. Presbycusis C. Presbystasis D. Cerumen impactions E. Vestibulobasilar insufficiency
The answer is B. EXPLANATION: Presbycusis is age related bilateral loss of high frequency hearing, and decreased word recognition. Presbystasis is age related balance disorder. Vestibular schwannoma (acoustic neuroma) causes unilateral hearing loss. Vestibulobasilar insufficiency results from atherosclerosis of the vertebral arteries, and can cause many symptoms including double vision, speech defects, vertigo, ataxia, and drop attacks.
A 45-year-old male presents with purulent discharge from his right ear for three weeks. He states that despite being treated by his family doctor for an ear infection one month ago, the problem continues to get worse. Upon exam, you note purulent discharge in the ear canal, an erythemic tympanic membrane, and a possible perforation. What are the pathogens most likely to culture positive? A. Strep pneumoniae B. Pseudomonas aeroginosa C. Escherichia coli D. Candida albicans E. Mycoplasma pheumoniae
The answer is B. EXPLANATION: The clinical vignette describes a chronic otitis media. Usually, this refers to a complication of acute otits media with perforation. Pathogens that culture from these infections are usually pseudomonas, proteus, or staphylococcus aureus. Strep pneumoniae is often seen in acute otitis media. E.coli is a urinary tract pathogen. Candida albicans is a cause of vaginitis, and mycoplasma is a respiratory pathogen.
A 43-year-old woman presents to the outpatient clinic complaining of right eye redness, photophobia, and pain. She notes some blurred vision and denies the presence of discharge. On physical exam her visual acuity is 20/20 left eye, and 20/60 right eye. Her right eye has circumcorneal injections and the pupil is 3 mm and responds poorly to light. Her left pupil is 5 mm and responds well. Fluorescein staining of the eye is unremarkable and intraocular pressures are normal. Which of the following treatment regimens should be prescribed? A. Homatropine 5% solution four times daily B. Homatropine 5% solution four times daily and prednisolone 1% solution every 1 or 2 hours while awake C. Prednisolone 1% solution every 1 or 2 hours while awake
The answer is B. EXPLANATION: The patient's presentation of acute uveitis is best treated with topical corticosteroids and cycloplegics (B) once infectious causes (e.g., HSV) have been ruled out. The addition of a cycloplegic helps reduce pain. Antibiotic drops (D) aren't indicated for acute uveitis.
You are evaluating a patient who is complaining of facial drooping , and inability to close his eye. During the cranial nerve exam you notice he is unable to wrinkle his forehead. Based on this information what is the most likely diagnosis? A. Cerebrovascular accident B. Transient ischemic attack C. Bell's palsy
The answer is C. EXPLANATION: Bell's palsy affects cranial nerve VII, the facial paralysis conforms to the all branches of the peripheral nerve including the side of the face, eyelid and forehead muscles. An acute cerebrovascular accident would present only with a facial droop, the ability to close the eye and wrinkle the forehead would be preserved and there would likely be other focal weakness on physical exam. Horner's syndrome is miosis, ptosis and facial flushing and anhydrosis caused by abnormalities of the supercervical ganglion along the internal carotid artery.
A 37-year-old male presents to your office with a history of vision loss in his right eye. He denies any pain, and states that the vision loss occurred suddenly. He noted there was a wavy, "curtain-like" visual disturbance preceding the vision loss. Upon physical exam you notice a cherry red spot over the macula and retinal pallor. What is the most likely diagnosis? A. Macular degeneration B. Retinal detachment C. Central retinal artery occlusion D. Cerebrovascular accident
The answer is C. EXPLANATION: Central retinal artery occlusion is characterized by a sudden, painless vision loss. A cherry red spot is characteristic on the macula, along with pallor to the retina.
Jane, a 21-year-old female, was seen in the office 10 days ago and was diagnosed with perennial allergic rhinitis and sent home with instructions for increased fluids, decongestants, and nasal steroids. She returns today with worsened symptoms of malaise, low-grade fever, nasal discharge, cough that is worse at night, mouth breathing, early morning unilateral pain over sinuses, and congestion. Physical examination reveals thick purulent nasal discharge, postnasal discharge visible in the posterior pharynx, periorbital swelling, and tenderness of sinuses upon palpation. She is 36-weeks pregnant and allergic to penicillin. Of the following, what is the most appropriate antibiotic? A. amoxicillin B. trimethoprim-sulfamethoxazole C. clindamycin D. levofloxacin
The answer is C. EXPLANATION: Most patients with a diagnosis of acute rhinosinusitis based on clinical grounds improve without antibiotic therapy. The preferred initial approach in patients with mild to moderate symptoms of short duration is therapy aimed at facilitating sinus drainage, such as oral and topical decongestants, nasal saline lavage, and—in patients with a history of chronic sinusitis or allergies—nasal glucocorticoids. Adult patients who do not improve after seven days, children who do not improve after 10 to 14 days, and patients with more severe symptoms (regardless of duration) should be treated with antibiotics. Empirical therapy should consist of the narrowest-spectrum agent active against the most common bacterial pathogens, including S. pneumoniae and H. influenzae—e.g., amoxicillin. But amoxicillin is contraindicated in patients with urticarial reactions to penicillins, and quinolones are similarly contraindicated in pregnancy. trimethoprim-sulfamethoxazole is contraindicated in the third trimester of pregnancy. The best choice is clindamycin.
A 55-year-old male presents with severe swelling to his left eye. He denies injury or allergies. He states that he has had a severe sinus infection for the past two weeks. What is the most likely diagnosis for the following physical finding? A. Allergic reaction B. Eyelid abcess C. Orbital cellulitis D. Erysipelas
The answer is C. EXPLANATION: The image shows a severe orbital cellulitis. These infections often spread from paranasal sinus infections. Multiple pathogens may be involved, such as s.aureus, s. pheumoniae, and anaerobes. An eyelid abscess would be more localized. Allergic reactions that cause angioedema around the eye are usually bilateral, and also pruritic.
A 68-year-old man presents to the outpatient clinic complaining of decreased hearing in his left ear. The following is seen on otoscopic evaluation. Which of the following is the most likely diagnosis? A. Acute otitis media B. Cerumen impaction C. Cholesteatoma D. Chronic otitis media
The answer is C. EXPLANATION: The photo depicts a classic cholesteatoma (C) effecting the pars flaccida. The localized nature of the findings and lack of inflammation make otitis media (A and D) unlikely. Any perforation in the TM (E) would be secondary to the cholesteatoma and the visible TM is inconsistent with a diagnosis of impacted cerumen (B).
An 18-year-old female presents with two weeks of severe sore throat and fatigue. Her exam shows an exudative tonsillitis. A mono-spot test is positive, and a rapid strep test is positive. Which of the following medications should be avoided? A. Erythromycin B. Clindamycin C. Cephalexin D. Ampicillin E. Prednisone
The answer is D. EXPLANATION: Ampicillin should be avoided, because a high percentage of mononucleosis patients develop a fine, non-allergic maculopapular rash when given ampicillin class drugs. The remaining antibiotics are appropriate for treating group A strep. Prednisone is used to reduce the pain and inflammation associated with severe tonsillitis.
A 20-year-old male presents with cough, nasal congestion, and a low grade fever for one week. His cough seems to be getting worse, which is the reason for his visit. His past medical history includes asthma and nasal polyps. On physical exam, his temperature is 101°F, his pharynx is erythemic, and there is grey nasal discharge with a few nasal polyps seen using a nasal speculum. His lungs have a few expiratory wheezes bilaterally. What medication is to be avoided in this patient? A. Penicillin B. Acetaminophen C. Erythomycin D. Aspirin E. Ciprofloxacin
The answer is D. EXPLANATION: Aspirin should be avoided in patients with asthma and nasal polyps. Aspirin can precipitate bronchospasm in these patients, due to immunologic salicylate sensitivity.
A 5-year-old boy presents to urgent care complaining of painful lesions in his mouth that have made eating difficult the past 2 days. The mother confirms he has been unable to eat for 48 hours, but has been able to sip water. On physical exam he has a temperature of 102.6 F; numerous small vesicles and ulcers on the buccal mucosa and tongue, inflamed gingiva; and tender anterior cervical adenopathy. Which of the following is the most likely diagnosis? A. Aphthous ulcers B. Hand, foot, and mouth disease C. Herpangina D. Herpes simplex gingivostomatitis
The answer is D. EXPLANATION: The classic presentation of initial herpes simplex infection (D) includes multiple small, painful vesicles or ulcers on the mucousa with gingival involvement, fever, and adenopathy. (A), (B), and (C) all present with ulcers, but typically involve an isolated area (A), or the tonsils and posterior pharynx (B and C). Reference:
A 63-year-old female complains of a 5-day history of a persistent left-sided headache, which she has not experienced before. She also notes a tender swollen area around her left temple, which appeared around the same time. On examination you note tenderness and prominence of the left temporal artery. You order an ESR, which is 75 mm/h. What is your best course of action at this time? A. Repeat the ESR in 72 hours. B. Begin prednisone 20 mg/d and increase if symptoms persist. C. Refer to a rheumatologist for appointment next month, with a trial of nonsteroidal anti-inflammatory drugs (NSAIDs). D. Begin prednisone 60 mg/d immediately. E. Refer for a temporal artery biopsy next week, with a trial of hydrocodone for analgesia.
The answer is D. EXPLANATION: The correct answer is (D). The patient's history and physical examination findings point to giant cell arteritis (temporal arteritis) as the most likely cause, prompting immediate treatment with high-dose prednisone to prevent visual loss. The patient meets the criteria for clinical diagnosis of giant cell arteritis without a temporal artery biopsy, but it is recommended for definitive diagnosis due to the complications associated with long-term corticosteroid treatment. Treatment with prednisone should not be withheld while waiting for a temporal artery biopsy. NSAIDs and hydrocodone do not prevent the complications of temporal arteritis.
A 23-year-old man presents to the outpatient clinic for follow-up from a recent urgent care visit. He complains of sore throat, fever, fatigue, myalgias, and a rash that started 5 days ago, and have worsened since he was seen in the urgent care 3 days ago. The patient appears non-toxic with a temperature of 39.4 degrees Celsius. Physical exam reveals pharyngeal and tonsillar erythema without exudates, generalized lymphadenopathy, a morbilliform rash on his trunk, and no hepatosplenomegaly. A rapid strep screen and Monospot performed at the local urgent care were reportedly negative. Which of the following laboratory tests is most likely to confirm the expected diagnosis? A. Complete blood count B. Cytomegalovirus titer C. Group A beta-hemolytic strep culture D. HIV viral load
The answer is D. EXPLANATION: The patient presentation is consistent with acute retroviral syndrome, which is best confirmed during this initial presentation phase through direct testing for the HIV virus, such as an HIV viral load (D). The lack of tonsillar exudates, a negative monospot, and presence of generalized adenopathy make infectious mononucleosis (B and E) less likely. A CBC (A) may show lymphopenia and support the diagnosis, but it doesn't confirm the diagnosis.
A 3-year-old girl presents to the otolaryngologist for evaluation of a persistent left ear infection and drainage that have failed to respond to multiple antibiotic regimens. Which of the following is the most likely causative organism for this patient's condition? A. Aspergillus B. Chlamydia pneumoniae C. E. coli D. Streptococcus pneumoniae E. Staphylococcus aureus
The answer is E. EXPLANATION: Chronic otitis media is typically caused by P. aeruginosa, H. influenzae, S. aureus (D), Proteus species, Klebsiella pneumoniae, or Moraxella catarrhalis. Aspergillus (A) and E. coli (C) are associated with otitis externa and streptococcus pneumoniae (D) is the most common bacterial cause of otitis media. Reference:
Chronic Otitis Media
The clinical Hallmark of this disease is purulent aural discharge. Results from recurrent acute variant, certain diseases, and trauma. Pathogens include P aeruginosa, Proteus species, S aureus, and mixed anaerobic infections. May present with TM perforation, mucosal changes, osseous changes, purulent aural discharge with or without otalgia, and conductive hearing loss. Tx with regular removal of infected debris, protection against water exposure. Definitive management is TM reconstruction. Topic ABX drops, oral Cipro.
A 50 year old female presents multiple episodes of sudden onset of vertigo over the past few months. She states this began after turning her head suddenly. The events last for about 30 seconds. She complained of nausea during the spells. She denies headaches, hearing problems, focal weakness or recent illnesses. What is the most appropriate clinical intervention.
The clinical history suggests benign paroxysmal positional vertigo (BPPV). The Dix-Halpike test and Nylen Barany test are physical exam techniques to diagnose positional vertigo. The Epley maneuver is a therapeutic canalith repositioning maneuver for debris in the posterior semicircular canal, which is the cause of BPPV. The maneuver works in 80% of the patients with BPPV. A head CT would be indicated for any patient with neurologic symptoms or a new onset of headache.
A 60-year-old male presents with scaling feet for several months. The nails are spared. The patient has tried over-the-counter hydrocortisone cream with no help. KOH shows branching hyphae and spores. Which of the following should be part of an appropriate treatment regimen?
The clinical presentation and KOH results are consistent with tinea pedis or athlete's foot. Since the nails are unaffected, topical treatment with clotrimazole is appropriate. Lotrisone contains an antifungal and a steroid; this combination medication is not appropriate for this patient. Fluticasone is a class 3 topical steroid that would worsen this patient's condition. Mupirocin is a topical antibiotic and will not help resolve a fungal infection.
An 18 month old female is brought to the pediatricians office with a history of cough, fever of 102, and decreased fluid intake. Her immunizations are not up to date as the family just moved to the United States from out of the country. On physical exam she is drooling and sitting up in a "tripod position" with mild stridor. What is the most appropriate treatment indicated for this condition?
The clinical presentation suggests epiglotitis. This is an emergent airway condition. The anesthesiologist , or the pediatric otolaryngologist must be called to stand by to intubate or insert a tracheostomy if the patients airway closes. Racemic epinephrine via nebulizer relieves much of the edema to the upper airway in a patient with epiglotitis. It is a stabilizing measure until definitive care can be arranged. Oxygen and antibiotics should administered emergently also. No x-rays are indicated when the presentation is classic. Albuterol is a beta-agonist used for treatment of asthma. Budesonide,a steroid and ipratropium, an anticholinergic agent are most often used in combination with albuterol for treatment emphysema and asthma.
An 18 month old female is brought to the pediatricians office with a history of cough, fever of 102, and decreased fluid intake. Her immunizations are not up to date as the family just moved to the United States from out of the country. On physical exam she is drooling and sitting up in a "tripod position" with mild stridor. What is the most appropriate treatment indicated for this condition? A. Humidified air B. Albuterol nebulizer C. Budesonide nebulizer D. Recemic epinephrine nebulizer E. Ipratropium nebulizer
The clinical presentation suggests epiglotitis. This is an emergent airway condition. The anesthesiologist , or the pediatric otolaryngologist must be called to stand by to intubate or insert a tracheostomy if the patients airway closes. Racemic epinephrine via nebulizer relieves much of the edema to the upper airway in a patient with epiglotitis. It is a stabilizing measure until definitive care can be arranged. Oxygen and antibiotics should administered emergently also. No x-rays are indicated when the presentation is classic. Albuterol is a beta-agonist used for treatment of asthma. Budesonide,a steroid and ipratropium, an anticholinergic agent are most often used in combination with albuterol for treatment emphysema and asthma.
A 71 year old female presents with complaint of a severe headache for 2 days. The patient denies a history of headaches in the past. She complains of a 2 week periods of morning shoulder and pelvic stiffness. There also a history of jaw pain when she chews her food. The past medical history is remarkable for well controlled hypertension, hyperlipidemia. On physical exam there is a markedly tender scalp and left temporal artery. The neurologic exam is normal. Besides a temporal artery biopsy what other diagnostic test is most indicated?
The clinical scenario suggests giant cell arteritis (GCA) or temporal arteritis. An erythrocyte sedimentation rate( ESR) or C-reactive protein( CRP) can aid in the diagnosis of GCA when evaluating an inflammatory vasculitis such as GCA. Treatment is based on history and physical and not the result of the ESR. Temporal artery biopsy is the gold standard for diagnosis.
A 12-month-old female presents with bilateral lichenification, scaling, and excoriations in the antecubital fossae and popliteal fossae. Which of the following should treatment include?
