HEENT Flashcards
(104 cards)
1
Q
Who is likely to get corneal ulcers?
A
Soft contact users
2
Q
Corneal Ulcer
A
MEDICAL EMERGENCY
S&S: severe eye pain, foreign body sensation, tearing, and photophobia
Presentation:
whitish lesion on the cornea
Use penlight, slit lamp exam, and fluorescein dye test
Pseudomonas, Staphylococcus, or Streptococcus
Complications: Permanent vision impairment d/t scarring or perforation
3
Q
Herpes Keratitis
A
S&S: Acute onset of severe eye pain, photophobia, tearing, and blurred vision in one eye
Dx: fluorescein dye
- fernlike lines in the corneal surface w/ fluorescein dye
Complications: permanently damages corneal epithelium, which may result in corneal blindness
Caused by: herpes simplex called herpes simplex keratitis
OR
herpes varicella zoster [shingles] called herpes zoster ophthalmicus
4
Q
How does herpes keratitis differ from corneal abrasion?
A
HK: fernlike lines in the corneal surface.
Corneal abrasions: round or irregularly shaped
5
Q
Herpes simplex keratitis
A
due to self-inoculation “cold sore”
6
Q
Herpes zoster ophthalmicus
A
MEDICAL EMERGENCY
shingles of the trigeminal nerve
acute eruption of crusty rashes that follow the ophthalmic branch -> one side of forehead, eyelids, and tip of nose
7
Q
Acute Angle-Closure Glaucoma
A
MEDICAL EMERGENCY
Sudden blockage of aqueous humor causes marked increase of the IOP, resulting in ischemia and permanent damage to the optic nerve
S&S Acute onset of severe eye pain accompanied by headache, nausea/vomiting, halos around lights, lacrimation, and decreased/blurred vision
PE: fixed and mid-dilated pupil(s) that is oval shaped. Slow reaction to light.
cloudy cornea
Cupping of the optic nerve
8
Q
Multiple Sclerosis (Optic Neuritis)
A
S&S: Woman 20-30s
loss of visual acuity over hours to days
Color vision is affected & central scotoma (blind spot central vision)
Other neuro sx: aphasia, paresthesia, abnormal gait, spasticity
Fatigue that worsens through day
Refer to neuro
9
Q
Multiple Sclerosis (Optic Neuritis) - Uhthoff phenomenon
A
Worsens in high temperatures
10
Q
Orbital Cellulitis
A
MEDICAL EMERGENCY
S&S Acute onset of erythematous swollen eyelid with proptosis and pain
history of recent rhinosinusitis or URI
More likely in children
PE: Restricted EOMs w/ pain
Cause: acute bacterial infection of the orbital contents (fat and ocular muscles)
11
Q
Retinal Detachment
A
MEDICAL EMERGENCY
S&S: Sudden onset of floaters (or increase in floaters) associated with “looking through the curtain” sensation with sudden flashes of light (photopsia)
12
Q
Auricular Hematoma
A
Direct blunt trauma to the ear that can cause bleeding in the auricular cartilage
Drain ASAP
Complications: cauliflower ear
13
Q
What professions are more at risk for an auricular hematoma
A
wrestlers, boxers, and mixed martial arts fighters
14
Q
Acoustic neuroma (vestibular schwannoma)
A
50s to 60s
Unilateral hearing loss and tinnitus lasting 3 to 4 years
Unsteady walking with veering or tilting
Cause: tumor of acoustic nerve
Refer to neuro
15
Q
Cholesteatoma
A
Unilateral heaving loss and discharge - purulent and foul smelling
On exam: TM perforation and White mass or intact with mass behind
H/o chronic or recurrent otitis media
Mass can erode into facial bones
Treat w/ abx or surgery
Refer to otolaryngologist
16
Q
Battle Sign (Basilar Skull Fracture)
A
Indicates serious head injury -> ER
Parietal bone fracture w/ linear fracture most common
Cause: fall, assault, MVC, GSW
SS: raccoon eyes and bruising behind ear after trauma
