NSS SAQ paper Flashcards
What 4 things need to be assessed on examination?
Signs of sepsis: eg EWS 3 or more, unwell looking patient, concern regarding acute change in mental state.
Visual acuity
Eye movements
Proptosis
Pupils for RAPD
Fundoscopy looking for optic disc swelling
What medical treatment should be instigated for orbital cellulitis?
Intravenous antibiotics covering aerobes and anaerobes
Nasal decongestants and analgesia
How should orbital cellulitis be investigated?
CT orbits and sinuses
FBC, CRP
Blood cultures
Swab of any discharge
The patient is reviewed by the consultants from Ophthalmology and ENT. There is non-axial proptosis and diplopia due to restriction of eye movements. There is a left relative afferent pupillary defect (RAPD). The CT scan shows maxillary and ethmoid sinusitis and a large (>10mm) medial orbital subperiosteal abscess.
What should be the next step?
Emergency drainage of orbital abscess and ethmoid and maxillary sinuses
Non-axial proptosis occurs when a lesion outside the muscle cone pushes the eye sideways as well as forwards
What are the potential complications of untreated orbital cellulitis?
Loss of vision/ blindness
Meningitis
Cerebral abscess
Cavernous sinus thrombosis
Give 4 differential diagnoses of eyelid swelling in adults (excluding orbital cellulitis)
Pre-septal cellulitis
Infected chalazion
Dacryoadenitis (inflammation of lacrimal gland)
Angioedema / Acute allergic reaction
What is the most likely aetiology of this current stroke?
Embolic event from a carotid dissection
What other non- atherosclerotic causes for stroke are seen in young patients?
Cardiac embolism - AF, prosthetic heart valves, infective endocarditis
Drugs - especially cocaine
Thrombophilia
Intracranial vascular malformations including aneurysms
What are the features of Virchow’s triad?
Intravascular vessel wall damage
stasis of flow
the presence of a hypercoagulable state.
A 22-year-old male patient presents to you 4 days after sustaining nasal trauma in a fight. His nasal breathing has been much worse since the injury, and he feels the shape of his nose has changed considerably.
How would you perform the initial assessment for this patient?
Palpation for orbital rim fracture
Examine full range of eye movements
Examine nasal cavity for septal deformity and obstruction
Palpate septum for septal haematoma
Intitial mx of patient with impaired nasal breathing after trauma to the nose?
Refer urgently to outpatient ENT clinic for manipulation under local anaesthetic – this improves nasal patency and appearance and may save a later operation
If a septal haematoma is found arrange for immediate ENT review and haematoma management
What advice would you give the patient with the nasal trauma ?
- Avoid any contact sports for four weeks
- Don’t try to clean the inside of the nose
What are the potential complications of nasal trauma that deform the nose?
- Nasal obstruction due to septal deviation
- Cosmetic change or deformity
- Septal necrosis secondary to a haematoma or abscess
What are the reasons, not related to nasal trauma, for long term nasal obstruction?
- Septal deviation
- Inferior turbinate hypertrophy
- Nasal polyps
- Allergic rhinitis
Can you think of other causes for nasal obstruction/bleeding or disease which are self-inflicted?
- Nose picking
- Cocaine use
- Nasal ketamine use
- Otrivine or Sudafed / oxymetazoline long term use
Using dermatology terminology, give four features seen in the images to support the diagnosis of psoriasis.
Erythema
Well defined plaques
White/silvery/thick scale
Extensor surfaces
Hyperkeratotic (or thick) nails, subungal hyperkeratosis, pitting of nails, onycholysis