The first line treatment for atopic dermatitis is a topical steroid, such as triamcinolone ointment. Oral hydroxyzine is an antihistamine that is used to control pruritis in atopic dermatitis. Clotrimazole/betamethasone diproprionate cream is a combination antifungal and topical steroid. There are no clinical indications for this medication. An antifungal such as ketoconazole is not indicated. The oral hydroxyzine is an antihistamine that is used to help control pruritis. Petroleum jelly is an excellent emollient; however, augmentin is not indicated unless there is a secondary infection. No infection is present in this patient.
The patient below comes to your office for a routine physical exam. She has no complaints. You note the following physical examination findings. There is an absence of tenderness with palpation. What is the most likely diagnosis?
The following finding represents xanthelasma, which is commonly associated with hyperlipidemia. In some familial hyperlipidemias, skin eruptions or nodules may form (xanthomas). Gout and rheumatoid arthritis are types of inflammatory arthritis and manifestations are more likely to be found around joints. Gouty tophi may also be found around the helix of the ear and are usually whitish in color in contrast to the yellow xanthelasma. There is no evidence of erythema consistent with cellulitis and the patient is asymptomatic. Lacrimal duct obstruction would likely be symptomatic and there would be tender swelling over the lacrimal duct.
You are evaluating an 80-year-old female for the first time. She has a history of mild Alzheimer's disease, for which she takes Aricept. She states that she feels fine but her daughter feels she is depressed and has been complaining of not feeling well. Her daughter admits that the patient has a history of primary hyperparathyroidism. What laboratory results would be most consistent with her diagnosis of hyperparathyroidism?
The hallmark of primary hyperparathyroidism is a high serum calcium and high intact PTH. A low intact PTH is consistent with hypoparathyroidism. The urine serum calcium is usually high in primary hyperparathyroidism. Cortisol is related to endocrine conditions affecting the adrenal cortex.
A 50-year-old male states that his eye is bothering him since yesterday. He complains of pain and redness. He states that he mowed his lawn yesterday and that it was windy outside. He attempted to irrigate the eye but still has significant irritation. He notes that it hurts to blink his eyes. What is the correct sequence of steps to treat this condition?
The history suggests a retained foreign body to the upper eyelid. A fluorescein stain will reveal significant superficial vertical scratches on the cornea. An upper eyelid eversion must be done, to inspect for and remove the foreign body. If the practitioner is successful in removing the foreign body, relief of the irritation will be immediate.
A 54-year-old female presents complaining of decreased visual acuity to her right eye over the past few hours. She denies pain, and describes having wavy vision and seeing flashes of light. Her visual acuity in the affected eye is 20/200. What condition best describes the following physical finding?
The image demonstrates a detached retina. The superior aspect of the retina appears wavy and flowing. A central retinal artery occlusion is characterized by a pale retina, as well as a cherry red spot on the macula. Open angle glaucoma does not cause acute vision loss. Angle closure glaucoma causes painful acute vision loss. Optic neuritis is characterized by painful visual loss and a swollen optic disc.
A 55-year-old male presents with severe swelling to his left eye. He denies injury or allergies. He states that he has had a severe sinus infection for the past two weeks. What is the most likely diagnosis for the following physical finding?
The image shows a severe orbital cellulitis. These infections often spread from paranasal sinus infections. Multiple pathogens may be involved, such as s.aureus, s. pheumoniae, and anaerobes. An eyelid abscess would be more localized. Allergic reactions that cause angioedema around the eye are usually bilateral, and also pruritic.
What is the most appropriate management for the lesion shown, which is noticed on a 50-year-old female?
The lesion is asymmetric with irregular margins. The optimal treatment of this lesion would be excision with 1 cm margins. A punch biopsy would only be performed if excision cannot be performed. Cryotherapy would destroy the lesion and prohibit a diagnosis and staging.
These lesions are visible on a 14-year-old female's forehead. What medication is this disorder best treated with?
The lesions are comedones (open and closed). Optimal treatment should be with topical retinoids such as tretinoin and adapalene, as these are comedolytic. Topical erythromycin is indicated in inflammatory acne, not comedonal acne as pictured. Benzoyl peroxide only has mild comedolytic activity and erythromycin has none. This combination medication would be more appropriate for inflammatory acne. Doxycycline has no comedolytic activity.
A 21-year-old man presents to the emergency department complaining of a swollen left ear (cauliflower) after he experienced blunt trauma in a collegiate wrestling match. Which of the following is the most appropriate management for this condition?
The patient has an auricular hematoma that must be evacuated to prevent cartilage necrosis or infection. answer: *Evacuation, antibiotics, and splinting* -remove the hematoma, minimize the risk of infection, and help prevent the re-accumulation of blood.
A 24-year-old female presents with hyperpigmented macules on her cheeks, nose, and upper lip. They have been present for a couple of months. Her current medications include oral LoEstrin 24 Fe, cetirizine, and a multivitamin daily. What is the most likely diagnosis?
The patient is experiencing melasma secondary to the use of oral contraceptives. This is a frequent cause of melasma. Melasma can also be precipitated by hormonal changes that occur during pregnancy. The condition will resolve upon discontinuation of the oral contraceptive. A congenital nevus is a nevus that presents within the first year of life. It is monitored in the same way as acquired nevi. They can be larger than acquired nevi, with only a slight increase in chance of malignant change over time. Post-inflammatory hyperpigmentation includes darker areas of pigmentation that can result after inflammation on the skin. Common causes include acne and atopic dermatitis. The hyperpigmentation will resolve over time. A Café-au-lait macule is a type of birthmark. It is usually light tan to light brown in appearance, and can vary greatly in size. They are usually benign, but can be associated with neurofibromatosis when more than six, with a diameter greater than 1.5 cm, are present.
A 25-year-old female presents with a complaint of dry, cracking hands for two months. She has never had any rashes or similar problems. She does not work outside the home. She is the mother of a 6-month-old healthy female. Over-the-counter lotions have been tried, but they sting with application. What is the next appropriate step?
The patient most likely has an irritant dermatitis, secondary to increased water exposure, from having an infant. Appropriate treatment includes a topical steroid, like triamcinolone. Ointments are better vehicles than creams, as they penetrate better and moisturize. Using petroleum based moisturizers are more effective than oil based in repairing the epidermis. There is no evidence at this point of an allergen causing the outbreak. If the disorder is resistant to treatment, then patch testing to determine the allergen may be an appropriate step. A punch biopsy is not indicated, unless there is no response to treatment. A KOH test would be indicated if the rash was suspicious for a fungal infection. If the patient does not respond to treatment with a topical steroid, KOH testing may be indicated.
A 45-year-old male presents with a history of thick, adherent yellow scaling in his scalp, and red scaling patches with fissuring in post auricular areas bilaterally. Which of the following are other areas of potential involvement?
The patient presents with seborrheic dermatitis. Other areas of potential involvement include the eyebrows, eyelashes, and beard area. Antecubital and popliteal fossae are common areas of involvement in atopic dermatitis; not seborrheic dermatitis. The palms and soles are not involved in seborrheic dermatitis. The trunk and neck are not usually affected in seborrheic dermatitis.
A 63-year-old female complains of a 5-day history of a persistent left-sided headache, which she has not experienced before. She also notes a tender swollen area around her left temple, which appeared around the same time. On examination you note tenderness and prominence of the left temporal artery. You order an ESR, which is 75 mm/h. What is your best course of action at this time?
The patient's history and physical examination findings point to giant cell arteritis (temporal arteritis) as the most likely cause, prompting immediate treatment with high-dose prednisone to prevent visual loss. The patient meets the criteria for clinical diagnosis of giant cell arteritis without a temporal artery biopsy, but it is recommended for definitive diagnosis due to the complications associated with long-term corticosteroid treatment. Treatment with prednisone should not be withheld while waiting for a temporal artery biopsy. NSAIDs and hydrocodone do not prevent the complications of temporal arteritis.
You are examining n 42-year-old male with the following physical examination findings (see picture below). What symptoms would most likely correspond to his diagnosis?
The patient's physical examination findings suggest acanthosis nigricans, a condition associated with diabetes mellitus. This patient would most likely present with polydipsia and polyuria at diagnosis. He may have weight loss and fatigue. Anxiety and palpitaions are not as likely to present symptoms of diabetes.
A 38-year-old male complains of increasing fatigue, weakness, weight loss, and intermittent nausea, vomiting, and diarrhea over the past few months. He has noted some agitation at times. When this first started he thought that this was related to a virus but the GI symptoms have reoccurred on multiple occasions. Labs show a complete blood count (CBC) within the normal reference range. He is noted to have hyponatremia. On examination you note the multiple areas of hyperpigmentation as seen below. His blood pressure in the office is 100/50, P = 66, T = 97.1˚F. What test would you order to confirm your suspected diagnosis?
The patient's symptoms and examination findings are consistent with a diagnosis of Addison's disease, which is most likely due to an autoimmune process that destroys the adrenal glands resulting in a chronic adrenal insufficiency. The cosyntropin (ACTH) stimulation test should reveal a low am cortisol level and an elevated ACTH level if he has Addison's disease. The dexamethasone suppression test, choice (A), is a laboratory test for Cushing's syndrome. The vasopressin challenge test, choice (B), is a laboratory test for diagnosis of diabetes insipidus. A radioactive iodine uptake scan, choice (C), is used in the diagnosis of thyroid disease (hyperthyroidism and thyroid nodules). A follicular stimulation test, choice (E), is a factitious test.
You are conducting a physical exam on a female, who was referred to you from an optometrist. She sought a visual screening due to progressive loss of visual acuity. She has not been seen by a physician in 10 years due to lack of insurance. She admits to a 15 lb weight gain in the past three years, and also complains of parasthesias in her feet. During an ophthalmoscopic exam you notice deep retinal microvascular hemorrhages, and cotton wool spots. What is the most likely cause of her visual disorder?
The patient's symptoms suggest a likelihood of diabetes. Retinal findings can include microaneurysms, deep hemorrhages, a flame-shaped hemorrhage, exudates, and cotton wool spots.
A 24-year-old female comes into the clinic complaining of a severe sore throat. She was seen three days ago at an urgent care facility, and was given amoxicillin. She states that the pain is worse, she is unable to drink fluids, and is now having difficulty swallowing. She talks with a muffled voice. A physical exam reveals a markedly swollen and erythemic right tonsil and tonsillar pillar, with the uvula deviating to the left. The patient has extreme difficulty opening her mouth. What is the most likely diagnosis?
The physical exam is highly suspicious for peritonsillar abcess, which must be considered first. Tonisllar cellulitis, or phlegmon, is swelling and enlargement of the tonsil and peritonsillar tissue, without the presence of fluctuant abcess. Uvulitis can exist with a peritonsillar abcess or tonsillitis, but isolated uvulitis usually includes symmetric swelling and erythema as a result of irritation (snoring), allergy (angioedema), or infection from upper respiratory pathogens. Diphtheria is a tonsillitis, with a characteristic gray pseudomembrane on the tonsils and upper airway, caused by corneybacterium diphtheriae.
An 8-year-old male with hair loss, pruritus, and posterior cervical lymphadenopathy has a + culture on dermatophyte test medium (DTM). Which of the following is the most appropriate treatment?
The positive DTM confirms the diagnosis of tinea capitis. The only approved treatment for tinea capitis is griseofulvin. In tinea capitis, the dermatophyte invades the hair shaft and topical treatment is not effective. An antifungal shampoo is often used as an adjunct to treatment. Keflex is an oral antibiotic, which will not help treat the fungal infection. Desonide is a topical steroid that will worsen the fungal infection.
What will fundoscopic exam reveal of the pt w/ retinal detachment?
There will be relative afferent pupillary defect. Fundoscopic exam may reveal the ridges (rugae) of the displace retina flapping in the vitreous humor
A 72-year-old farmer presents with multiple rough adherent scaly lesions on his scalp. They are better felt than seen. He reports mild pain when he inadvertently scratches them. What would the most effective management include for this patient?
These lesions are consistent with actinic keratoses. Treatment is indicated, as 10% of these lesions progress to squamous cell carcinoma. First line treatment is 5-Fu cream 5%. Excision is not indicated for actinic keratoses. Doxycycline is an antibiotic used to treat acne and various bacterial infections, and it is not an effective treatment for actinic Keratosis.
A two-year-old male presents with a noduleon the side of his index finger. His mother states that he has hadthis nodule on one prior occurrence during infancy, and it resolved onits own. What is the most likely diagnosis?
This child has a recurrent digital fibroma. It is a smooth, firm,pink nodule that occurs on the fingers and toes up through earlychildhood. Surgical excision is recommended so that the functionof the digit is not impaired.
A 5-year-old boy presents with a tense,fluid filled blister on his fingertip. What organism is most likelyto be found when the lesion is cultured?
This child has blistering distal dactylitis. This is a form ofimpetigo, and is caused by either streptococcuspyogenes or staphylococcus aureus.
A 12-year-old female presents with linearlydistributed light brown papules on her arm. They are asymptomaticand have been present for several years. The mother states that theyappear to grow as the child grows. What treatment is necessary?
This condition is consistent with a linear epidermal nevus. Theycan appear at any age, but are usually present at or shortly afterbirth. The pigmented papules are arranged linearly and can occuron any skin surface. They are not symptomatic and will grow withthe child. There is no treatment necessary.
A six-month-old infant presents to the primary care provider with complaints of a spreading rash. The physical exam shows multiple yellow-brown macules and plaques that urticate when stroked. What would an appropriate treatment regimen include?
This condition is consistent with urticarial pigmentosa, and it will resolve over time. However, certain things such as NSAIDS, codeine, and scopolamine, as well as extreme temperatures, can cause such reactions as anaphylaxis. This condition is frequently mistaken for child abuse, as the lesions can look like small finger sized bruises. It is consistent, however, with urticaria pigmentosa, which is an accumulation of mast cells in the skin, as indicated by urtication of the lesion after gentle stroking. Urticaria pigmentosa will resolve; however, it will take longer than a week to resolve. Ketoconazole cream is an antifungal that is used to treat fungal infections.
Cholesteatoma
This condition presents with granulation debris or keratin over the tympanic membrane. Variety of chronic otitis media, due to prolonged eustachian tube dysfunction. Creation of squamous epitherlium-lined sac filled with keratin, which may become chronically infected. Will usually erode bone (penetration of mastoid). May eventually erode inner ear, facial nerve, and spread intracranially (rare). Presents with epitympanic retraction pocket or marginal TM perforation that exudes keratin or granulation debris. Tx with surgical marsupialization or removal of sac.
How will papilledema look on fundoscopic exam?
This disc appears swollen and the margins are blurred with an obliteration of the vessels. The patient may be asymptomatic or may cmplain of transient visual alterations that last for seconds.
A two-month-old bottle fed infant female presents with a sharply demarcated scaling red rash on the face and in the diaper area. The mother reports that her child has been irritable and has had diarrhea. The primary care provider has treated with hydrocortisone 2.5% ointment bid for two weeks with no improvement. What should be the next step in confirming the diagnosis?
This infant is displaying classic signs of zinc deficiency. This disorder can occur in infants who are bottle fed. Treatment with topical steroids will not improve the condition until the zinc level is corrected. A punch biopsy would not help in diagnosing the zinc deficiency that this patient is exhibiting. Bacterial and viral cultures will not be helpful in establishing the diagnosis. A KOH is used to diagnose fungal infections. The KOH and bacterial culture will not be helpful in establishing the diagnosis of zinc deficiency.
A 26-year-old female presents with a history of a rash around her neck, off and on for several years. It has been treated with mid potency prescription topical steroids, only to recur again. She reports that during treatment she will discontinue wearing jewelry until the rash resolves. The patient complains of pruritis but no other symptoms. What is the most likely diagnosis?
This is a classic contact dermatitis, secondary to nickel allergy. Nickel is a very common metal that is contained in metals, clothing, and jewelry. It is a delayed, cell mediated hypersensitivity reaction, so it takes multiple exposures before an allergic response is exhibited. Atopic dermatitis is usually manifested prior to the age of six. The classic distribution is the flexural surfaces of the extremities. Herpes zoster presents with prodromal neuralgic pain two to three weeks prior to outbreak. The rash has vesicles and erythema in a dermatomal distribution that crust over after three to five days. The pain may last after resolution of the lesions. Presentation of tinea corporis is pruritic, annular scaling patches that enlarge with central clearing.