PE: clear, golden serous discharge from ear or nose or hemotympanum (blue/ purple color to TM)
17
Q
Avulsed tooth
A
DENTAL EMERGENCY
Need to reimplant tooth quickly
OK if baby tooth
If permanent tooth: don’t touch root, only touch crown
Rinse w/ saline, irrigate socket, reimplant tooth, bite on gauze
Can store tooth in milk, saline, or cheek if unable to reimplant
18
Q
Peritonsillar Abscess
A
MEDICAL EMERGENCY
Sx: sore throat, odynophagia, trismus (jaw spasm), not potato voice. Malaise, fever
PE: unilateral swelling, uvula displaced
19
Q
Diphtheria
A
REFER TO ED
Contact precaution
Sore throat, fever, and markedly swollen neck (“bull neck”)
Posterior pharynx, tonsils, uvula, and soft palate are coated with a gray to yellow pseudomembrane that is hard to displace
Very contagious
20
Q
Virchow’s Node (Troisier’s Sign/Node)
A
enlarged and hard left-sided supraclavicular node(s)
can be malignancy (cancer of GI/GU)
Need biopsy
21
Q
Normal Findings: Eyes
A
Fundi: veins larger/darker than arteries
Cones: color perception
Rods: low-light vision (night vision), peripheral vision.
Macula (and fovea): central vision and color vision. Fovea contains large numbers of cones. Diseases of the macula -> loss of central vision
22
Q
Presbyopia
A
Age-related
decreased ability of the eye to accommodate and focus due to stiffening of the lenses;
usually starts at the age of 40 years;
near vision is affected with decreased ability to read small print
23
Q
Blepharitis
A
Inflammation of the edges of the eyelids
oil glands at the base of the eyelashes become clogged.
eyelids are red, irritated, and itchy. Small scales like dandruff may be present.
Blepharitis tends to recur.
May be associated with dandruff, seborrheic dermatitis, or rosacea.
24
Q
Normal Findings: Ears
A
Bones (ossicles) of the ear: Malleus, incus, and stapes. The stapes is the smallest bone in the body.
TM: translucent off-white to gray color with the “cone of light” intact. The pars tensa is located on the lower aspect and appears to bulge slightly. It is the area of the TM where the cone of light is visible.
Tympanogram: most objective measure to test for presence of fluid inside middle ear (results in a straight line vs. a peaked shape). Acute otitis media (AOM) and serous otitis media will show a straight line on testing
Pinna: Has a large amount of cartilage.
Tragus: A small cartilage flap of tissue on the front of the ear.
Cerumen: Ear wax; the color can range from yellow to dark brown.
25
Normal Findings: Nose
Kiesselbach’s plexus: Located on the anterior inferior aspect of the nose (lower one-third).
Turbinates: Only the inferior nasal turbinates are usually visible. The medial and superior turbinates are not visible without special instruments. Bluish, pale, and/or boggy nasal turbinates are seen in allergic rhinitis.
Cartilage: Lower third of the nose is cartilage.
Septum: Perforation of the nasal septum can result from inhalation of cocaine, which is a potent vasoconstrictor. Refer to plastic surgeon for repair.
26
Normal Findings: Sinuses
Sinuses are air-filled cavities in the skull. There are four types: ethmoid and maxillary (both present at birth), frontal (age 5 years), and sphenoid (age 12 years). By age 12 years, a child’s sinuses are nearly at adult proportions.
27
Normal Findings: Mouth
Mucous membranes are pink to dark pink and moist.
The tongue should not be red or swollen (glossitis).
A normal adult has 32 teeth.
Vermilion border: Vermilion border is at the edges of the lips. The corners of the lips are called the oral commissures (cheilosis, perleche).
