Module 1

Question 1

Ear Conditions: otoscopic exam
-normal findings

Answer 1

shiny, pearl gray, intact, mobile TM, bony landmarks visualized (malleolus 12 O’clock position)

Question 2

Ear conditions: otitis external
-key sx

Answer 2

child who has recently swam, bottle fed with rapid onset of tenderness of tragus/pinna, TM erythema (may not be visualized), fullness (can be stated by older child)

Question 3

Ear conditions: otitis external
if patient has otorrhea - what must be ruled out before tx starts?

Answer 3

PE tubes (if they’re draining = they are working) or is TM ruptured

Question 4

Ear conditions: otitis external
-If you are unable to visualize TM and you have otorrhea, you must assume what?

Answer 4

TM ruptured (perforation)

Question 5

Ear conditions: otitis external
-what would you treat with if the TM is assumed perforated?

Answer 5

Fluoroquin drops - ciprodex + pain meds

Question 6

Ear conditions: otitis external
-Patient presents with c/o otitis externa sx for 5-7 days, and also has pain behind the ear. What could be occurring?

Answer 6

Mastoiditis (more than 60% of pt <2yr old have mastoiditis as this is a common complication with AOM - which has the same prevalence in <2yr old)

Question 7

Ear conditions: otitis external
-you are ABLE to visualize TM and sx are uncomplicated. What do you do in the office for patient?

Answer 7

ear irrigation w/ warm saline or removal of debris with cotton tip

Question 8

Ear conditions: otitis external
-you cannot visualize the TM because the ear canal is swollen. There is no otorrhea. What do you do?

Answer 8

use pope ear wick and give drops that can be given for TM rupture (ciprodex - as you still need to tx like you assume a perforation exists)

Question 9

Ear conditions: otitis external
-you’re d/c this patient home. What are preventative measures you can teach mom?

Answer 9

don’t bottle prop; 1:1 vinegar/ethyl alcohol 2-3 drops before swimming; no swimming until improvement (do not use the prevention drops while there is an active otitis externa)

Question 10

Ear conditions: otitis external
-mom asks if she should routinely clean the child’s ears, so this issue doesn’t happen again. Your response?

Answer 10

No. Cerumen is protective of the acidic environment.

Question 11

Ear conditions: acute otitis media
-key sx

Answer 11

infants, recent viral URI, smoke in household, daycare attendance presents with mod-severe bulging TM, MEE, tugging/pulling on ear (infants), and TM redness, painful

Question 12

Ear conditions: acute otitis media
-patient is 3 months old - can you watchful wait on AOM?

Answer 12

No. Less than 6 months must treat with abx (prone to meningitis)

Question 13

Ear conditions: acute otitis media
-what are the age groups/presentations that you can “watchful wait”?

Answer 13

> 2yr bilateral/unilateral AOM without otorrhea; <6MO - 2YR unilateral AOM without otorrhea

Question 14

Ear conditions: acute otitis media
-patient presents with otorrhea, you note in hx that patient has PE tubes. What does this signify and what is the 1st line treatment? Why wouldn’t you need PO abx?

Answer 14

This means patients PE tubes are working/draining appropriately. You will prescribe ciprodex (fluroquin) drops. No PO abx because there are no systemic sx like fever or pain.

Question 15

Ear conditions: acute otitis media
-Patient presents with otorrhea, fever, and pain. What is your 1st line tx?

Answer 15

Amoxicillin + drops (treat systemic infection and local infection; amoxicillin is best tx to fight against pneumoniae)

Question 16

Ear conditions: acute otitis media
-patient sent home on amoxicillin is brought back by mom due to rash. What’s next step?

Answer 16

“cefs” drugs
-cephalosporins drug class

Question 17

Ear conditions: acute otitis media
-patient sent home on amoxicillin (finished full tx) and returns 2 weeks later. You note continued TM redness, effusion, bulging TM. What is your 2nd line tx?

Answer 17

Augmentin (<30 days you move to 2nd line abx)

Question 18

Ear conditions: acute otitis media
-Patient’s mother reports her son is SEVERELY allergic to PCN. What drug would you prescribe for AOM as 1st line treatment?

Answer 18

Bactrim or macrolides “mycins”

Question 19

Ear conditions: acute otitis media
-mother reports that patient with AOM is refusing her bottle at home due to pain in ears. What would you prescribe?

Answer 19

IM ceftriaxone (1 shot, given up to 3 days)

*not realistic

Question 20

Ear conditions: acute otitis media
-patient is d/c home on amoxicillin. Mother brings patient back 5 weeks later. Patient’s sx remained unchanged. What do you prescribe?

Answer 20

Amoxicillin (always start back to amoxil unless they had a rash or SERIOUS allergy)

Question 21

Ear conditions: acute otitis media
-perforated TM - does it require surgical repair?

Answer 21

most often will spontaneously heal itself within 6 months. (unhealed TM after 6 months; generally performed after the age of 7 yrs; book says 6-8yrs)

Question 22

Ear conditions: otitis media with effusion
-key sx

Answer 22

infants, allergy hx, or recent AOM (within last 6 weeks) presents with no pain, no redness, and fluid in middle ear

Question 23

Ear conditions: otitis media with effusion
-4MO old returns to clinic after tx for AOM occurring 5 weeks ago. You note resolved redness, no pain. Fluid remains. The tx for AOM was successful (as evidenced by the cessation of these sx). Is the fluid remaining in the middle ear normal or is it sterile?