An 8-year-old male presents to his primary care provider with the onset of a new rash, consisting of small, oval, discrete scaling plaques on his trunk, and a large red plaque with overlying thin, silvery scales in the gluteal cleft. Which of the following is a potentially important historical finding in this patient?
This is a classic guttate psoriasis. An acute strep infection is a known precipitating factor of guttate psoriasis. All patients need to be checked and treated for a strep infection. Atopy has no correlation with guttate psoriasis. It is not caused by contact with an allergen or irritant. It is also not caused by an allergic reaction.
A 30 year old male presents with bright red erythema over her cheeks and nose after spending a week at the beach. She has had no prior rashes. She states that the rash is pruritic and she has had a low grade fever accompanied by lethargy. Lab results show a (+) ANA and anti DS-DNA with an elevated ESR. What is the most likely diagnosis?
This is a classic presentation of systemic lupus erythematosus (SLE). This autoimmune disorder is more common in women who are in their 20s or 30s. Frequently it is precipitated or worsened by sun exposure.
A mother presents with her four-month-old infant for a well child check. While examining the child, you notice ill defined bluish macules on the back and lumbosacral regions. What is the appropriate next step?
This is a common presentation of hypermelanosis, sometimes commonly referred to as Mongolian spots. These usually occur in patients with more pigmented complexions. They usually spontaneously resolve prior to the child entering grade school. Hypermelanosis can sometimes be mistaken for child abuse by an inexperienced practitioner; however, hypermelanosis is a common benign condition that occurs in patients with pigmented skin. There is no increased incidence associated with hypermelanosis, and no treatment is required or available.
An 8-year-old female presents with numerous discrete, skin colored papules with a central umbilication. The lesions are mildly pruritic. What is the most likely diagnosis?
This is classic presentation of Molluscum contagiosum. Molluscum primarily affects younger children, from infancy through elementary age. Lesions appear as pearly, skin colored papules with a central umbilication. They can be pruritic. Herpes simplex virus is described as a vesicle that crusts after a few days. Neurogenic pain is associated with the outbreak. The varicella zoster virus is chicken pox. These lesions are described as "a dew drop on a rose petal," due to the characteristic vesicle on a red base. They occur in crops, with some being vesicular and some being crusted. There is no umbilication. Comedonal acne primarily affects teens. These lesions are located on the face, back, and chest.
A 62-year-old female diabetic patient complains of a pruritic rash under her breasts. A physical exam shows an eroded red plaque with satellite papules. What is the most likely cause?
This is consistent with a yeast infection of the skin, caused by Candida albicans. Diabetic patients are particularly susceptible to these infections. A staph infection of the skin will have either honey colored crusting or inflammatory papules and pustules with erythema of the skin. A strep infection of the skin will have inflammatory papules and pustules with erythema of the skin. A herpes simplex infection will have vesicles that crust over after a few days. There is often preceding neurogenic pain prior to the outbreak.
A 6-year-old male presents with multiple lesions on his shins. The lesions are annular dermal plaques with a central depression. There are no epidermal changes. He states the lesions are asymptomatic. The child has no other medical problems and is a normal active child. What is the most likely diagnosis?
This is the classic distribution of granuloma annulare. These lesions commonly occur over bony surfaces and are thought to be secondary to minor trauma (such as playing soccer, normal play activities, or insect bites). The lesions will spontaneously resolve and no treatment is indicated. The distribution in this patient is similar to that of classic necrobiosis lipoidica; however, the dermal changes are classic for granuloma annulare. Necrobiosis lipoidica starts as brown-red plaques that evolve to become waxy appearing. They are commonly misdiagnosed as tinea corporis; however, there are no epidermal changes such as scaling. The lesions are completely dermal. Atopic dermatitis in a 6-year-old child is most commonly distributed on the flexural surfaces and consists of red scaling plaques that are pruritic.
A 7-year-old presents with vesicles withsurrounding erythema, located on the sides of his fingers and toesand in his mouth. He has a low-grade fever and has difficulty eating,secondary to pain. What is the most likely cause of this rash?
This is the classic eruption of hand-foot-and-mouth (HFM) disease,which is caused by the Coxsackie A16 virus. HFM is highly contagious.Patients will present with painful ulcerative lesions, which maymake it difficult to eat. There are also vesicles on the hands and feetthat are relatively asymptomatic. HFM may be associated with a low-gradefever, malaise, abdominal pain, and respiratory symptoms.
A 30 year old female complains of a dome shaped slightly erythematous nodule on her right thigh. Upon clinical examination it exhibits the "dimple sign". The patient states the lesion is not changing and is asymptomatic. What is the most likely diagnosis?
This is the classic presentation of a Dermatofibroma. The dimple sign is when a depression forms after the lesion is laterally compressed between the fingers
A 22-year-old complains of a spreading rash. He states it began about a week ago, with one large spot on his abdomen. Very shortly thereafter, the rash rapidly spread on his torso. The lesions are small oval red plaques with a collarette of scale. He states they are only mildly pruritic. What is the most likely diagnosis?
This is the classic presentation of pityriasis rosea. The large initial lesion is the herald patch. The ensuing lesions are small, oval, and have a collarette of scale. The lesions are distributed along Blaschkoe's lines, which is the "Christmas tree" distribution. Presentation of tinea corporis is pruritic, annular scaling patches that enlarge with central clearing. Guttate psoriasis presents as salmon-pink papules or small plaques with overlying fine silvery scales. Atopic dermatitis is usually manifested prior to the age of six. The classic distribution is the flexural surfaces of the extremities.
A 25-year-old female presents for a skin exam. She has no family history of skin cancer, and has no moles that itch, bleed, or ulcerate. She is concerned about a mole on her arm that is surrounded by a hypopigmented area. She states that the mole appears to be decreasing in size. What would appropriate management of the lesion include?
This lesion is consistent with a halo nevus. The depigmented macule that surrounds the nevus is similar to vitiligo and may consume the nevus; therefore, reassurance that this will resolve is appropriate for this patient. There is no need for excision with margins as this is not indicative of malignant changes. Hydrocortisone 2.5% ointment is a low potency topical steroid. This treatment is not indicated for a halo nevus. Ketoconazole is an antifungal used to treat fungal infections. There are no indications of fungal infection in this halo nevus.
The parents of a four-month-old child present with concern regarding a birthmark on the child's scalp and left side of face. The lesion has been present since birth and is growing. It has an orange, pebbly appearance. What is the appropriate treatment?
This lesion is consistent with a nevus sebaceous. It will grow as the child grows. After puberty, the lesion becomes thicker with a warty appearance. There is a slight increase in incidence of basal cell carcinoma as the patient ages. It is recommended that the lesion be excised prior to puberty, when these changes occur in response to hormone secretion. It is confined entirely to the skin; therefore, a CT is not necessary. Laser therapy is not an effective treatment for a nevus sebaceous. It requires complete excision. It also has an increased risk of basal cell carcinoma. It will not spontaneously resolve.
A 28-year-old male presents with a tan-pink, well-demarcated waxy plaque, with raised firm borders located in the pretibial region of the left lower extremity. What is the next appropriate step to confirm the diagnosis?
This lesion is consistent with necrobiosis lipoidica, and is associated with diabetes mellitus. The patient should undergo glucose tolerance testing to be evaluated for diabetes.
An 8-year-old male with a history of atopicdermatitis presents with a widespread rash consisting of vesiclesand eroded lesions. What is the causative organism?
This patient has eczema herpeticum. This is caused by the herpessimplex virus. Transmission can occur innocuously via the parent.Atopic dermatitis is a risk factor for eczema herpeticum, secondaryto the impaired barrier function of the skin. This impaired barrier functionallows the virus to spread rapidly.
A 78-year-old Caucasian female has a 3-year history of stiffness and achiness of bilateral shoulders and hips. She has been tested for rheumatoid arthritis in the past and has been found negative. Multiple radiographs of her hips and shoulders are unremarkable. She admits that she was placed on prednisone for an allergic reaction and noted a temporary resolution of her symptoms. For the past two weeks she complains of increasing symptoms now involving her neck and pain in her jaw with chewing. Today she noticed that her scalp is sore when she brushed her hair on the right side. What is the most feared complication of this condition that may be prevented with prompt diagnosis and treatment?
This patient has long standing symptoms of PMR with current symptoms suggestive of giant cell (temporal) arteritis. Visual loss is the most feared complication of temporal arteritis, but it can be prevented by prompt initiation of high-dose prednisone. PMR often occurs with or prior to development of temporal arteritis and is not considered a complication. Large vessel involvement--which may result in choices (B), (C), and (D)--is less common than temporal artery involvement in GCA. The patient does not have symptoms of large vessel involvement.
A mother presents with a four-month-old male infant complaining of a dry, itchy rash that never seems to completely resolve. There are days when it appears to improve. She currently uses baby wash and baby lotion to care for his skin. She recently discontinued the lotion because he screams when it is applied. Which of the following is this condition exacerbated by?
This patient has the classic presentation of infantile atopic dermatitis. There are numerous factors that can irritate this condition including frequent (more than once a day) or long baths, soap based cleansers, cold dry environments, illness, stress, itchy clothing, and allergies. Lotions may sting, especially if the skin is dry and the skin barrier is broken. Atopic dermatitis usually improves in warm, humid environments. Petroleum based moisturizers are an important part of the treatment of atopic dermatitis. Soap free cleansers are recommended for patients with atopic dermatitis, as they are less irritating and drying. Topical steroids are the first line treatment of atopic dermatitis.
Parents present with their 8-month-old childwith complaints of a new rash. This rash appears as monomorphic,flat, and red papules, some of which coalesce to form plaques. Theyare present on the face, buttocks, and extremities. What is theappropriate management of this condition?
This patient has the rash of Gianotti-Crosti. It is also calledpapular acrodermatitis of childhood. This rash starts with classicmonomorphic, flat, and red papules that coalesce to form plaques.It is symmetric in its distribution and classically affects theface, elbows, and knees. It will resolve on its own; therefore,no treatment is necessary.
A 12-year-old male presents with hyperkeratoticpapules located on both hands. What is the causative organism?
This patient has verruca vulgaris orthe common wart. The causative organism is the human papillomavirus(HPV). They can affect patients of any age and can occur on anyskin surface. There is a predilection for the hands and fingers.
A 4 year old male presents with a fever for 3 days. His highest temperature was 39.4C. His mother brings him to the ED because she noticed this morning that his palms and soles were red. Now, there is blotchy erythema on the trunk with bulbar conjunctivitis and diffuse erythema on the tongue and prominent papillae. CBC shows leukocytosis. What is the appropriate management of this patient?
This patient is exhibiting classic signs and symptoms of Kawasaki Disease. Complications of Kawasaki Disease include coronary artery aneurysms, myocarditis, myocardial ischemia or infarction, and stroke. Recommended treatment is hospitalization to monitor for complications and administration of IvIg with aspirin.
An 18-year-old male presents with a rashconsisting of erythematous target-like lesions on his arms. Physicalexam shows a healing cold sore on his lips, but no other skin or mucosallesions are present. What is the most likely cause?
This patient is exhibiting the classic rash of erythema multiformeminor. Etiology of this disorder can be traced to herpes simplexoutbreaks or other viral or bacterial infections. Recurrent diseaseis most often associated with herpes simplex outbreaks.
A 14-year-old female presents with a 24-hour history of episodic outbreaks on her hands and feet. She describes the outbreaks as beginning on the sides of her fingers and toes, with small intensely pruritic vesicles. What should be the next step in treatment?
This patient is experiencing probable dyshidrotic eczema. It is necessary to rule out a secondary bacterial infection, so a bacterial culture is necessary. It is also necessary to rule out a fungal infection or parasitic by performing a KOH. This does not have any features of a viral infection, so a viral culture is not necessary. A punch biopsy is also not necessary because it can be diagnosed with a non-invasive procedure. A shave biopsy is not indicated because non-invasive techniques can be used to diagnose. Shave biopsies are not indicated when vesicles are present.
A 6-year-old male presents with crusted erythematous lesions on the nose, mouth, and chin. He has a history of atopic dermatitis. Which of the following should be part of an appropriate treatment regimen?
This patient is suffering from impetigo. Impetigo is easily treated with a topical antibiotic, such as mupirocin. Hydrocortisone is a topical steroid and may worsen the infection. Lotrisone is a combination medication that includes an antifungal and a topical steroid, neither of which is indicated in this patient. Ketoconazole cream is used to treat fungal infections, not bacterial infections.
A 15-year-old obese male presents with annularlyconfigured lesions in a generalized distribution. They are asymptomatic.What can these lesions be associated with?
This patient presents with a generalized form of granuloma annulare(GA). Generalized GA can be associated with diabetes mellitus.
A 15 year old male presents with lesions on his palms, dorsum of his hands and lower arm. They began as red macules that developed a central vesicle of a few days. The lesions are pruritic with no other symptoms. What is the most common etiology?
This patient presents with the classic iris or target lesion of erythema multiforme (EM). The most common cause of recurrent EM is herpes simplex outbreak which usually precedes EM by a few days.
A six-month-old male has recurrent diaper rashes, which are not responding to ketoconazole cream or zinc oxide diaper creams. Physical exam shows well demarcated perianal erythema, with scattered red papules on the buttocks. A KOH is negative. What would appropriate management include?
This rash is consistent with a perianal staph or strep infection. This bacterial infection is easily treated with topical mupirocin. If the rash does not resolve after two weeks of topical treatment, treatment with an oral antibiotic such as Keflex is usually successful. Treatment with a topical steroid may worsen the infection. Tretinoin is a topical retinoid indicated to treat acne, and is not appropriate for this patient. Lotrisone is a combination medication that includes an antifungal and a topical steroid, neither of which is indicated in this patient.
A 16-year-old male complains of a recurrent rash that is noticed each year during the summer. He states that the rash is asymptomatic but is spreading. A physical exam shows small hypopigmented macules with fine scale. A KOH exam shows budding yeast. What is the most likely diagnosis?
Tinea versicolor is a yeast infection that primarily affects teens and young adults. The area of infection is usually the upper back, upper chest, and lower face. It occurs in warm, humid environments and can recur yearly. The appearance of the infection can be hypo- or hyper-pigmented, slightly scaling macules. The characteristic microscopic appearance on a KOH is described as "spaghetti and meatballs," due to the shortened hyphae and spores of the yeast. Atopic dermatitis in a teen patient would normally be described as red scaling plaques that affect the flexural surface. Atopic dermatitis is also described as being pruritic. Post inflammatory hypopigmentation occurs following an inflammatory reaction on the skin. The hypopigmentation is not scaling and will have a negative KOH. Tinea corporis can be hypopigmented and scaling, but usually exhibits central clearing and pruritis. It does not recur seasonally and affects exposed surfaces. A KOH will show branching hyphae and spores.
Dysfunction of Eustachian Tube
Tube that connects the middle ear to the nasopharynx. When compramised, air becomes trapped in the middle ear causing negative pressure, usually results from viral URI or allergies. Presents with aural fullness, fluctuating hearing, discomfort with barometric pressure changes. Yawning or swallowing may elicit a pop or crackle. Retraction and decreased mobility of TM is present. Tx with forced autoinflation (unless active intranasal infection is present). Use of systemic or intranasal decongestants and oxymetazoline. Prevent with intranasal corticosteroids for allergies. Avoid air travel, altitude changes or driving during active disease.
Pain, decreased hearing and bloody drainage from the ear after a recent diving trip is the most likely what diagnosis?
Tympanic membrane perforation due to barotrauma
Bacterial Keratitis
Type of Corneal Ulcer commonly seen in people who wear contacts while sleeping, or following trauma or surgery. MC pathogens are pseudomonas, pneumococcus, Moraxella and staph. Has hazy cornea with central ulceration and hypopyon. Tx with high concentration topic antibiotics (typically quinolones) for 48 hours. Add aminoglycoside if quinolone resistance is prevalent in the area.
Herpes Zoster Ophthalmicus
Type of Corneal Ulcer that frequently involves ophthalmic division of the trigeminal nerve. Patients present with malaise, fever, HA, and periorbital burning and itching. Symptoms may precede eruption by a day or more. Rash is vesicular, then pustules develop which quickly crust. Lesions of the tip of the nose or lid margins predict eye involvement. Ocular symptoms include conjunctives, Keratitis, episcleritis, anterior uveitis, elevated intraocular pressure. HIV is a strong risk factor. Tx with high dose acyclovir, valacyclovir, or famciclovir started within 72 hours of rash presentation reduces ocular complications and postherpetic neuralgia.