28
Leukoplakia
White-to-light-gray patch that appears on tongue, floor of mouth, or inside cheek. Rule out oral cancer. Chewing or smoking tobacco, alcohol abuse, and human papillomavirus (HPV) are risk factors for oral cancer.
29
Aphthous stomatitis (canker sores)
Painful shallow ulcers on soft tissue of the mouth that usually heal within 7 to 10 days
Cause is unknown.
Treat: “magic mouthwash” (combination of liquid diphenhydramine, viscous lidocaine, and glucocorticosteroid). Swish, hold, and spit every 4 hours as needed.
Orabase cream/ointment (OTC).
30
Normal Findings: Salivary Glands
There are three salivary glands: parotid, submandibular, and sublingual. The glands may become infected (sialadenitis, sialadenosis, mumps) or can become blocked with calculi (“stone”; sialolithiasis).
31
Mumps (Parotitis)
School-aged child to adult
Sx: acute onset of fever, headache, fatigue, myalgia, and anorexia. Within 48 hours, the salivary/parotid gland(s) becomes swollen and tender. It can be unilateral (25%) or bilateral. The cheek appears puffy, and the angle of the jaw on the involved side appears swollen. The swelling and tenderness usually subside in about 1 week.
Complications are rare and include orchitis (of one testicle), meningitis, encephalitis, deafness, and others.
Mumps is a nationally notifiable disease; report all cases to local or state health department.
32
Normal Findings: Tonsils
Also known as the palatine tonsils; tonsils are made up of lymphoid tissue. Butterfly-shaped glands with small pore-like openings that may secrete thick white exudate (mononucleosis) or purulent exudate that is a yellow-to-green color (strep throat).
A peritonsillar abscess (quinsy) is a serious deep-neck infection, and it is a rare complication of tonsillitis. Assess for airway obstruction. About half of cases occur in children and adolescents. Refer to ED or call 911.
33
Normal Findings: Posterior Pharynx
Hard palate: Look for any openings (cleft palate), ulcers, redness.
Uvula: Should be in midline position; is displaced if infected and abscessed (peritonsillar abscess).
34
Which lymph nodes enlarge with allergies?
Retropharyngeal lymph nodes can be mildly enlarged and distributed evenly on the back of the throat
35
Normal Findings: Lymph Nodes
Anterior cervical nodes (superficial chain) drain the lymph from the skin and superficial surfaces of the anterior neck.
Posterior cervical nodes (superficial chain) drain the scalp, neck, and skin of the upper thoracic area.
36
Which lymph nodes enlarge with viral or bacterial inflection?
The anterior cervical lymph nodes can become enlarged with viral or bacterial infections (strep throat).
37
Which lymph nodes enlarge with mononucleosis?
Mononucleosis can cause posterior cervical lymphadenopathy.
38
Palpebral conjunctiva:
Mucosal lining inside eyelids
39
Bulbar conjunctiva:
Mucosal lining covering the eyes
40
Buccal mucosa:
Mucosal lining inside the mouth
41
Soft palate:
Area where uvula, tonsils, and anterior of throat are located
42
Hard palate
Roof” of the mouth
43
Hyperopia
Farsightedness”; distance vision is intact, but near vision is blurry.
44
Myopia
Nearsightedness”; near vision intact, but distance vision is blurry.
45
Amblyopia
Also called “lazy eye.” Usually starts in infancy. The affected eye has reduced vision. Refer to ophthalmologist.
46
Miosis
Excessive constriction of the pupil of the eye
47
Ptosis
Drooping of the upper eyelid
48
Geographic Tongue
Benign
Tongue surface has a maplike appearance; patches may move from day to day.
may complain of soreness with acidic foods, spicy foods
49
Torus Palatinus
Benign
Painless bony protuberance midline on the hard palate (roof of the mouth); may be asymmetric; skin should be normal.
Does not interfere with normal function.
50
Fishtall or Split Uvula
Benign
Uvula is split into two sections and resembles a fishtail.