Answer 23

Yes. This is normal and can occur in children. The fluid is sterile, therefore - NO ABX NEEDED!

Question 24

Ear conditions: otitis media with effusion
-4MO old returns to clinic after tx for AOM occurring 4 months ago. Effusion is persistent no S/S of AOM present. What does this patient require?

Answer 24

REFER TO audiologist (>3MO of effusion requires referral due to risk of language delay)

Question 25

Ear conditions: otitis media with effusion
-repeat incidences of OME can cause scarring or granulation tissue that appears as a “greasy looking mass”. What is it? What does the FNP do for this?

Answer 25

Cholesteatoma - requires IMMEDIATE REFERAL to ENT
-this can erode ear bones –> no bones = hearing loss –> mastoiditis

Question 26

Ear conditions: otitis media with effusion
-do you have conductive or sensory hearing loss with OME?

Answer 26

conductive (movement of air is the issue; sensorineural = actual anatomy issue regarding inner ear)

Question 27

Ear conditions: otitis media with effusion
-what are the reasons a patient would need a tympanostomy

Answer 27

> 40db hearing loss (>20db in infants = significant), cholesteatoma (all things associated with it: eroded bones, retraction pockets), and glue ear (effusion so thick TM will not move)

Question 28

Ear conditions: mastoiditis
-key sx

Answer 28

postauricular pain and redness (severe tenderness when palpating mastoid process)

Question 29

Ear conditions: mastoiditis
-you’ve decided its mastoiditis on physical exam ONLY - what do you need to order to have to dx definitively?

Answer 29

CT scan (CT can visualize cells; x-ray visualizes bones)

Question 30

Ear conditions: mastoiditis
-CT confirmed dx. You need to start treatment ASAP. What would be the treatment route and what do you prescribe?

Answer 30

IV abx (you can switch to PO with improvement of s/s but continues PO tx for 2-3 weeks)

Question 31

Ear conditions: mastoiditis
-the patient with AOM comes in for follow-up. They have nuchal rigidity and positive Kernig’s sign. What do they have?

Answer 31

meningitis (in neonates, meningeal irritation can present as labile temperature)

Question 32

at what point of an exam should you delay the otoscopic exam in pediatric patients?

Answer 32

end

Question 33

difference between:
-reason for visit
-present illness
-medical history

Answer 33

-the patient’s or parents’ concerns, stated in their own words, serve as the focus for the visit
-a concise chronologic summary of the problems necessitating a visit, including the duration, progression, exacerbating factors, ameliorating interventions, and associations
-a statement regarding the child’s functionality and general well-being, including a summary record of significant illnesses , injuries’, hospitalizations, and procedures

Question 34

how often should an exam of the eyes and assessment of vision be performed?

Answer 34

at EVERY health supervision visit

Question 35

common eye problems in children

Answer 35

refractive errors
-myopia (nearsighted)
-hyperopia (farsighted)
-astigmatism (cornea or lens has a different shape than normal distorting images)

amblyopia
-loss of visual acuity from cortical suppression of the vision of the eye)

strabismus (misalignment of the eyes)

Question 36

what eye exam is completed at birth?

Answer 36

movement/alignment of eyes should be assessed with pupils/red reflexes examined

Question 37

red reflex
-how is this performed?
-what does this check for?

Answer 37

performed on each pupil individually –> both eyes simultaneously; used to detect eye opacities (cataracts or corneal clouding) and retinal abnormalities (retinal detachment or retinoblastoma)

Question 38

-at what age is visual acuity checked?
-how is vision checked?

Answer 38

-3Y
-Allen cards (tumbling E chart or pictures tests
*each eye is tested separately, with nontested eye completely covered
*credit given for any line the child gets more than 50% correct
*uncooperative children should be retested (w/i 1 MO) –> persistently uncooperative children should be referred to ophthalmologist

Question 39

what is developmentally appropriate for a 3MO to do with eyes/vision?

Answer 39

should be able to track or visually follow moving object with both eyes

Question 40

what should happen if there is a two-line discrepancy between two eyes during visual acuity tests?

Answer 40

referred to ophthalmology

Question 41

how to check for undetected strabismus (ocular misalignment) throughout childhood (3 months, 6 months)

Answer 41

-corneal light reflex test (Hirschberg test)
*simple exam that checks for eye alignment by observing how light is reflected from cornea of the eyes; during test, pt centers their focus on special ight and eye doctor observes where light is reflected
*positive: the reflection of light appears to be in a symmetrical position in the pupil of each eye
*refer if reflection of light appears to be in an asymmetrical position in one eye compared to the other (helpful to detect pseudostrabismus, false appearance of strabismus)
-cover test
*occluder is help in front of eye for a few seconds and then removed; when fixing eye is occluded, examiner will observe non-occluded eye move to pick up fixation if a tropia is present; if no tropia is present, the non-occluded eye will remain stationary