Herpes Simplex Keratitis
Type of Corneal Ulcer that has recurrent cases that may be observed with colonization of trigeminal ganglion. Dendritic (branching) ulcer is characteristic. Tx with debridement, patching, topical antivirals. Consider long term oral antivirals in specific populations.
acute sinusitis
URI leads to edema which blocks drainage of the sinuses leading to fluid buildup & bacterial colonization; commonly caused by strep pneumo, GABHS, H. flu, M. catarrhalis
Bacterial conjunctivitis
Unilateral purulent discharge
Peritonsillar Abscess
Unilateral sore throat, hot potato voice, trismus, displaced uvula. I&D
A 14-year-old female patient presents to your family practice clinic having received a 1% total body surface area first and second degree burn to the left forearm. Of the following, what would you recommend for your patient?
Unless a critical surface (face, genitalia or hands) is involved, first and second degree burns may be treated in the outpatient setting. Blisters may be left intact as a physiologic dressing, and deroofed after they rupture. The patient requires tetanus prophylaxis and a topical antibiotic cream, usually either silver sulfadiazine or bacitracin. Sulfadiazine may permanently stain skin, so use it cautiously in potentially exposed skin areas for cosmetic reasons.
Which of the following is a result of untreated or partially treated otitis media, which presents with fever, ear pain, otorrhea, tenderness behind the ear, fluid collection, and destruction of air cells seen on head CT?
Untreated or partially otitis media can result in mastoiditis. Tenderness, redness, and fluctuance over the mastoid bone is characteristic. Peritonsillar abcess symptoms include severe sore throat, drooling, dysphonia, and outpouching of the tonsillar pillar on the affected side and trismus. Ethmoid sinusitis presents with nasal congestion, discharge, and headache. Suppurative otits media is contained in the middle ear, without spreading to adjacent structures.
Corneal Abrasion
Usually a result of minor trauma, such as AZ fingernail, contact lenses, eyelash or small FB. Presents with severe pain and sensation of FB and may be accompanied by photophobia, tearing, injection, and blepharospasm. Record visual acuity BEFORE examination or treatment. Slit lamp or fluorescein stain will reveal defect but a clear cornea. Must search for FB. Tx with topical anesthetics for immediate relief; however, only to assist in confirming Dx, DO NOT PRESCRIBE. ABX ointment, Acetaminophen or NSAIDS for analgesia. Patching for no more than 24 hours, only for large abrasions (>5-10mm), longer than 24hrs retards healing. 1-2 day follow ups are essential.
Patient presents with acute onset of unilateral or bilateral erythema of the conjunctiva, copius watery discharge and ipsilateral tender preauricular lymphadenopahy. It started yesterday. What are you suspicious of?
VIRAL conjunctivitis
What condition is most likely in a patient with acute vertigo who was recently diagnosed with toxoplasmosis?
Vestibular neuronitis
Peripheral Causes of Vertigo
Vestibular neurotics/labryinthitis Menieres disease Benign positional vertigo Ethanol intoxication Inner ear barotrauma Semicircular canal dehiscence
In which type of Conjunctivitis is tearing "profuse?"
Viral
Is the most common cause of pharyngitis viral or bacterial?
Viral
Is the most common cause of sinusitis in adults viral or bacterial?
Viral
Acute onset of erythema of the conjunctiva Copious watery discharge Ipsilateral tender preauricular lymphadenopathy Highly contagious
Viral Conjunctivitis clinical features
What is left supraclavicular adenopathy called?
Virchows node (often associated with lung/gastric malignancy)
A 12-year-old presents with sharply demarcated depigmented macules on bilateral knees. The parents report that this began about one year ago, after the child fell and skinned his knees. After healing, he was left with these markings. What is the most likely diagnosis?
Vitiligo is the most likely diagnosis. Vitiligo is an autoimmune disorder that affects the melanocytes. There is often a history of trauma that can precede an occurrence of vitiligo. The course for vitiligo is variable. Sometimes it will resolve spontaneously. Other times, it will continue to progress despite treatment. Post-inflammatory hypopigmentation are areas of lighter pigment, not complete depigmentation, which result from a resolved inflammatory process. The pigment will return over time. A hypertrophic scar is one which is enlarged but stays within the borders of the original injury. No pigment changes are associated with these scars. Pityriasis alba is a yeast infection of the skin, and usually appears on the face. It usually occurs in elementary school aged children, and is more apparent in late summer or early fall.
8 - If hearing trouble
Weber Test - strike tuning fork and place on midline of skull - where do you hear it loudest? - Sound will be louder on affected side **"CONDUCTIVE" hearing loss
ultraviolet keratitis
Welder's flash; severe pain 6-12 hrs after exposure; treated with cyclopentolate
Macular Degeneration can be described as either "wet" or "dry". Which happens quickly?
Wet happens quickly. Due to neovascularization
Topical steroids
What do you avoid with herpes of the eye?
DONT remove object Ophthalmology referral Analgesics Prophylactic antibiotics
What do you do with penetrating trauma to the globe?
Dendritic lesions on fluorescein stain
What do you see with herpes of the eye?
You are examining a 65-year-old male who complains of partial vision loss in his right eye. Besides obtaining visual acuity, what is the most important physical exam to perform in order to evaluate his condition?
When a patient complains of vision loss, all of the choices are important parts of the eye examination; the visual field by confrontation exam is a screen to detect visual field defects.
Blepharitis
When bacterial in origin, this inflammatory eyelid condition is usually caused by Staphylococci. Chronic inflammation of the eyelid margins. Caused by seborrhea, strep or Staph infection, dysfunction of the meibomian glands. Anterior involves the eyelid, lashes and nearby glands. May become ulcerative due to infection with sataph, or seborrheic due to seborrhea of the scalp, brows, and ears. Posterior results from meibomian gland inflammation. Staph may also cause infection in the posterior type. Glandular dysfunction in posterior type is strongly associated with acne rosacea. May present with irritation, burning, and itching of the eyelids. Anterior presents as "RED RIMMED" eyes with scales or granulations adhering to lashes. Posterior presents with hyperemic lid margins with telangiectasias, inflamed meibomian glands and ducts, abnormal secretions, FROTHY or GREASY tears, and mild entropion. TX with lid scrubs using baby shampoo on cotton tip swab and/or topical antibiotics if infection is suspected.
Leukoplakia
White lesion of the tongue that cannot be scraped off the mucosal surface. Hyperkeratosis in response to chronic irritation (dentures, tobacco, lichen planes). Up to 6% of lesions are dysplastic or early Squamous cell carcinoma. Presents with a white lesion that cannot be scraped off the mucosal surface. Dx with biopsy, reveals Hyperkeratosis. No approved treatment available.
Oral leukoplakia
White patched. Cant be scraped. Pre-cancerous. Biopsy
What anatomical location is the most common site of posterior epistaxis?
Woodruff's Plexus is the most common site for posterior nose bleeds
A 12-year-old male exhibits prominent brownscaling on his neck, trunk, and extremities with involvement offlexural regions. The palms and soles are spared. What is the most likelydiagnosis?
X-linked ichthyosis is a recessive condition affecting males.The patient will have large scales that appear brown in color. This condition spares the palms and soles, and begins between the ages of two to six weeks.
Do thyroid masses move with swallowing.
Yes
Does thyroglossal duct cyst move with tongue protrusion?
Yes
acidic
_____ burns of the eye cause coagulative necrosis
alkali
______ burns of the eye are the worst type of chemical burns; denatures proteins & collagen & causes thrombosis of vessels
posterior (blepharitis)
_______ blepharitis is caused by a dysfunction of the meibomian gland; treated with eyelid massage
posterior
_______ lymphadenopathy is seen with mono
anterior
_______ lymphadenopathy is seen with strep pharyngitis
A "Stye" is AKA . . .
a Hordeolum
What usually precedes otitis media?
a URI that leads to eustachian tube dysfunction or blockage
cavernous sinus thrombosis
a blood clot in an area at the base of the brain, in the cavernous sinus, that contains a vein, which carries blood from the brain to the heart
what is the number one cause of optic neuritis
a demyelinating disease i.e. mutiple sclerosis
blow out fracture
a fracture of one or more of the bones surrounding the eye and is commonly referred to as an orbital floor fracture
dental abscess
a localized collection of pus associated with a tooth
what are the findings of hypertensive retinopathy on fundoscopic exam
a/v nicking, copper/silver wiring, papilledema, flame hemorrhages, cotton wool spots
cholesteatoma
abnormal growth of squamous epithelium leading to mastoid bony erosion; causes epitympanic retraction pocket & TM perforation; treated with surgical excision
arterial narrowing
abnormal light reflexes on dilated tortuous arteriole shows up as colors- copper/silver; seen with hypertensive retinopathy
sx of vertigo
accelerated with movement nystagmus peripheral: sudden, N/V, tinnitus, hearing loss, horizontal nystagmus central: slower onset, nonfatigable nystagmus, motor or sensory defecitis accompany
acute angle closure glaucoma tx
acetazolamide to lower pressure and once pressure drops then start topical pilocarpine
vestibular schwannoma
acoustic neuroma; common benign intracranial tumor; causes central vertigo & unilateral hearing loss; treated with microsurgical excision or sterotactic radiotherapy
eye pain, blurred vision, halos, steamy cornea, hard globe. what dx
acute angle closure glaucoma
bacterial rhinosinusitis
acute sinus infection; caused by strep pneumoniae, H. influenzae, S aureus, M. catarrhalis; causes facial pain/pressure, fever, headache, fatigue, cough
sx of dacryoadenitis
acute: rapid, unilateral, severe pain, redness, and pressure in the supratemporal region chronic: MORE COMMON, uni/bilateral, painless enlargement of the lacrimal gland present for more than a month looks like swelling of the lateral third of the upper lid (S-shaped lid)
viral conjunctivitis
adenovirus 3, 8, 19 HIGHLY CONTAGIOUS, even by swimming pool
typical cause of viral conjunctivitis
adenovirus 3, 8, or 19
postseptal cellulitis tx
admit to hospital IV 2nd or 3rd gen ceph, ampicillin/sulactam, carbapenems, clinda
tx of orbital cellulitis
admit, broad spectrum AB (staph and strep most commonly)
cause of macular dengeration
age, toxic effects of drugs (chloroquin/phenothiazine)
results of a normal rinne test
air conduction is greater than bone conduction. the patient hears the fork when placed beside the ear
ocular antihistamines used for
allergic conjunctivis
IgE mediated reactivity to airborne antigens (pollen, molds, dust). commonly occurs in people who have other atopic dz and those with fam hx.
allergic rhinitis
tx of OM
amoxicilin or azithromycin recurrent (x3 in 6 months) --> tubes if untx risk of mastoiditis --> IV ABs
AOM tx
amoxicillin 2nd line: amoxi/clav, cefaclor, cefixime, erythromycin
In sinusitis, antibx can be recommended in extended duration of symptoms... >10days or severe symptoms such as facial pain. What is the first line drug?
amoxicillin usu. 7-10 days azithromycin, bactrim or doxy can be used in penicillin allergy. augmentin may be used if there is no improvement after 3 days of first line agents or w/ recent antibx use.
hordeolum
an acute, painful staphylococcal abscess of the eyelid; treated with warm compress &/or antibiotic ointment
Mc location of epistaxis
anterior
he source of most cases of epistaxis comes from what anatomic location?
anterior nasal septum-95 percent of epistaxis come from Kesselbach's plexus, which is a superficial, fragile group of arterioles and veins that are the most likely cause of nosebleeds. Five percent are posterior bleeds that originate along the sphenopalentine artery.
keisselbach's plexus
anterior nose bleeds come from __________; most common site of nose bleeds
periorbital cellulits
anterior to orbital septum (so limited to eyelids) -from trauma, skin infection
anterior/ posterior glenohumeral shoulder dislocation
anterior-sx- arm abducted, externally rotated -dx- axillary and Y view determine anterior vs. posterior -tx- reduction, must rule out axillary nerve injury (pinprick over deltoid) posterior- adducted, associated with siezure, shock -tx- reduction
uveitis
anterior: inflammation of iris (iritis) or ciliary body (cyclitis) posterior: choroid inflammation etiology: systemic inflammatory disease: may be associated with HLA-B27 spondyloarthropathies, sarcoid, Behcets disease infectious: CMV, toxoplasmosis, syphilis, TB trauma anterior: unilateral ocular pain/redness/photophobia; excessive tearing but no discharge - blunt trauma posterior: blurred/decreased vision, floaters, absent sx of anterior involvement, no pain PE: ciliary injection (limbic flush), consensual photophobia, possible visual changes, inflammatory cells and flare within aqeuous (WBCs and protein) - topical steroids for anterior, homatropine - systemic steroids for posterior
anterior vs posterior blepharitis
anterior: staph infection, viral or seborheic posterior: dysfunction of meibomian glands
tx of otitis externa
antibacterial drops, keep dry if immunocompromised or DM risk of malignant OE --> IV AB
ofloxacin
antibiotic ear drops used to treat otitis externa & chronic otitis media; 5 drops QD x7 days (6mo-13yr), 10 drops QD x7 days (13+)
treatment for corneal abrasion
antibiotic ointment like polymyxin/bacitracin. acetaminophen for analgesia. patching only for large abrasions greater than 5 - 10 mm.
amoxicillin
antibiotic used to treat acute otitis media & serous otitis media
nafcillin
antibiotic used to treat most orbital cellulitis
flagyl/clindamycin
antibiotic used to treat orbital cellulitis caused by an anaerobic bacteria
ceftriaxone/cefazolin
antibiotics used to treat orbital cellulitis caused by trauma
What is the treatment for labrynithitis?
antibx are indicated with assoc fever or signs of bacterial infection vestibular suppressants are helpful during acute sx
Your patient presents with redness and swelling of the ear canal, and pain with movement of the auricle. You diagnose OE. What is your treatment plan?
antibx otic drops (aminoglycoside or fluoroquinolone + steroids) and avoid further moisure or ear injury
tx for allergic conjunctivitis
antihistamines topical steroid mast cell degranulation inhibitor
valganciclovir/foscarnet
antivirals used to treat CMV retinitis
tx for epistaxis
apply pressure 10-15 minutes can cauterize or pack
What is the tx for PTA?
aspiration, I&D and antibx. tonsillectomy considered.
what drugs are associated with increased tinnitus
aspirin and NSAIDS
blepharitis
associated with seb derm and rosacea. crusting/flaking eyelid rims "red swollen lids" usually staph tx: warm compresses
sx of TMP
audible whistling sounds during sneezing and nose blowing, decreased hearing, increased ear infections if with infection: painful, purulent drainage
dx of meniere's ds
audiogram caloric stimulation (will be abnormal)
What is the treatment for allergic rhinits?
avoid any known allergens and use antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes and immunotherapy
tx of blepharitis
baby shampoo topical AB if infected
sialadenitis
bacterial (S. aureus) infection most commonly affecting submandibular & parotid glands; causes swollen, red & tender gland; treated with nafcillin
acute otitis media
bacterial infection of middle ear; caused by strep pneumoniae, H influenzae, or strep pyogenes; causes erythema & decreased mobility of tympanic membrane & bulging; treated with amoxicilin
periorbital cellulits
bacterial infection of the skin surrounding the orbital area; causes swelling, tenderness & erythema; normal eye exam; tx w/ oral antibiotics
Patient presents with purulent nasal dc, facial pain and pressure, nasal obstruction, congestion and fever. Likely dx?
bacterial sinusitis
bacterial vs viral vs chlamydial vs allergic
bacterial: minimal itchy, generalized bright red, moderate tearing, profuse discharge, no adenopathy, occassional sore throat and fever viral: minimal itchy, generalized hyperemia, profuse tearing, minimal discharge, common preauricular adenopathy, occasional sore throat and fever chlamydial: minimal itchy, generalized hyperemia, moderate tearing, profuse discharge, never sore throat or fever allergic: severe itching, generalized milky hyperemia, moderate tearing, minimal discharge, no adenopathy or sore throat
brachial cleft cyst
benign. SIDE OF NECK tx by excision
vertigo symptoms that are brought on by changing in position of the head. dx?