May be a sign of an occult cleft palate (rare).
51
Physiologic Gaze-evoked Nystagmus
Benign usually
On prolonged, extreme lateral gaze, a few beats of nystagmus that resolve when the eye moves back toward midline in healthy patients is normal.
Can also be caused by brain lesions.
52
Abnormal Findings: Eyes
Papilledema
Optic disc swollen with blurred edges due to increased intracranial pressure (ICP)
2/2 bleeding, brain tumor, abscess, pseudotumor cerebri
53
Abnormal Findings: Eyes
Disc Cupping
A/w glaucoma
Cx: increased IOP
Measured using “cup-to-disc” ratio. The “cup” of the optic disc is the center, and the surrounding area is the “disc.” As glaucoma progresses, the cup-to-disc ratio becomes abnormal.
54
Abnormal Findings: Eyes
Hypertensive Retinopathy
Copper and silver wire arterioles (caused by arteriosclerosis)
Arteriovenous nicking is c/b compression of a vein by an arteriole as it passes over it
Appears as if it is “nicked” or it is missing a small area.
Retinal hemorrhages
55
Abnormal Findings: Eyes
Diabetic Retinopathy
-Microaneurysms (small bulges in retinal blood vessels that often leak fluid) c/b neovascularization (new fragile arteries in the retina that rupture and bleed)
-Cotton-wool spots (fluffy yellow-white patches on the retina)
56
Abnormal Findings: Eyes
Cataracts
Opacity of the lens of the eye, which can be central (nuclear cataract) or on the sides (cortical cataract)
Up to 20% of older adults (age 65–74 years) are affected
Cataracts can appear at any age from infants (congenital cataracts) through adults to the elderly.
Sx: difficulty with glare (with headlights when driving at night or sunlight), halos around lights, and blurred vision.
57
Abnormal Findings: Nose
Allergic Rhinitis
Blue-tinged or pale and swollen (boggy) nasal turbinates associated with increased clear nasal discharge
May be accompanied by itchy nose, sneezing, and nasal congestion
58
Abnormal Findings: Nose
Nasal Polyps
Painless, soft round growths inside the nose. Look for fleshy mass inside nasal cavity.
Tx: Intranasal glucocorticoids (fluticasone or budesonide twice a day)
If poor response or recurrent sinus infection, refer to ENT for surgical treatment.
Increased risk of aspirin sensitivity or allergy.
59
Abnormal Findings: Mouth
Koplik’s Spots
Clusters of small red papules with white centers inside the cheeks (buccal mucosa) by the lower molars
Pathognomonic for measles (rubeola)
60
Abnormal Findings: Mouth
Hairy Leukoplakia
Elongated papilla on the lateral aspects of the tongue that is pathognomonic for HIV infection
Caused by Epstein–Barr virus (EBV) infection of tongue
61
Abnormal Findings: Mouth
Leukoplakia of the Oral Mucosa/Tongue
Bright-white plaque on the inner cheeks (buccal mucosa)
c/b chronic irritation, such as from chewing tobacco or snuff (rule out oral cancer).
Refer to oral surgeon for biopsy.
62
Abnormal Findings: Mouth
Cheilosis (Angular Cheilitis, Perleche)
Painful skin fissures and maceration at the corners of the mouth d/t excessive moisture.
Cx: dentures, oversalivation, nutritional deficiency (Vit B), lupus, autoimmune dz, pacifier use, thumb sucking
Acute or chronic.
2* infection w/ Candida albicans (yeast) or bacteria (Staphylococcus aureus).
TX: Check vitamin B12 level; consider checking other B vitamins (B3, B6, B9).
Remove underlying cause (i.e dentures)
If yeast, microscopy with KOH, treat with topical azole ointment (e.g., clotrimazole, miconazole) twice a day.
If staph, order C&S, treat with topical mupirocin ointment twice a day.