bernign paroxysmal positional vertigo
treatment for open angle glaucoma
beta blockers, prostaglandin analogs (latanoprost). carbonic anhydrase inhibitors, and alpha agonists
tim/carte-olol
beta-adrenergic blocking agents used to treat chronic glaucoma
raccoon eyes
bilaterial periorbital ecchymosis seen with basilar skull fracture; diagnosed fracture with CT
cause of cholesteatoma
birth defect chronic ear infection
what shows on fundoscopy for a cataract
black on a red background
sx of hyphema
bleeding eye pain photophobia vision abnormalities
blot & dot hemorrhages
bleeding into the deep retinal layer; seen with nonproliferative diabetic retinopathy
flame-shaped hemorrhages
bleeding into the nerve fiber layer; seen with nonproliferative diabetic retinopathy
oral candidiasis
bleeds after scraping off erythematous base DM or HIV? Tx: fluconazole
Patient presents with "red rimmed eyes" and adhered eyelashes with dandruff like deposits (scurg) and fibrous scales (collarettes) on exam. The conjuncitva is clear but there is thick cloudy dc visible. What is the likely dx?
blepharitis
scotomas
blind spots, shadows; seen with macular degeneration
retinal hemorrhages
blood & thunder appearance seen with retinal vein occlusion
subconjunctival hemorrhage
blood between conjunctiva & sclera; generally asymptomatic; no treatment is required
Hyphema
blood in anterior chamber trauma HOB 30 degrees
hyphema
blood in anterior chamber of eye (behind cornea, in front of iris)
whats a hyphema
blood in the anterior chamber following trauma
dx of dacryoadenitis
blood/discharge culture lacrimal gland biopsy (if doesn't subside after 2 weeks) r/o sarcoidosis, graves, sjogrens, syphilis, gonorrhea CT
Allergic shiners are...
bluish discoloration below the eyes
sx of retinal detachment
blurred/blackened vision, curtain falling, floaters, flashing lights
allergic rhinitis
boggy turbinates blue allergic shiners allergic salute IgE RAST test = radio allergosorbent test
results of an abnormal rinne test
bone conduction is greater than air conduction; patient does not hear the fork placed beside the ear
labyrinth
bony & membranous part of the inner ear, consists of cochlea & vesibular system
otosclerosis
bony overgrowth of the stapes bone leading to conductive hearing loss; presents with slowly progressive hearing loss & tinnitus; treated with a stapedectomy with prosthesis
complications of cholesteatoma
brain abscess, meningitis
In macular degeneration, drusten deposits are found in the ____ membrane, leading to degenerative changes, loss of nutritional supply, atrophy and neovascular degeneration.
bruchen
sx of cavernous sinus thrombosis
bulging eye HA loss of vision
bunion/ hammer toe
bunion- hallux valgus- deformity of bursa over 1st metatarsal - hammer toe- deformity of PIP joint with flexion of PIP joint and hyperextension of MTP and DIP joint
glossodynia
burning & pain of the tongue; caused by DM, meds, tobacco, candidiasis; treated with alpha-lipoic acid & clonazepam
sialolithiasis
calculus (stone) formation in salivary glands; more common in Wharton duct; causes post-eating pain & local swelling; teated with removal or lemon drops
bullous myringitis
caused by mycoplasma pneumoniae; causes erythematous & blistering TM; treated with azithromycin & augumentin
gingival hyperplasia
caused by: CCB, phenytoin, cyclosporine
orbital cellulitis
cellulitis involving tissues that surround the orbital area as well as structures of the eye; causes fever, redness, swelling/pain of periorbital tissues & decreased vision; treated with IVantibiotics
ludwig angina
cellulitis of sublingual & submaxillary spaces; usually secondary to dental infections; can be caused by strep, staph, etc.; causes edema & erythema of upper neck under chin & floor of mouth, tongue displaced; treated with securing airway, & IV antibiotics
CHERRY RED SPOT =
central retinal artery occlusion
Opthalmic emergency with poor prognosis even w/ immediate treatment.Patient presents with sudden painless and marked unilateral loss of vision. Fundoscopy reveal pallor of the retina, arteriolar narrowing, separation of arterial flow (box carring) , retinal edema, and periofoveal atrophy (cherry red spot). Dx?
central retinal artery occlusion
Your 66 year old female presents with sudden, unilateral painless blurred vision or complete visual loss. Exam reveal an afferent pupilarry defect, optic disc swelling and a *blood and thunder* retina. Likely dx? central retinal artery or central retinal vein occlusion?
central retinal vein occlusion
vascular compromise
central vertigo; common cause of vertigo in the elderly; triggered by change in posture or neck extension; treated with aspirin or vasodilators
pure vertical, pure horizontal, or pure rotary nystagmus almost always represents
central vestibular dysfunction
what abx can be used to prophylax in epistaxis
cephalexin, augmentin, clinda, bactrim
granulomatous inflammation of meibomian gland. what dx?
chalazion
painless, red hard, contender swelling on eye lid. what dx
chalazion
otitis externa
cheesey, painful must visualize TM before gtt abx NO GTTS IN RUPTURED TM use ear wick
what do you see on the fundoscopic exam for central retinal artery occlusion
cherry red spot, arteries appear bloodless, embolic obstruction
This bacteria causes bacterial conjunctivitis and patients will usu. present with mucopurulent dc with a marked follicular response on the inner lids. Nontender preauricular adenopathy is noted
chlamhydia
otalgia, pruritus, brown/yellow discharge with strong odor. what dx?
cholesteatoma
pilocarpine
cholinergic agonist used to treat acute angle-closure glaucoma
pinguecula
chronic actinic exposure, repeated trauma, dry/windy conditions yellowish on sclera ADJACENT TO CORNEA, painless
dx of acute sinusitis
clinical CT if chronic and resistant to tx
schaffer's sign
clumping of pigment cells in the anterior vitreous; seen with retinal detachment
viral conjunctivitis
cobblestoning MCC = ADENOVIRUS self limiting watery d/c
thyroid nodule
cold (CA) not (not CA) order FNA. MCC = radiation
pyogenic granuloma
common skin growth; shiny red mass in the mouth; treatment may or may not be necessary
bacterial pharyngitis
commonly presents with a fever, sore throat, petechiae on pharynx, sandpaper-like rash, strawberry tongue & tonsillar hypertrophy/exudate/erythema; diagnosed with a rapid strep test & culture
viral pharyngitis
commonly presents with a sore throat with additional URI symptoms without tonsillar exudate; treated with supportive care & salt water gargles
Chornic OM may result in what kind of hearing loss?
conductive
pterygium
conjunctiva grows in a triangular shape onto the nasal side of the cornea; treatment often not necessary, artificial tears, topical NSAIDs or low dose steriods
eustachian tube
connects middle ear to nasopharynx
allergic conjunct tx
cool compresses topical vasoconstrictors or antihistamines topical mast cell stabilizer
viral conjunct tx
cool compresses vasoconsticture, antihistamine artificial tears
sx of bacterial conjunctivitis
copious purulent discharge, decreased visual acuity, discomfort, glued shut on awakening
Slit lamp examination of the eye reveals an epithelial defect but a clear cornea. What is the likely dx?
corneal abrasion
Your 21 year old patient is complaining of a feeling of a "foreign-body sensation" in their eye, but nothing is there. She wears contacts. What is the likely dx? (chalazion, corneal abrasion, hordeolum)
corneal abrasion
avoid patching if
corneal abrasion d/t organic material or soft contact lens
what tests can be used to diagnose strabismus
corneal light relfex aka hirschburg test and the cover-uncover exam
what is the treatment for optic neuritis
corticosteriods, especially if multiple sclerosis is suspected
Bell's palsy affects What cranial nerve?
cranial nerveVII, the facial paralysis conforms to the all branches of the peripheral nerve including the side of the face, eyelid and forehead muscles.
treatment for orbital cellulitis
ct of orbits, IV antibiotics, ophthalmology consult
treatment for corneal abrasion
cycloplegics - dilates pupils and relieves pain topical antibiotics- erythromycin pressure patch? - may help with comfort and photophobia cover for pseudomonas in soft contact lens wearers- tobramycin or flouroquinolone NO TOPICAL ANESTHETICS
corneal abrasion tx
cycloplegics to dilate pupil and relieve pain topical abx (erythromycin or tobramycin or fluoroquinolone f/u 24 hr and avoid contacts for 1 week
cholesteatoma
cyst in the middle of ear and skull bone, TM retracts due to cyst and tissue/skin fills in space
CMV retinitis
cytomegalovirus attacks the eye; less common when HIV is treated; causes retinal opacification, retinal hemorrhages; treated with valganciclovir, ganciclovir, foscarnet
esotropia
deviating eye turns inward
exotropia
deviating eye turns outward
What are the RFs for having a central retinal VEIN occlusion?
diabetes, hyperlipidemia, glaucoma, hyperviscosity states (polycythemia, leukemia)
What is the leading cause of blindeness in adults in the USA?
diabetic retinopahty
monospot
diagnostic test for infectious mononucleosis
What are the signs of hypertensive retinopathy?
diffuse ateriolar narrowing, copper or silver wiring, arteriovenous nicking (artherosclerosis)
MC cause of epistaxis
digital trauma
spread of bacterial conjunctivitis
direct contact--can infect other eye, fomites
dx of epiglottitis
direct visualization of epiglottis is dx but manipulation may initiate sudden fatal airway obstruction CBC, epiglottic cultures, after airway secure thumbprint sign on lateral neck radiograph
Critical: Optic disk
disc is yellowish-orange, margins are sharp cup to disc ratio is 1 to 2.
tx of meniere's ds
diuretics NaCl restriction
dx of vertigo
dix hallpike maneuver + with peripheral vertigo audiometry caloric stimulation CT/MRI
what test to dx BPPV
dix halpike
how to diagnose bppv
dix-hallpike maneuver
sx of cholesteatoma
dizzy, ear drainage, hearing loss, perforation
stensen duct
drains parotid glands
wharton duct
drains submandibular glands; most common duct for sialolithiasis
peritonsillar abscess
drooling, hot potato voice, deviatio of uvula toward abscess Tx: I&D, clindamycin
epiglottitis
drooling, tripod, thumb print sign on lateral x-ray
FB ear:
drown bug in lidocaine kids with chronic smelly otorrhea
what is the most common type of macular degeneration
dry (atrophic)
keratoconjuncivitis sicca
dry eyes; treated with artificial tears, restasis
If a chronic dacryocystitis, what other intervention may be warrented?
duct cannulation, dacryoplasty, stenting, other surgery
debrox
ear solution that softens wax; used to treat cerumen impaction; Generic Name: carbamide peroxide
The edge of the eyelid everts secondary to advanced age, trauma, infection or palsy of the facial nerve. Is this an entropion or an ectropion?
ectropion
Ectropion/entopion
ectropion- eye lid turned outward entopion- eye lid turned inward
What are the RFs for developing a central retinal artery occlusion?
emboli, thrombotic phenomenon and vasculitides
orbital cellulitis
emergency infection of tissue behind eye proptosis pain with movement decreased EOM
What is the treatment for retinal detachment?
emergency optho to discuss laser surgery or cryosurgery remain supine with head turned to the side of the retinal detachment
What is the trx for a central rentinal artery occlusion?
emergency optho. recumbent position an dgentle ocular massage. vessel dilation and paracentesis are attempted to save the eye. Work up and mgmt of artherosclerotic dz or arrythmias is warranted to reduce the risk of reccurence
menieres affects what part of ear
endolymphatic compartment of inner ear
thumbprint sign
enlarge epiglottitis seen on X-ray
double vision in blowout fracture is due to what
entrapment of inferior rectus muscle
The lid and lashes are turned in secondary to scar tissue or a spam of the orbicularis oculi muscles. Is this an entropion or an ectropion?
entropion
how to treat bppv
epley maneuver
cholesteatoma
erosion of ossicles from long term retraction of TM hearing loss requires surgery
corneal ulcer
erosion of the cornea; causes pain, photophobia, tearing, & reduced vision
corneal ulcer
erosion or sore of the outer layer of the cornea (usually from infection)
sx of viral conjunctivitis
erythema of conjuctiva, copious watery discharge, tender PREAURICULAR lymps
What is the tx for BACTERIAL laryngitis?
erythomycin, cefuroxime or augmentin oral or IM cortico steroids can hasten recovery for performers but req. vocal coard eval
glycosylation
excess sugar attaching to proteins such as the collagen of the blood vessels; leads to diabetic retinopathy
what predisposes a person to cataract development
excess sun
vertigo
experience of false sensation of movement
Acute/chronic otitis media/ externa
externa MC- Pseudomonas. otitis media= Step Pnuemonia***= infection of middle ear, temporal bones and mastoid air cells. MC preceded by URI** URI CAUSES EUSTACHIAN TUBE EDEMA- NEGATIVE PRESSURE- TRANSUDATION OF FLUID AND MUCOUS IN MIDDLE EAR, COLONIZATION BY BAC. -sx- tender tragus/oracle -tx- externa- Keep dry+ ciproflomacin (if TM perforated= ofloxacin)= immuno compromised (foul discharge)--- CT--- hospitalization+ antibiotics media- amox, augmentin
This is caused by the inflammation and infection of the glands of the Moll or Zeis, with pustular formation in those glands. They are situated immediately adjacent to the palpebral margin. Is this an internal or extrenal hordeola? (STYE)
external
treatment for cataracts
extraction and lens replacement
What is the tx for viral conjunctivitis?
eye lavage with normal saline twice a day for 7 to 14 days, vasoconstrictor-antihistamine drops warm to cool compresses ophthalmic sulfonamide drops
tx of viral conjuctivitis
eye lavage with normal saline x 2 days vasoconstrictor-antihistamine warm/cool compress sulfonamide drops to prevent bacteria
Pts with retinal detachment may complain of a "curtain" falling over their eye, or if smaller, they may complain of...?
flashes of light Floaters
corneal abrasion or ulcer
flourescein stain contacts? think PSEUDOMONAS Tx: tobramycin for abrasion ophth referral for ulcer
cotton wool spots
fluffy, gray-white spots from micro-infarction of the nerve fiber layer; seen with nonproliferative diabetic retinopathy
-floxacin
fluoroquinolones used to treat bacteria keratitis (levo/o/nor/cipro)
atrophic candidiasis
follows thrush or antibiotic use; causes oral mucosal burning & sensitivity to foods; treated with antifungals
vestibular neuronitis
follows viral infection n/v, vertigo DOES NOT AFFECT HEARING
80-90
for acute otitis media, amoxicillin is given at _______mg/kg/day BID x 10-14 days
removal of ear foreign body
forceps, irrigation but not if material is organic; 2% lidocaine if the insect is live
proptosis
forward protusion of the eye; occurs in 50% of pts with hyperthyroidism; treated with systemic steroids, radiotherapy or surgical decompression
retinal detachment vs amaurosis fugax
fugax: transient detach: continuous until surgery to fix it
how to diagnose retinal detachment
fundoscopic exam and ultrasound
how to diagnose central retinal artery occlusion
funduscopic exam is usually confirmatory; fluorescein angiography. once the diagnosis is made, a carotid doppler and echo should be done to locate embolic source
mucormycosis
fungi that invades the sinuses & may enter the CNS; seen in immunocompromised patients; treated with amphotericin B
laryngopharyneal reflux
gastroesophageal reflux into the larynx; causes chronic hoarseness/cough, throat discomfort, asthma
monocular vision loss is seen in:
giant cell arteritis retinal artery occlusion multiple sclerosis
what is a possible consequence of a hyphema
glaucoma by obstructing the trabecular meshwork
do not palpate eye if suspect
globe rupture
treatment of labyrinthitis
goes away on its own; meclizine, antihistamine
Macular degeneration
gradual CENTRAL vision loss DRY DRUSDEN causes: age, smoking
atrophic (dry) degeneration
gradual breakdown of the macula leading to gradual blurring of central vision; presents with drusen; treated with amsler grid & vitamins to slow progression
What is the chief clinical feature of macular degeneration?
gradual loss of central vision
central vertigo
gradual onset of "dizziness"; becomes progressively worse & debilitating; causes vertical nystagmus, gait ataxia & CNS symptoms
atrophic (dry) mac degen ssx
gradual progressive drusen (yellow deposits) retinal pigment atrophy
dx of bacterial conjunctivitis
gram stain
What diagnostic tests are indicated in bacterial conjunctivitis?
gram stain if rare bacteria is suspected, gram stain and giemsa stain
chronic sinusitis lasts how long
greater than 12 weeks
diptheria
grey pseudomembrane Tx: Antitoxin, erythromycin
Hair and scalp palpation
hair texture is normal, scalp has no scaling, lesions or areas of tenderness
What is the tx for bacterial conjunctivitis?
hand washing, application of topical antibx (gentamicin, tobramycin, ciprofloxacin, ofloxacin) rare pathogens may need systemic antibx (azithromycin, penicillin etc)
coxsackievirus
hand, foot & mouth disease seen in children
what are the findings of diabetic retinopathy on fundoscopic exam
hard exudates, micro aneurysms,
A 45-year-old male presents with purulent discharge from his right ear for three weeks. He states that despite being treated by his family doctor for an ear infection one month ago, the problem continues to get worse. Upon exam, you note purulent discharge in the ear canal, an erythemic tympanic membrane, and a possible perforation. What are the pathogens most likely to culture positive?
he clinical vignette describes a chronic otitis media. Usually, this refers to a complication of acute otits media with perforation. Pathogens that culture from these infections are usually pseudomonas, proteus, or staphylococcus aureus. Strep pneumoniae is often seen in acute otitis media. E.coli is a urinary tract pathogen. Candida albicans is a cause of vaginitis, and mycoplasma is a respiratory pathogen.
Menieres disease
hearing loss vertigo tinnitus aural fullness
hereditary hearing loss
hearing loss that is seen in children; 2/3 are nonsyndromic & 1/3 are syndromic
conductive hearing loss
hearing loss usually from disorders in the auricle, external auditory canal & middle ear; can be caused by obstruction, mass loading, stiffness effect or discontinuity; often correctable with medical or surgical therapy
sensorineural hearing loss
hearing loss usually from disorders in the inner era & central auditory pathways; many causes; diagnosed with whisper, weber & rinne tests; treated with hearing aids, cochlear implants, etc.
clinical features of labyrinthitis
hearing loss, dizziness, vertigo
signs and symtpms of cholesteatoma
hearing loss, painless drainage that is unremitting, and muscle paralysis
pulsatile tinnitus
hearing one's own heartbeat in ears; suspicious for vascular disease
hyphema
hemorrhage into the anterior chamber of the eye; acute eye pain, irregular pupil shape; treated with rest, elevate head, topical corticosteroids or atropine
oral herpes simplex
herpes cold sore; causes clusters of lesions on lips or vermillion border & adjacent skin; can also cause malaise, headache, fever, etc; treated with topical antiviral meds
herpes simplex keratitis
herpes infection of the cornea; diagnosed with dendritic ulcer; treated with simple debriment & patching
what is hutchinsons sign
herpes zoster on tip of nose = eye involvement
tx of cavernous sinus thrombosis
high dose IV ABs
sx of laryngitis
hoarseness--HALLMARK little to no pain with loss of voice
Patient presents with acute onset of pain and edema in the involved eyelid. There is a palpable indurated area in the involved eyelid which has a central area of purulence with surround erythema. What is the likely dx?
hordeolum (stye)
Diabetics or immunocompromised patients may develop malignant OE. What treatment will this require?
hospitalization and parenteral antibx
oral lichen planus
idiopathic cell-mediated autoimmune response seen in HIV patients; presents with a lacy leukoplakia lesion of oral mucosa; treated with local or systemic corticosteroids
meniere disease
idiopathic distention of endolymphatic compartment of the inner ear by excess fluid leading to increased pressure within the inner ear; presents with episodic (peripheral) vertigo lasting minutes to hours + fluctuating hearing loss, tinnitus & ear fullness; diagnosed with a dix-hallpike maneuver & transtympanic electrocochleography
acanthamoeba keratitis
important cause of keratitis in contact lens wearers; causes severe pain; treated with topical biguanides
prostaglandin analogs used
in chronic but not acute glaucoma
bone
in conductive hearing loss, the rinne test will present with _____ conduction greater
affected
in conductive hearing loss, the weber test will present with lateralization to the ______ ear
what is amblyopia
in older children with strabismus the brain may learn to ignore input from one eye and cause permanent decrease in vision
air
in sensorineural hearing loss, the rinne test will present with _____ conduction greater
normal
in sensorineural hearing loss, the weber test will present with lateralization to the ________ ear
barotrauma
inability to equalize the barometric stress exerted on the middle ear by air travel, rapid altitudinal change, or underwater diving; causes ear pain, clogged ears, tinnitus, hearing loss & ruptured TM; treated with swallow, yawn, pseudoephed & phenylephrine
trismus
inability to open the mouth fully; seen in ludwig angina & peritonsillar abscess
anterior ischemic optic neuropathy
inadequate perfusion of posterior ciliary arteries that supply anterior portion of optic nerve; can be caused by giant cell arteritis
papilledema
increased ICP ie: tumor, bleed Dx: increased pressure seen with LP
Papilledema
increased intracranial pressure
glaucoma
increased intraocular pressure (>21mmHg) with optic nerve damage (canal of schlemm blocked, decreased flow of aqueous humor)
what are the physical finddings for optic neuritis
indistinct optic disc border with raised ridge, visual acuity reduced, color vision altered, afferent pupillary defect, and optic nerve inflammation ( most inflammation cannot be seen because inflammation is retrobulbar)
postseptal cellulitis associated with what illness
infection from paranasal sinuses
cause of Tympanic membrane perforation (TMP)
infection most common -also blow to ear, severe atmospheric overpressure, exposure to excessive water pressure (eg, in scuba divers), and improper attempts at wax removal or ear cleaning.
Hordeolum
infection of external sabecous gland. Staph areus -sx- small painful nodule on eye lid -tx- warm compresses several times a day for 48 hours
dacryocystitis
infection of lacrimal sac; infants & >40y; presents with tenderness, edema & redness to the nasal side of the lower llid; treated with a warm compress, topical & systemic antibiotics
lymphadenitis
infection of lymph nodes; can be caused by TB, cat-scratch disease, sacroidosis; treated with antibiotics or surgical excision
mastoiditis
infection of the mastoid; caused by s pneumoniae, H influenzae & s pyogenes; causes postauricular pain, redness, & swelling; treat with cefazolin
Acute OM
infection of the middle ear (70-90% bacterial) kids more likely to get b/c shorter, more horizontal canal also increased with pacifer use or down syndrome
dental abscess
infection of the mouth, jaw or face; toothache in a tooth; treated with antibiotics, pain meds & dental block
peritonsillar abscess
infection of the peritonsillar space; causes severe sore throat, fever, "hot potato voice", unilateral tonsil hypertrophy & deviated uvula; treated with IV antibiotics, IV fluids, I&D, tonsillectomy
periodontitis
infective, inflammatory process of supporting structure presenting with gum recession & formation of "pockets" at tooth base/gumline; may lead to tooth loss & systemic disease
Dacryoadenitis/Dacryocystitis
inflamed nasolacrimal duct as a result of obstruction. Common pathogens are Staph aureus, Group B strep, Staph epidermidis and Candida. May present with pain, swelling, tenderness, redness, and prudent discharge Tx: warm compresses or ABX gentamicin, tobramycin, erythromycin for infection.
blepharitis
inflammatin of both eyelids--- DOWNS+ ECEZEMA -anterior- staph a./ seborrhic, posterior- meiobian gland -sx- eyelash flaking, red rimming of eyelids -tx- anterior- eyelid hygiene, warm compresses, eyelid scrubbing. posteior- eyelid massage
epiglottitis
inflammation & infection of epiglottis; presents with rapid onset sore throat, fever, odynophagia, respiratory distress
blepharitis
inflammation of BOTH eyelids - common in patients with downs syndrome and eczema - posterior: dysfunction of meibomian gland ( associated with rosacea and allergic dermatitis) - eye irritation/itching - eyelid changes: burning, erythema with crusting, scaling, red-rimming of eyelid and eyelash flaking - +/- entropion or ectropion (esp with posterior) anterior: eyelid hygience: warm compresses, eyelid scrubbing, baby shampoo, possible abx posterior: eyelid massage/expression of meibomian gland regularly
when is treatment of mastoiditis surgical?
inflammation of bone and connective tissue surrounding bobne
etiology of labyrinthitis
inflammation of inner ear that usually occurs after cold or flu
parotitis
inflammation of parotid gland; "mumps"; causes parotid tenderness & enlargement; diagnosed with IgG detection; treated with pain relievers
acute pharyngitis
inflammation of pharynx/tonsils; causes sore throat with additional URI systems; can be viral (rhinovirus/coronavirus) or bacterial (strep)
dacryoadenitis
inflammation of sac -sx- swelling of outportion of eye lid -tx- topical ocular and oral anti-staphylococcal antibiotics= clinda+ Cefalexin/cefaxlone. warm compresses, anagelsics defintiveremoval of sac= dacrosysetetomy
Acute Sinusitis
inflammation of sinuses usually following URI
gingivitis
inflammation of soft tissues surrounding teeth caused by the lack of proper oral hygiene with accumulation of plaque & calculus; treated with thorough, professional cleaning, repair, good dental health
vestibular neuritis
inflammation of teh vestibular portion of CN8 in the inner ear; causes peripheral vertigo- single attack of vertigo with no accompanying auditory symptoms; treated with meclizine & valium
conjunctivitis
inflammation of the conjunctiva; most common eye disease; red irritated eyes
Blepharitis is . . .
inflammation of the eyelid(s)
etiology of dacryoadenitis
inflammation of the lacrimal glands via viral or bacterial infection
A Chalazion is . . .
inflammation of the meibomian gland
medicamentosa rhinitis
inflammation of the nose caused by cocaine or afrin abuse
gustatory rhinitis
inflammation of the nose caused by eating spicy foods
vasomotor rhinitis
inflammation of the nose caused by irritants such as smoke or perfume
optic neuritis
inflammation of the optic nerve
optic neuritis
inflammation of the optic nerve; associated with MS, autoimmune disorders, etc.; causes unilateral vision loss that presents over a few days; treated with methylprednisone
dacryoadenitis
inflammation of the tear-producing gland (lacrimal gland)
glossitis
inflammation of the tongue; caused from nutritional deficiencies, drug reactions, dehydration, etc.; causes red, smooth-surfaced tongue
keratitis
inflammation/infection of the cornea; causes extreme pain; mostly due to bacteria, viruses & fungi; presents with pain, photophobia & reduced vision
what is retinitis pigmentosa
inherited autosomal dominant recessive or Xlinked night blindness in childhood
what is blepharitis
inlfmmation of the lid margin
tympanic membrane signs and symptoms
instant relief from pain associated with middle ear effusion
dx of OM
insufflation of TM to look for immobility clinical bulging TM
These are caused by the inflammation and infection of a meibomian gland, with pustular formation in that gland. They are situated deep from the palpebral margin. is this an internal or external hordeolum (STYE)
internal
types of hordeolum
internal --> inf of meibomian gland, rare external --> sty --inf of moll or zeis gland, edge of palpebral margin
ipratropium
intranasal anticholinergic used to treat viral rhinosinusitis
oxymetazoline
intranasal decongestant used to treat Eustachian tube dysfunction
chronic glaucoma
intraocular pressure is elevated due to reduced drainage of aqueous fluid through trabecular meshwork; presents with slow, progressive bilateral peripheral vision loss; treated with prostaglandin analogs or surgery
The initial treatment for menieres dz is a low sodium diet and diuretics (acetazolamide). What if the case is unresponsive?
intratympanic corticosteroid
how to differentiate papilledema and optic neuritis
isolated disk edema without elevated CSF pressure is not considered papilledema
allergic conjunctivitis
itch bilateral
how do you keep RBCs from staining the cornea in a hyphema?
keep HOB at 45 deg
ear wick
keeps EAC open so drops can get into ear; used to treat otitis externa
treatment for periorbital cellulitis
keflex
What is the most common location of epistaxis?
keissenbachs plexus
This disorder of the eye presents with redness and irritation, fever, sore throat, cough and *decreased visual acuity*. What is the likely dx? conjunctivitis, uveitis, keratitis
keratitis (note the decreased visual acuity is not usu. present in conjunctivitis)
When viral conjuncitvitis is transmitted in swimming pools what is it called?
kertaocojunctivitis
dysfunction of eustachian tube
kids have short tubes down syndrome is risk factor leads to chronic ear infections
MC site of epistaxis
kiesselbach's plexus
labyrinthitis vs menieres
lab: CONTINUOUS men: EPISODIC
peripheral vertigo causes
labyrinthitis, meniere's ds, positional vertigo, vestibular neuronitis, migrainous vertigo, obstructing anatomic abnormality
definititive tx for glaucoma
laser trabeculoplasty surgery
photocoagulation
laser treatment for retinal detachment, retinal vein occlusion, proliferative diabetic retinopathy & sickle-cell retinopathy
cranial nerves
lateral rectus- CN VI abducens superior oblique- CN IV trochlear
what are the results of a weber test for unilateral conductive loss
lateralizes to affected ear
what are the results of a weber test for unilateral sensorineural loss
lateralizes to the normal ear or side you hear better in
macular degneration
leading cause of irreversible CENTRAL visual loss
proliferative (neovascular) diabetic retinopathy
less common diabetic retinopathy, but severe vision loss; causes new, abnormal blood vessel growth & vitreous hemorrhages; treated with laser photocoagulation or intravitreal injection of VEGF inhibitors
entropion
lid margin rolls in toward the eye; treated with surgery or botox
ectropion
lid margin rolls outwards; treated with surgery
Blepharitis tx
lid scrub (baby shampoo) warm compresses oral tetracycline or topical erythromycin or bacitracin
What is the tx for blephoritis?
lid scrubs using diluted baby shampoo on cotton tipped sswabs. Massage to express meibomina glands. Topical antibx if infection is suspected.
what is the treatment for blepharitis
lid scrubs with diluted baby shampoo with cotton tipped swabs. use topical antibiotics if infection is suspected
epiglottitis
life-threatening infection of epiglottis
Lips
lips are pink and moist without ulcers or cracking
homonymous hemianopia
loss half of vision field in each eye, associated with central vertigo
corneal abrasion
loss of superficial epithelium of cornea; treated with topical antibiotics, topic antiinflammatories & oral analgesics
In menieres dz, with caloric testing, nystagmus is gained or lost on the impaired side?
lost
menieres dz tx
low salt diet anti-vert (dimenhydrinate, meclizine, diazepam, or scopolamine patch) diuretics (HCTZ)
treatment for meniere's disease
low salt diet, diuretics, steroid or gentamycin injection
What is the treatment for menieres dz initially (non-pharm)?
low sodium diet and diuretics (acetazolamide)
conjunctival foreign bodies
low velocity projectile into the eye
What are the usu. bacterial causes of laryngitis?
m. catarrhalis and h.ifluenzae
Cholorquine or phenothiazine are drugs that can cause this disorder of the eye.
macular degeneration
what is leading cause of blindness in elderly
macular degeneration
causes of papilledema
malignant HTN hemorrhagic strokes acute subdural hematoma psuedotumor cerebri
In diabetic or immunocompromised patient who present with auricle pain on movement, and erythematous, swollen ear canal suspect this condition which is a necrotizing infection extending to the blood vessels, bone and cartilage. This requires hopsitalization and parenteral antibx.
malignant OE
mallet finger/ boutonniere deformity
mallet finger- avulsion of extensor tendon -tx- splint DIP uninterrupted extension X 6 weeks. boutonniere- sharp force against tip of paritally extended digit- hyperflexion of PIP, extend DIP -tx- splint PIP in extension X 4-6 weeks.