When infection has cleared, apply barrier cream with zinc or petroleum jelly at night.
High rate of recurrence.
63
How to test distance vision
Snellen chart
If illiterate, use Tumbling E chart. stand 20 feet away
If pt wears glasses, test the vision with the glasses in both eyes (OU), the right eye (OD), and the left eye (OS).
Abnormal: Two-line difference between each eye; fewer than four letters out of six correct.
64
How to test near vision
Ask pt to read small print
65
How to test peripheral vision
“visual fields of confrontation” exam
Look for blind spots (scotoma) and peripheral visual field defects.
66
How to test color blindness
Ishihara chart
67
Definition of Snellen chart result
Top number (or numerator): The distance in feet at which the patient stands from the Snellen or picture eye chart (always 20 feet and never changes).
Bottom number (or denominator): The number of feet at which the patient can see compared with a person with normal vision (20/20 or less). Number changes, dependent on patient’s vision.
68
Legal blindness
Best corrected vision of 20/200 or less or a visual field less than 20 degrees (tunnel vision).
69
What age can you start using the Snellen chart
Age 6
If vision is not 20/30 in either eye, refer to ophthalamologist
70
Weber Test
Place the tuning fork midline on the forehead.
Normal finding: No lateralization.
Lateralization (hears the sound in only one ear or sound is louder in one ear) is an abnormal finding
71
Rinne Test
Place tuning fork first on mastoid process, then at front of the ear. Time each area.
Normal finding: Air conduction (AC) lasts longer than bone conduction
72
Types of Hearing Loss: Results of Weber and Rinne Tests
Sensorineural loss: Lateralization (louder) to “good” ear, AC>BC
Presbycusis
Ménière’s disease
Conductive loss: Lateralization (louder) to “bad” ear BC>AC
Otitis media
Serous otitis media
Ceruminosis
Perforation of tympanic membrane
73
Conductive Hearing Loss
Outer Ear and Middle Ear
Any type of obstruction
Other causes include blockage of the outer ear (ceruminosis, otitis externa) or fluid inside the middle ear (otitis media, serous otitis media).
74
Sensorineural Hearing Loss
Inner Ear
Damage (or aging) of the cochlea/vestibule (presbycusis, Ménière’s disease) and/or to the nerve pathways (CN VIII or acoustic nerve) causes sensorineural hearing loss.
Other causes are ototoxic drugs (e.g., oral aminoglycosides, erythromycin, tetracyclines, high-dose aspirin, sildenafil) and stroke. Usually results in permanent hearing loss.
75
Corneal Abrasion
C/o acute onset of severe eye pain with tearing. Feeling of a foreign body sensation on the surface of the eye.
Always ask any patient with eye complaints whether they wear contact lenses.
76
Contact Lens–Related Keratitis
S&S: acute onset of red eye, blurred vision, watery eyes, photophobia, and sometimes a foreign-body sensation
Hx: sing contacts past prescribed time schedule, sleeping with contact lens, bathes/showers or swims with contacts, and use of tap/well water or poor disinfection practices
PE: fluorescein dye strip with Wood's lamp shows fern-like or branching curves lines
Tx: check for trauma, foreign body, if suspect bacterial get C&S. Use topical ophthalmic abx with pseudomonal coverage (ciprofloxacin, ofloxacin). Don't patch eye. IF no improvement in 24 hr, refer to ED
Avoid steriod eye drop
Consider NSAID Acular drops for pain
77
Hordeolum
"you hord like a pig 'Stye'"
External hordeolu: abscess of a hair follicle and sebaceous gland
Internal hordeolum: inflammation of the meibomian gland
S&S: acute onset of a swollen, red, and warm abscess. May rupture with purulent drainage
TX: Hot compress for 5-10 min 2-3xper day. If infection spreads (preseptal cellulitis) use dicloxacillin or erythromycin orally
I&D w/ opthalmologist
78
Chalazion
Chronic inflammation of the meibomian gland
C/o gradual onset of a small superficial nodule on the upper eyelid that feels like a bead and is discrete and movable. Painless. If large, can press on cornea and blur vision
Tx: may resolve spontaneously in 2 to 8 weeks. Refer to ophthalmology for I&D, removal or injections.