Mc complication of AOM
mastoiditis
postauricular pain and erythema, fever, bulging tm, what dx?
mastoiditis
MC sinus affected in acute sinusitis
maxillary (1. maxillary, 2. ethmoid, 3. frontal, 4. sphenoid)
otitis externa "swimmers ear"
mechanical obstruction + infectious agent (pseudomonas, proteus)
tx of labyrinthitis
meclizine (dizzyness) promethazine (motion sickness) dimenhydrinate (motion sickness) usually resolves in a few weeks
What is the treatment for chronic OM?
medical - remove infected debris, avoid water exposure and topical antibx drops definitive treatment will include surgery and TM repair/reconstruction
internal hordeolum
meibomian gland abscess that usually points to the conjunctival side of the eyelid
PAtient presents with recurrent vertigo (lasting minutes to hours), with lower range hearing loss, tinnitus and one sided aural pressure. Likely dx?
menieres dz
This condition is also known as endolympthatic hydrops
menieres dz
The phenomenon of wavy or distorted vision and can be measured with an amsler grid.
metamorphopsia
A 34-year-old woman presents to the clinic with complaints of intermittent flushing and blushing that started 3 to 4 weeks ago. Since then, she has noticed several inflammatory papules on the cheeks, nose, and chin. Upon exam, you notice an overall rosy hue to the face and the absence of any comedones. Which of the following would be the best course of topical therapy at this time?
metronidazole gel Metronidazole is the topical treatment of choice for rosacea, which is consistent with the clinical findings in this 34-year-old female patient. Mupirocin ointment is a treatment option for impetigo, whereas permethrin is indicated for scabies. Tretinoin is effective and is indicated for comedonal acne. Topical hydrocortisone has not been shown to be effective for rosacea.
tzanck smear
microscopic exam of vesicle fluid or base of lesion for virally infected cells; diagnosis for oral herpes simplex
non-proliferative diabetic retinopathy
mild, moderate or severe diabetic retinopathy; causes microaneurysms, retinal hemorrhages, venous beading, retinal edema, & cotton-wool spots; treated wtih fluorescein angiography or vitrectomy
tx of hyphema
mild: blood will absorb acetominophen for pain (NSAIDS cause rebleeding) topical cycloplegics patch
strabismus
misalignment of the eyes; diagnosed with a corneal light reflex & cover test; need early treatment to prevent amblyopia
corneal foreign bodies
moderate to high velocity projectile into the eye
staph aureus
most common bacteria that causes chronic sinusitis
Hib (H influenza B)
most common cause of epiglottitis
laryngitis
most common cause of hoarseness; usually viral; can be treated with corticosteroids
allergies
most common cause of rhinitis
presbyacusis
most common cause of sensorineural hearing loss
adenovirus
most common cause of viral conjunctivitis
benign paroxysmal positional vertigo
most common form of vertigo; onset of peripheral vertigo a few secs after assumption of a certain head position; diagnosed with a dix-hallpike maneuver
adenoid cystic carcinoma
most common malignant tumor of the mouth; treated with excision of gland or fine needle aspiration biopsy
maxillary
most common sinus site for an acute sinusitis; presents with cheek pain/pressure that may radiate to the upper incisors
rhegmatogenous
most common type of retinal detachment; retinal inner layer detaches from the choroid plexus
tx of TMP
most heal on their own within a few weeks paper-patch method, fat-plug tympanoplasty, a Gelfoam plug avoid some AB eardrops as they can be ototoxic
what is positive dix halpike test
move patient from sitting to supine with head turned 45deg and tilted back 20 deg and you lay them down and they have nystagmus
optic neuritis MC etiology
multiple sclerosis
MCC of optic neuritis
multiple sclerosis other causes: syphillis, lyme, herpes, lupus, IBD, vasculitis, DM, B12 deficiency
samter triad
nasal polyps, asthma & aspirin sensitivity
phenylephrine
nasal spray decongestant used to treat barotrauma
myopia
near-sightedness, close objects are clear, far away objects are blurry; corrected with minus lenses
cortisporin otic suspension
neomycin/polytrim B/hydrocortisone otic; antibiotic used to treat otitis externa; 3 drops TID-QID x 7-10d; NOT used if TM perforated
gonorrhea
neonatal conjunctivitis in days 2-5 of life is mostly due to __________
chlamydia
neonatal conjunctivitis in days 5-7 of life is mostly due to _________
HSV
neonatal conjunctivitis in days 7-11 of life is mostly due to __________
silver nitrate
neonatal conjunctivitis in the first day of life is mostly due to _____________
neovascular (wet) degeneration
new, abnormal vessels grow leading to accumulation of serous fluid, hemorrhage, & fibrosis; loss of central vision; treated with anti-angiogenics
Anterior chamber
no crescent shadow noted
Cranial nerve 1
no deficit of the olfactory nerve
Critical: Tongue
no discoloration or lesions of the tongue
What is the treatment for macular degeneration?
no effective treatment, if detected early laser therapy or intravitreal injections of monoclonal antibody drugs may slow progression
Critical: Fundus
no hemorrhages or exudates
conjunctiva, sclera and cornea
no injection, icterus, lesions, edema or foreign bodies, cornea is clear
results of a normal weber test
no lateralization of sound at all
Gingiva, teeth, breath odor
no lesions, swelling or discoloration of the gingiva, teeth are in good repair, non-tender with good oral hygiene and no abnormal breath odor
Neck Inspection
no lesions, swelling, or discoloration
Paranasal sinuses
no maxillary or frontal sinus tenderness
Cranial Nerve 5 sensory
no sensory deficit of cranial nerve 5
Lacrimal ducts
no swelling or regurgitation
External ear canal
no swelling, redness or obstruction
Auditory Acuity
no unilateral deficits
barotrauma to ear
normally the middle ear has same pressure as outside, if different =trauma the problem often occurs with altitude changes, such as flying, scuba diving, or driving in the mountains. If you have a congested nose from allergies, colds, or an upper respiratory infection, you are more likely to develop barotrauma.
Nose inspection
nose is midline with out lesions
micropsia
object seen by the affected eye looks smaller than in the unaffected eye; seen with macular degeneration
thyroglossal duct cyst
occur along embryologic course of thyroid's descent from tongue to lower neck; most common before age 20; treated with surgical excision
fungal keratitis
occurs after corneal injury involving plant material or agricultural setting; diagnosed with scrapings of the site; treated with topical antifungals
Auricular hematoma
occurs after direct trauma to the ear, typically during sports and can result in cauliflower ear
acute angle-closure glaucoma
occurs when pt has a preexisting narrow anterior chamber angle; can be caused by pupillary dilation (darkened room), stress, or from certain medications; causes red eye with cloudy cornea, halows around lights & peripheral loss of vision; treated with acetazolamide
astigmatism
occurs when the refractive error in the horizontal & vertical axes are different
Elevated IOP without optic disc damage is known as...
ocular hypertension
sx of Peritonsillar abscess
one sided neck/throat pain fever HA dysphagia change in voice odynophagia deviation of uvula MUFFLED VOICE tracheal "rock sign"
when should you patch for a corneal abrasion
only for large abrasions measured 5-10 mm to promote healing
cataract
opacity of crystalline lens; #1 cause of blindness worldwide; can be caused by congenital, traumatic, systemic disease or age-related/senile; causes blurred vision & halos around lights; treated with surgical removal or intraocular lenses
What type of glaucoma is most common?
open angle affects ppl > 40 and african americans
what nerve is herpes zoster ophthalmicus involves
ophthalmic branch of the trigeminal nerve
what do you see on physical examination for open angle glaucoma
optic cupping and elevated intraocular pressure and loss of peripheral vsion
papilledema
optic disk swelling commonly from hypertensive retinopathy; sign of hypertensive emergency
herpes zoster tx
oral acyclovir - topical steroids if posterior uveitis present
oropharyngeal mucosa
oral mucosa is pink and without ulcers or other lesions
acyclovir/valcyclovir
oral or topical antivirals used to treat herpes simplex keratitis & herpes zoster ophthalmicus
acute/chronic sinusitis tx
oral/nasal decongestants Abx: amoxi/clav. (acute: 10-14 days. chronic: 2-3wks) 2nd line: levofloxacin, clindamycin
These are serious complications of sinusiits.
orbital cellulits, osteomyelitis or cavernous sinus thrombosis
blowout fracture
orbital floor fx to orbital rim blunt trauma inferior rectus muscle entrapment enophthalmos
Inflammation of the area near the __________ complex is an important component differentiating sinusist sfrom allergic or viral rhinitis.
osteomeatal
malignant otitis externa
osteomyelitis at skull base d/t psuedomonoas (DM and immunocompromised pts) - IV abx (cipro)
malignant otitis externa
osteomyelitis at the skull base secondary to pseudomonas infection; seen in diabetic or immunocompromised; causes persistent greenish, foul-smelling discharge, deep ear pain, mastoid tenderness; treated with IV cipro
otitis externa tx
otic neomycin, polymyxin if fungal: amphotericin B
Ramsay Hunt-
otitis externa caused by herpes zoster
serous otitis media
otitis media with effusion; more common in children; causes dull & hypomobile TM & air bubbles; treated with prednisone or amoxicillin
ruptured globe
outer membranes of the eye are disrupted due to penetrating trauma to the eye; presents with misshaped eye, enophthalmos, severe conjunctival hemorrhage, irregular shaped pupl & positive seidel's test; treated with eye shield & consult ophthalmology
cerumen impaction
overproduction of cerumen; causes feeling of fullness, hearing loss & pain/discharge; treated with irrigation, ear curettes & hydrogen peroxide
sx of optic neuritis
pain on eye movement sudden loss of vision (usually UNILATERAL) blurry vision change in color persception
sx of otitis externa
pain, tenderness with tragus, edematous canal, purulent debris
clinical features of angle-closure glaucoma
painful eye loss with injection, steamy cornea, and fixed mid dilated pupil. decreased visual acuity, nausea, and vomiting. usually unilateral
etiology of a hordeolum
painful inflammation of the gland or hair follicles of the eyelids typically due to staph aureus
how does dacryoadenitis present?
painful swelling in outer portion of upper eyelid plus preauricular lymphadenopathy
clinical features of macular degeneration
painless progressive central vision loss and color loss
thyroid CA
papillary = MC, best prognosis anaplastic = rare, most deadly medulary thyroid CA in MEN 2A, 2B
mumps
paramyxovirus parotid gland self limited orchitis
Parotid glands
parotid glands without nodules or irregularity
seidel's test
parting of the fluorescein dye by a clear stream of aqueous humor from the anterior chamber
tripod position
patient leaning forward on hand to ease breathing; seen with epiglottitis
intraocular foreign bodies
penetrating eye injury usually involving hammering on metal equipment, metal grinding, or other ocular trauma; dx w/ CT
tinnitus
perception of sound in the absence of actual sound; "ringing in the ears"; causes pulsatile or tonal tinnitus; treated with antidepressants, surgery, masking efforts
What are the main finding of CHRONIC OM?
perforated TM and chronic ear discharge with our w/o pain. May result in condunctive hearing loss
labyrinthitis
peripheral cause of vertigo associated with ear infection
Meniere syndrome, labyrinthitis, vestibular neuronitis, and perilymphatic fistula are causes of?
peripheral vertigo.
movement-related vertigo
peripheral vertigo; onset of vertigo with almost any position change
20 year old female complains of a cold, sinus pain and difficult breathing. She's gained some weight recently. You look in your mouth and you see deviation of the soft palate and assymetric rise of the uvula...likely dx?
peritonsillar abscess deviation of the soft palate and assymetric rise of uvula highly suggestive
Trismus
peritonsillar abscess ludwig's angina dental abscess tetanus
Patient presents with a significant sore throat, pain with swallowing, trismus, deviation of the soft palate and uvula and muffled "hot potato voice". What is the diagnosis?
peritonsollar abscess
Sore throat, a common reason for outpt visits, is assoc w/ about half of outpatient anitbiotic use.
pharyngitis
abnormal growth of tissue only present over the sclera
pinguecula
how to dx orbital fracture
plain films or CT
foreign body tx after removal
polymyxin-bacitracin or erythromycin ointment
tarsal tunnel syndrome
post tibial nerve compression from overuse, restrictive footwear -sx- pain/numbness @ medial mallelous and sole, tarsal tunnel syndrome increases pain through out day (plantar facititis- decreases throughout day) -dx- tinels sign
oral leukoplakia
precancerous hyperkeratosis due to chronic irritation ( tobacco, ETOH) -sx- white patchy lesions that cannot be rubbed off, painless -tx- cryotherapy
leukoplakia
precancerous hyperkeratosis due to chronic irritation (tobacco, smoking, ETOH, dentures); white patchy lesion that cannot be rubbed off, painless; treated with cryotherapy & laser ablation
erythroplakia
precancerous lesions similar to leukoplakia but with erythema
sensorineural hearing loss
presbycusis acoustic neuroma syphillis lyme dz
meniere's ds
pressure in fluid tubes too high
diabetic retinopathy
progressive damage to the retinal blood vessels from glycosylation; non-proliferative or proliferative
Your diabetic pt has neovascularization and vitreous humor on fundo exam. Is this a sign of non proliferative or proliferative diabetic retinopathy?
proliferative
what do you use to eval foreign body with a fluoroscein stain
proparacaine
-posts
prostaglandin analogs used to treat chronic glaucoma (bimato/latano/taflu/travo-)
late SCC
protruding masses with central necrosis, ulceration in the mouth
otitis externa clinical features
pruritis, pain, tenderness to pinna/tragus
causes of corneal abrasion
pseudomonas acanthamoeba keratitis (contact users) herpes keratitis (dendritic ulcer) foreign body scratches allergies bells palsy (eye open) autoimmune ds (RA)
step pneumo, h. influenzae, moraxella catarrhalis, strep pyogenes These are the most common bugs in acute OM. What are the most common bugs in chronic OM?
pseudomonas aeruginosa, s. aureus, proteus, anaerobes
What bugs most commonly cuase OE?
pseudomonas, proteus and fungi
common otitis externa orgs
pseudomonas, staph, proteus, fungi (aspergillus)
chronic OM orgs
psuedomonas, staph aureus
abnormal growth of tissue encroaching on the cornea
pteerygium
Oral Anti-histamines should be avoided in what population?
pts with Urinary retention Anti-histamines are anti-cholinergics
types of tinnitus
pulsatile and non-pulsatile (vascular cause)
what 3 triggers in acute glaucoma
pupillary dilation pharmacologic mydriasis anticholinergic meds
Iris and Pupils, RAPD, and Position and alignment
pupils are equal, round, and reactive to light, no RAPD, no tropia
bacterial conjunctivitis
purulent d/c staph PIC organisms strep pneumo, H. flu, M. cat Tx: sulfacetamide, erythromycin, cipro, ofloxacin, tobramycin, polytrim rule out gonorrhoea
clinical features of bacterial conjunctivitis
purulent discharge from both eyes. eyes glued shut on awakening
exudative (wet) mac degen ssx
rapid onset hemorrhages neovascularization
dx of pharyngitis
rapid strep test antigen assay, strep culture
Patient presents w/ a corneal abrasion. What should you do before examining or treating?
record visual acuity
Red reflex and clarity
red reflex is present, cornea, anterior chamber, lens and vitreous are clear
clinical features of blepharitis
red rims, dandruff like depositis or scales near eyelashes; conjunctiva is clear
cherry red macula
red spot seen with retinal artery occlusion
marcus gunn pupil
relative afferent pupillary defect; when bright lights shone from the unaffected eye to the affected eye, the pupils appear to dilate rather than constrict; seen with optic neuritis
laryngectomy
removal of part of the larynx; used to treat advanced cases of squamous cell carcinoma of larynx
sialoendoscopy
removal of salivary gland to treat chronic cases of sialolithiasis
metal foreign body tx
remove within 24 hr
treatment for nystagmus
removing inciting etiology, botox, or surgery
macula
responsible for central vision (detail & color vision)
cochlea
responsible for hearing; converts wave impulses from the middle ear into auditory nerve impulses
dental caries
result of mineral dissolution of tooth by bacterial products; most common cause of tooth loss before 35
Your 45 year old patient presents with acute onset of painless blurred or blackened vision that occurs over several mintues to hours and progresses to complete or partial MONOCULAR blindness. Likely dx?
retinal deatchment
"A curtain being drawn over the eye from the top to bottom" is the classic description of...
retinal detachment
In this condition the patient may sense "floaters" or flashing lights at the initiation of symptoms. Intraocular pressure is normal or reduced.
retinal detachment
_____________ is cuased by the overzealous use of decongestant drops or sprays containing oxymetazoline or phenyephrine. This cuases a rebound congestion which prompts increased use of the agent, creating a vicious cycle.
rhinits medicamentosa
typical orgs in viral acute sinusitis
rhinovirus, parainfluenza, influenza, RSV
tinnitus
ringing 90% associated with sensorineural hearing loss causes: ASPIRIN LOOP DIURETICS aminoglycosides CCB
test for conductive hearing loss
rinne test
what two viruses can cause congenital cataracts
rubella, cmv
what do you see on the fundus exam for retinal detachment?