79
Pinguecula
raised, yellow-to-white, small round growth in the bulbar conjunctiva. Nasal and temporal side of the eye.
C/b chronic sun exposure.
Tx: Use artifical tears. If inflammed refer to opthalmology for steriod drops. Use good quality sunglasses. Remove surgically
80
Pterygium
"Surfers eye"
Yellow triangular (wedge-shaped) thickening of the conjunctiva that extends across the cornea on the nasal side. Can be red and inflamed. Can cause foreign body sensations
C/b Chronic sun exposure
Tx: Use artifical tears. If inflammed refer to opthalmology for steriod drops. Use good quality sunglasses. Remove surgically
81
Subconjunctival Hemorrhage
Blood that is trapped underneath the conjunctiva and sclera 2/2 broken arterioles. Painless, does not affect vision.
C/b coughing, sneezing, heavy lifting, vomiting, or local trauma or spontaneous.
Resolves within 1 to 3 weeks (blood reabsorbed) like a bruise, with color changes from red, to green, to yellow.
Increased risk if patient is on aspirin or anticoagulants or has hypertension
82
Primary Open-Angle Glaucoma
Gradual onset of increased IOP >22 mmHg due to blockage of the drainage of aqueous humor inside the eye. CNII can get permanently damaged.
S&S: Elderly. asymptomatic in early stages. GRadual changes in peripheral vision, then central vision.
PE: If cupping of optic disc, refer to ophthalmologist
Tx: Check IOP with tonometer (normal 8-21 mmHg). If >30 refer to ED
Betimol - beta blocker eye drops to decrease aqueous production
Latanoprost - Prostagladin drops to increase aqueous drainage
83
Anterior Uveitis (Iritis)
Insidious onset of eye pain with conjunctival injection
Complication of autoimmune disorders (rheumatoid arthritis [RA], lupus, ankylosing spondylitis), sarcoidosis, syphilis, others.
No purulent discharge
Refer to ophthalmologist within 24 hr
Can cause blindness
84
Age-Related Macular Degeneration
Gradual damage to the pigment of the macula, results in severe visual loss or blindness. Common in smokers
S&S: Asymptomatic in early stages. Unilateral or bilateral. Sudden and painless loss of central vision. Straight lines become distorted or curved. Peripheral vision preserved.
Dx: Amsler grid
Tx: Refer
85
Age-Related Macular Degeneration Dry vs Wet
Atrophic (dry form) or exudative (wet form)
The dry form of AMD is more common (85%–90%) and is “less severe”
The wet form of AMD is responsible for 80% of vision loss (choroidal neovascularization).
86
Sjögren’s Syndrome
Chronic autoimmune disorder characterized by decreased function of the lacrimal and salivary glands.
S&S: daily symptoms, dry eyes and mouth for >3 months. Sandy or gritty sensation in eyes (keratoconjunctivitis sicca). Increase in dental caries.
Tx: OTC artificial tears. Refer to ophthalmologist and dentist
87
Blepharitis
Inflammation of the eyelids
A/w seborrheic dermatitis and rosacea
Lid may be colonized by staph.
C/o itching or irritation in the eyelids (upper/lower or both), gritty sensation, eye redness, and crusting.
Intermittent exacerbations.
Tx: Johnson’s Baby Shampoo with warm water. Could use abx drops (erythromycin). Warm compress for itching.
88
Entropion
The eyelid (usually the lower eyelid) is turned inward
The eyelashes continuously rub against the cornea, causing irritation, watery eyes, redness, pain, and/or foreign body sensation.
More common in the elderly.
89
Ectropion
Like "ectopic" - outside
The eyelid is turned outward or sags away from the eye.
It causes irritation and eye dryness.
More common in the elderly.
90
Allergic Rhinitis
Inflammatory changes of nasal mucosa due to allergy.
Atopic family history (asthma, eczema).
S&S: chronic or seasonal congestion w/ clear mucus rhinorrhea or post nasal drip. Coughing worsens supine.
PE: nasal turbinates boggy, blue or pale. Posterior pharynx has thick mucus. Undereye circles (venodilation).
Tx: topical nasal sprays. Flonase (steriod), Astelinl (anti-histamine), combo. Decongestants like Sudafed. Don't give to young children. Oral antihistamines, 2nd gen less drowsy.
91
Rhinitis Medicamentosa
Prolonged use of topical nasal decongestants (>3 days) causes rebound effects that result in severe and chronic nasal congestion.
S&S: daily severe nasal congestion and nasal discharge (clear, watery mucus).
Tx: D/c nasal decongestants. Nasal saline spray to control symptoms.
92
Epistaxis (Nosebleeds)
Anterior nasal bleeds (bleeding from Kiesselbach’s plexus) are milder and more common than posterior nasal bleeds (can lead too severe hemorrhage).
Posterior risks: NSAIDs, Cocaine, HTN, anticoags
Refer to ED
Anterior: usually caused by trauma, self-limiting
Tx: apply pressure, use nasal decongestants (Afrin) to shrink tissues
93
Septal Perforation
A hole on the nasal septum (cartilage)
Cause: snorting or inhalation of cocaine, a potent vasoconstrictor, which can cause ischemia. Trauma, prior septal surgery, untreated septal hematomas, and self-induced lesions.
PE: Shining a light on one nostril will transilluminate both sides.
94
Streptococcal Pharyngitis/Tonsillopharyngitis
(“Strep” Throat)
**Suspect viral etiology (or coinfection) if cough and symptoms such as stuffy nose, rhinitis with clear mucus, and watery eyes (coryza)
C/b group A streptococcal bacteria (Streptococcus pyogenes)
S&S: Abrupt onset of fever, sore throat, pain on swallowing, and mildly enlarged submandibular nodes.
PE: Pharynx is dark pink to bright red. Anterior cervical lymph nodes mildly enlarged.
Dx: Rapid antigen detection testing (RADT) is a rapid “strep” test or throat C&S
Tx: First line: Oral penicillin V 500 mg two to three times a day × 10 days
Alternative: Amoxicillin 500 mg twice a day × 10 days
Penicillin or beta-lactam allergy: Azithromycin (Z-Pak) × 5 days
Complications: Scarlet fever, Acute rheumatic fever, Peritonsillar abscess, Poststreptococcal glomerulonephritis
95
Centor Criteria
Centor criteria are a clinical decision tool used to help diagnose “strep” throat.
Tonsillar exudate
Tender anterior cervical adenopathy
History of fever
Absence of cough.
96
Acute Otitis Media (Purulent or Suppurative Otitis Media)
Acute infection of the middle ear cavity with bacterial pathogens due to mucus that becomes trapped in the middle ear
More likely in children b/c temporary eustachian tube dysfunction.
S&S: ear pain (otalgia), popping noises, muffled hearing. Recent cold. Adult infections develop more slowly. Afebrile.
PE: middle ear effusion (MEE)
Tx: Amoxicillin 500 mg PO TID × 5 to 7 days is first-line treatment. Severe, treat 10 days. If no response in 24-48 hr, switch to Augmentin or other 2nd line treatment
97
Bullous Myringitis
Type of AOM infection that is more painful due to the presence of blisters (bullae) on a reddened and bulging TM
S&S:
PE: Conductive hearing loss. TM: Bulging or retraction with displaced light reflex (displaced landmarks); may look opaque, Erythematous
Tx: same as AOM, Amoxicillin 500 mg PO TID × 5 to 7 days is first-line treatment. Severe, treat 10 days.