rugae or orange peel appearance to retinal surface
What pathogen usu. causes a hordeolum
s. aureus
treatment for viral conjunctivitis
saline eye lavage twice a day for 7-14 days. warm compress to reduce discomfort
tx of acute sinusitis
saline nasal spray decongestants steam AB (amoxicillin)
causes of blepharitis
seborrhea, staph, strep, dysfuncton of meibomian glands (sebaceous gland)
what are the causes of blepharitis
seborrhea, staph/strep, or dysfunction of the meibomian blands. Seborrheic blepharitis is commonly associated with seborrhea of the face, eyebrows, external ears, and scalp
Though bacterial conjunctivitis is usu. self limiting, this serious infection can develop.
secondary keratitis
etiology of chalazion
secondary to chronic inflammation of the meibomian gland
tx of epiglottitis
secure airway broad spectrum ABs (cephlasporin 7-10 days)
which generation antihistamines are non sedating? sedating?
sedating: gen 2 non sedating: gen 1
vertigo
sensation of movement (spinning, tumbling, falling) or sensation of objects spinning around him/her
retinal detachment
separation of retina from pigmented epithelial (appears to flap in vitreous humor)
sx of labyrinthitis
severe vertigo, hearling loss, tinnitus, N/V
orbital cellulitus
sinus infection through ethmoid bone
woodruff plexus
site where posterior nose bleeds come from
FB in eye
slit lamp always irrigate
pterygium
slow thickening of bulbar conjuctiva CAN COVER CORNEA--comes from nasal side
vocal fold nodules
smooth, paired lesions that form at the junction of anterior 1/3 & posterior 2/3 of vocal folds
brachial cleft cyst
soft cystic mass along SCM muscle; treated with complete excision
If pressure doesn't stop the posterior nosebleed what is aonther option?
specialist eval, surgery packing is dangerous
treatment for tympanic membrane perforation
spontaneous healing within a few days; if not then surgical repair called tympanoplasty; antibiotic drops if infected
retinal detachment
spontaneous tear in peripheral retina due to degenerative changes; causes "curtain being pulled UP over eye"; diagnosed with retina hanging in vitreous & positive schaffer's sign
treatment for foreign body of eye
stain with fluorescein, observe with woods lamp, and remove with irrigagion or cotton tipped applicator.
most common cause of hordeolum
staph aureus
chronic sinusitis common orgs
staph aureus, anaerobes, h flu, fungi
Ophthalmoscope exam
stay steady! 2 deep breaths!
tx of retinal detachment
stay supine with head turned toward side with retinal detachment ER ophthalmologist laser surgery 80% recover 5% blind
What are the most common offending agents in otitis media?
step pneumo, h. influenzae, moraxella catarrhalis, strep pyogenes
optic neuritis tx
steroids
metamorphopsia
straight lines appear bent; seen with macular degeneration
Cranial nerve 11
strength is 5 out of 5 and symmetric
Patient presents with a fever over 38C, tender anterior cervical adenopathy, LACK OF COUGH and pharngotonsillar exudate. What is the likely dx?
strep GABHS
Mc AOM org
strep pneumo
otomastoiditis
strep pneumo Dx: CT air cells surgical debridement can reach brain protrusion of ear (asymmetrical ears)
bacterial conjunctivitis common orgs
strep pneumo staph aureus H flu
all AOM orgs
strep pneumo, H flu, M catarrhalis, or viral
typical orgs in bacterial acute sinusitis
strep pneumo, h flu, m. catarrhalis
what are the usual bacterial offenders for sinusitis
strep pneumo, h. flu, and m. cat
bacterial conjunctivitis
strep pneumo, s. aureus, H. aegyptius, moraxella, rare = G/C
What are the common pathogens that cause bacterial conjunctivitis?
strep pneumo, staph aureus, haemophilus aegyptius and moraxella
what are the common pathogens for otitis media
strep pnumo, m cat, h. flu
sx of epiglottitis
sudden high fever respiratory distress severe dysphagia drooling muffled voice mild stridor sit upright with neck distended
How would a retinal vein occlusion present?
sudden loss or blurring of vision in one eye Think Central retinal vein occlusion (CRVO)
peripheral vertigo
sudden onset of "dizziness" with nausea/vomiting; causes horizontal nystagmus, tinnitus & hearing loss
sx of Retinal artery occlusion
sudden, painless, unilateral vision loss, pale retina, afferent pupil defect, arteriolar narrowing retinal edema, separation of a. flow (box-carring), CHERRY red spot
sx of Retinal vein occlusion
sudden, unilateral, painless, blurred vision or visual loss "blood and thunder" retina (dilated v, hemorrhages, edema, exudates)
tx of laryngitis
supportive don't overuse voice to prevent formation of vocal nodules
TM perforation
supportive tx
What is the treatment for VIRAL laryngitis?
supportive tx - vocal rest and avoidance of singing or shouting
What is the recommended tx for viral sinusitis?
supportive, NSAIDs for pain, saline washes, steam and oral and or nasal decongestants (mucinex). intranasal corticosteroids can be helpful (fluticasone)
ectropion tx
surgery
entropion tx
surgery
vitrectomy
surgery involving removing vitreous fluid; treatment for non-proliferative diabetic retinopathy
tx of cholesteatoma
surgery to remove cyst
trabeculoplasty
surgery/laser done to treat chronic glaucoma
papilledema stems from
swelling of the optic disk due to increased intracranial pressure
tympanic membrane perforation
sx-Hx of closed AOM, head injury or direct ear trauma Hearing loss ≥40 dB serious middle ear injury. Hearing loss <40 dB w/o CSF, vestibular symptoms (eg, nystagmus, vertigo), or facial nerve injury suggests TM Perf w/o middle ear injury, middle ear fluid, or impaired baseline hearing. -dx- Physical Exam. CT if: ●Basilar skull fracture suspected ●Trauma & facial nerve dysfunction ●Blunt / penetrating middle ear trauma w/ hearing loss at ≥40 dB or with vestibular symptoms
hypertensive retinopathy
systemic HTN affect both retinal & choroidal circulation; most noticeable in young patients with abrupt elevations in BP; marker for current & future end-organ damage; causes arterial narrowing & AV nicking
pseudoephedrine
systemic decongestant used to treat Eustachian tube dysfunction, barotrauma, & viral/bacterial rhinosinusitis
amaurosis fugax
temporary monocular vision loss with complete recovery; feeling of "curtain being pulled down over eye"; caused by retinal emboli or ischemia
dix-hallpike maneuver
test to diagnose BPPV & meniere's disease
Children with allergic rhinits may develop a horizontal nasal crease called __________________ from habitually rubbing the nose.
the allergic salute
viral rhinosinusitis
the common cold; caused by the rhinovirus or adenovirus
emmetropia
the normal state of vision
Critical: Bimanual exam
there are no stones, masses or areas of induration
Middle ear
there is no visible evidence of fluid in the middle ear
Your patient presents with a fever, pharyngotonsillar exudate, lack of cough and anterior cervical adenopathy. You are soooo sure its strep! Rapid strep test comes back negative. What test can you do now to confirm it?
throat culture
central retinal vein occlusion
thrombus causes fluid backup in retina; presents with acute, sudden monocular vision loss; diagnosed with extensive retinal hemorrhages, retinal vein dilation & macular edema; no specific treatments
central retinal artery occlusion
thrombus or embolus blocks artery causing acute, sudden monocular vision loss; diagnosed with cherry red macula; treated with acetazolamide, lie on back, massage orbit & vessel dilation
oral candidiasis
thrush; common fungal disease caused by candida albicans; causes cottage cheese-like plaque readily scraped off to reveal erythematous base which may bleed; treated with antifungals
Critical: Thyroid
thyroid is normal size, shape, and consistency without nodules or tenderness
signs and symptoms f meniere's disease
tinnitus, hearign loss, vertigo that lasts for several hours, and nausea
Tonsils and uvula, Cranial nerve 9 and 10
tonsils are grade zero and equal with midline uvula, no exudate or lesions, uvula and soft palate rise symmetrically, gag reflex active
tx of bacterial conjunctivitis
topical AB, sys AB for rare pathogen
Tx of closed angle glaucoma
topical B blocker (timolol) alpha agonist (apraclonidine) carbonic anhydrase inhibitor (-amide) osmotic diuresis IV acetazolamide, IV mannitol --to reduce intraocular pressure laser or surgical iridotomy AVOID decongestants and anticholinergic medications
tx of corneal abrasion
topical anesthetic (not Rx) acetominophen for pain AB ointment (polymixin/bacitracin) FU in 1-2 days, patching no longer than 24 hours
diagnosis for corneal abrasion
topical anesthetic to confirm. slit lamp exam or fluorescein staining will reveal epithelial defect but a clear cornea
What is the treatment for a corneal abrasion?
topical anesthetic will provice immediate relief, but will retard healing. -saline irrigation - antibiotic ointment (gentamicin) patch for no longer than 24hrs daily f/u
ketorolac tromethamine
topical anti-inflammatory used to treat corneal abrasions
treatment for bacterial conjunctivitis
topical antibiotics
optivar
topical antihistamine used to treat allergic conjunctivitis
open angle glaucoma tx
topical beta blocker (timolol or betaxolol) prostaglandin analogs carbonic anhydrase inhibitors (acetazolamide)
If pressure and position change doesn't stop a nose bleed (anterior), what are options?
topical cocaine (anesthetic and vasoconstrictor), oxymetazoline and topical anesthtetics (lidocaine) rhinorocket
flunisolide
topical intranasal corticosteroids used to treat bacterial & viral rhinosinusitis
patanol
topical mast cell stabilizer used to treat allergic conjunctivitis
Avoid this treatment in a corneal ulcer because they will cause further tissue loss and increase risk of perforation
topical steroids
acute iritis tx
topical steroids, analgesics, refer to ophth.
What is the tx for Apthous ulcers (canker sores, ulcerative stomatitis)?
topical therapy such as corticosteroids can provide symptomatic relief 1 week oral prednisone taper can be helpful cimetidine can be used as maintenance tx
biguanides
topical treatment for acanthamoeba keratitis
transient vs sudden vs gradual vision loss
transient: TIA, emboli ( amoursosis fugax), or temporal arteritis sudden: central retinal vein or branch vein occlusion, optic neuritis, papillitis, and retrobulbar neuritis gradual: macular dengeration, tumors, cataracts, glaucoma
necrotizing ulcerative gingivitis
trench mouth; common in young adults during stress; causes painful, bleeding & necrosis gums; treated with 1/2 strength peroxide rinse
true or false: strabismus is normal in newborns
true
vocal fold cysts
true cysts or pseudocysts on the vocal folds, may fluctuate in size
tx of vertigo
tx cause
sialolithiasis & sialadenitis
tx: cephalosporin, increased hydration, sialogogues can be caused by dehydration- think elders stenson's duct (top) wharton's duct (bottom)
cortical cataract seen in what dz
type 1 dm
viral conjunctivitis
type of conjunctivitis; May be part of a viral prodrome followed by adenopathy, fever, pharyngitis, & URI; treat underlying URI/ virus symptoms
allergic conjunctivitis
type of conjunctivitis; bilateral redness, itching, watery & chemosis; treated with antihistamines & topical/systemic corticosteroids
chemical conjunctivitis
type of conjunctivitis; hx of chemical exposure to eyes; pain, redness, tearing, photophobia; tx by removing foreign matter, irrigation of eyes, topical antibiotics & pain relief
bacterial conjunctivitis
type of conjunctivitis; most commonly caused by strep/staph; presents with purulent discharge & lid crusting, usually unilateral; treated with topical erythromycin
exudative
type of retinal detachment; fluid accumulates beneath the retina leading to detachment
posterior uveitis
type of uveitis; causes gradual loss of vision with no pain; treated with systemic corticosteroids
anterior uveitis
type of uveitis; causes unilateral ocular pain, redness, photophobia & excessive tearing; treated with topical corticosteroids & mydriatics
labyrinthitis tx
typically self limiting, but may use diazepam/meclizine/or dimenhydrinate
is wet macular degeneration unilateral or bilateral?
unilateral
vocal fold polyps
unilateral masses that form within vocal fold
clinical features of viral conjunctivitis
unilateral or bilateral erythema of conjunctiva
Rheumatic fever
untreated strep throat (GAS)
avoid oral antihistamines in pts with:
urinary retention
weber test
used to diagnose hearing loss; practioner holds tuning fork on top of patient's head, sound should be equal in both ears
rinne test
used to diagnose hearing loss; practitioner holds tuning fork on mastoid bone, then moves to in front of ear once sound diminishes, air conduction should be greater than bone conduction
whisper test
used to diagnose hearing loss; practitioner stands behind patient, asks to cover 1 ear, whispers 3 words & asks patient to repeat them
dental block
used to provide pain relief for 12 hrs from a dental abscess
mastoiditis
usually from OM that extends to mastoid bone
corneal abrasion
usually from minor trauma (fingernail, contact, eyelash, small foreign body)
what is the treatment for hyphema
usually resolves spontaneously. AVOID NSAIDS because of rebleeding of that vessel
Retinal vein occlusion
usually secondary to thrombotic event
etiology of mastoiditis
usually untreated bacterial otitis media
acute pharyngitis
usually viral, or s. pyogenes
MCC of viral otitis externa:
varicella zoster
Rhinorrhea cuased by increased secretion of mucus from the nasal mucosa. It may be precipitated by changes in temperature or humidity, odors or alcohol or result from a neurovascular imbalance.
vasomotor rhinitis
vertebral basilar insufficiency:
vertigo + syncope
labyrnthitis
vestibular neuritis + hearing loss/tinnitus; presents with acute onset of continuous, severe peripheral vertigo lasting several days to a week; treated with antibiotics, meclizine, valium
tx of pharyngitis
viral = supportive bacterial = PCN tx done to avoid rheumatic fever and post-strep glomerulonephritis
tx of dacryoadenitis
viral: self limiting bacterial: cephlasporin chronic: tx underlying systemic condition
clinical features of optic neuritis
vision loss and mild eye pain
tx of of optic neuritis
vision usually spontaneously returns high dose steroids may speed return
dx of corneal abrasion
visual acuity slit lamp fluorescein staining
dx of hyphema
visual acuity tonometry (measure pressure) b scan ocular US
Visual fields
visual fields are full and equal by confrontation
These supplments can reduce the progression of macular degeneration.
vitamins, antioxidants, zinc, copper and omega 3 fatty acids
How do you resolve a CRVO?
w vision typically is resolved w/ time at least partially. a work up for further thrombosis is indicated. neovascularization can be treated with intravitreal injection of vascular endothelial growth factor inhibitors
bact conjunctivitis tx
warm compress trimethoprim/polymyxin
treatment for chalazion
warm compress. elective excisionif not resolved
hordeolum tx
warm compresses abx ointment (e-mycin or bacitracin) no improvement: I&D
chalazion tx
warm compresses topical erythromycin i&D
treatment for hodeolum
warm compresses, topical antibiotics, incision and drainage if no resolution
sensorineural hearing loss weber and rinne findings
weber: lateralizes to UNaffected ear rinne: AC > BC
conductive hearing loss weber and rinne findings
weber: sound lateralizes to affected ear rinne: BC > AC
which is the most severe type of macular degeneration?
wet (exudative) which causes more rapid and more severe visual loss
When is surgical intervention necessary for retinal detachment?
when a tear occurs
Entropion is . . .
when the eyelid and lashes are turned *inwards*, irritating the conjunctiva
Ectropion is . . .
when the eyelid and lashes are turned *outwards, exposing the conjunctiva*
oral hairy leukoplakia
white patch with a hairy surface on the tongue that cannot be scraped off; associated with EBV; treated with acyclovir
laryngeal leukoplakia
white spots/plaques on the larynx; commonly found in smokers with hoarseness; treated with serial resection
roth spots
white-centered retinal hemorrhages, seen in leukemia & bacterial endocarditis
dentail carie
whitish discoloration at the gingiva margin
posterior bleed in the nose
woodruff's plexus--this is an ER! you will see blood in posterior pharynx posterior pack increases risk for TSS
tx of barotrauma to ear
yawn, swallow, chew gum,
hard exduates
yellow spots with sharp margins often circinate due to lipid or lipoprotein deposits from leaky blood vessels; seen with nonproliferative diabetic retinopathy
pinguecula
yellow, elevated nodule on nasal side of eye (fat and protein)- DOES NOT GROW
pinguecula
yellowish, slightly raised thickening of the sclera; treated with avoiding irritants & lubricating eye drops
blowout fracture = direct trauma to what structure
zygomatic prominence