98
Acute Bacterial Rhinosinusitis
The maxillary and frontal sinuses are most affected. Fluid trapped in sinuses causing secondary bacterial (S. pneumoniae, H. influenzae) or viral infection
History of a “bad cold”
S&S: unilateral facial pain or upper molar pain with nasal congestion for 10 days or longer.
PE:
Posterior pharynx: Purulent dark-yellow to green postnasal drip
Sinuses: Tender to palpation, Transillumination (frontal and maxillary sinuses)
Fever seen more often in children than adults
Tx: abx rarely needed, Symptomatic treatment. If severe, Augmentin first line.
Complications:
Refer to ED
Mastoiditis, Preorbital or orbital cellulitis, meningitis, cavernous sinus thrombosis.
99
Otitis Media with Effusion (Serous Otitis Media)
Sterile serous fluid is trapped inside middle ear.
May follow AOM. Can also be caused by chronic allergic rhinitis.
S&S: ear pressure, popping noises, and muffled hearing in affected ear.
PE: TM may bulge or retract. Tympanogram abnormal
Tx: Oral decongestant, steriod nasal spray, oral anti-histamine
100
Otitis Externa
(Swimmer’s Ear)
Bacterial infection of the skin of the external ear canal
Pathogen: Pseudomonas aeruginosa (gram-negative) or S. aureus (gram-positive)
S&S: external ear pain, swelling, discharge, pruritus, and hearing loss. Recent history of swimming
PE: Ear pain with manipulation of the external ear or tragus. Erythematous and swollen ear canal
Tx: Polymyxin B-neomycin-hydrocortisone (Cortisporin Otic) suspension 4 gtt QID × 7 days. Ofloxacin otic or ciprofloxacin (Cipro HC) otic ear drops BID × 7 days.
101
Infectious Mononucleosis
EBV (herpesvirus family). After acute infection, EBV lies latent in oropharyngeal tissue. Can become reactivated and cause symptoms. Virus is shed mainly through saliva, h/o kissing. Age 15-24
Classic triad: Fever, pharyngitis, lymphadenopathy (>50% cases)
S&S: sore throat, enlarged posterior cervical nodes, symmetric lymphadenopathy, and fatigue
PE: Lymphocytosis, abnormal LFTs, enlarged cervical nodes, pharynx erythemous. Hepatomegaly and splenomegaly
Dx: Heterophile antibody test (Monospot). Abd ultrasound
Tx: Limit physical activity to prevent spleen rupture. Avoid amoxixillin if "strep" throat drug rash. Symptomatic treatment.
102
Vertigo
Peripheral vertigo is caused by disorders of the vestibular apparatus of the inner ear or by the inflammation of vestibular nerve (CN VIII).
Central vertigo is associated with serious to life-threatening conditions such as stroke (cerebellar or brainstem bleeding), multiple sclerosis, infections, or tumor.
S&S: sensation of the room spinning or of rotational movement. May be associated with nystagmus.
PE: Dix-Hallpike maneuver (Gold-standard clinical test for benign paroxysmal positional vertigo disease (BPPV)). A positive finding is rotary nystagmus with latency of limited duration.
Tx: Epley maneuver, meclizine.
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Dix–Hallpike maneuver:
Gold-standard clinical test for benign paroxysmal positional vertigo disease (BPPV).
A positive finding is rotary nystagmus with latency of limited duration.
Assuming affected ear is on the right, with the patient sitting on the examination table (facing forward, with eyes open), turn the patient’s head 45 degrees to the right. While standing behind the patient and supporting the patient’s head with one hand, rapidly move the head from an upright to “head hanging” position, where the patient’s head is at least 10 degrees below horizontal. To achieve complete dependency of the patient’s head during the maneuver, the patient should be positioned in such a way that their shoulders will meet the head of the table when they are reclined
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