Ophtalmology, ENT, Dental Flashcards
(39 cards)
“<span>Aside from historical features of the patient with epistaxix, what features of a nose bleed would be consistent a posterior source for the bleeding?</span>”
-No anterior bleeding site visible<br></br>-Failure to achieve hemostasis despite anterior source control<br></br>-Bleeding from both nares<br></br>-Unstable hemodynamics
“<span>The epistaxis persists. Along with adequate topical anesthesia, name 3 topical pharmacologic agents which could aid with hemostasis.</span>”
-Oxymetazoline<br></br>-Phenylephrine<br></br>-Epinephrine<br></br>-Cocaine<br></br>-Silver nitrate<br></br>-Tranexamic Acid
“<span>What is the next most appropriate step in management of refractory epistaxis?</span>”
-Posterior nasal packing. (double balloon nasal pack, foley tamponade, etc)
What are the potential complications of nasal packing?
-Septal necrosis<br></br>-Sinusitis/OM<br></br>-Septal hematoma/abscess (trauma from pack insertion)<br></br>-Dislodgement of packing/ packing failure/ rebleeding
“<span>26 year old female presents with a 1 day history of worsening dysphagia, odynophagia, and dyspnea that is worse while lying flat.<br></br></span><span>Name 5 diagnoses on your differential.</span><span><br></br></span>”
-Epiglottitis<br></br>-Pharyngitis<br></br>-Infectious Mononucleosis<br></br>-Diphtheria<br></br>-Deep space neck abscess<br></br>-Retropharyngeal abscess<br></br>-Laryngeal trauma<br></br>-Foreign body aspiration<br></br>-Laryngospasm
“<span>Name the 2 most likely etiologic organisms in this patient (adult)</span>”
-Streptococcus sp.<br></br>-Staphylococcus sp.<br></br><br></br>** note this question specifics “this” patient, ie an adult who is likely immunized against H influenzae type B. Therefore, although this a possible organism it is no longer the most likely offending organism in this age group.
Most common bacteria in orbital cellulitis
Staph aureus<br></br>strept pneumoniae
“<span>48 year old male presents with a 4hr history of increasingly severe right eye pain, blurred vision after a routine optometry appointment screening for diabetic retinal changes. Physical exam reveals the following:<br></br></span><img></img><span><br></br></span>”
-Cloudy appearance of the cornea<br></br>-Conjunctival injection<br></br>-Fixed mid-dilated pupil<br></br><br></br>* Note the stem should cue you to a common precipitant of acute angle closure glaucoma – administration of dilatory agents in those who are prone to this condition
“<span>Painless acute persistent loss of vision:</span>”
“<ul> <li><a>central retinal artery occlusion</a>(CRAO)</li> <li><a>central retinal vein occlusion</a>(CRVO)</li> <li><a>retinal detachment</a>or hemorrhage</li> <li><a>vitreous hemorrhage</a></li> <li><a>optic or retrobulbar neuritis</a></li> <li><a>internal carotid artery occlusion</a></li> </ul>”
Painful acute loss of vision:
“<ul><li><a>acute angle closure glaucoma</a></li><li>Temporal arteritis</li><li>Corneal ulcer</li><li><a>endophalmitis</a></li><li><a>uveitis</a>/irits</li><li>keratoconus</li></ul>”
Medication classes for Rx of Glaucoma
-Topical B-blocker (Timolol)<br></br>-Topical alpha-agonist (Apraclonidine)<br></br>-Carbonic anhydrase inhibitor IV/PO (Acetalzolomide)<br></br>-Osmotic IV (mannitol)<br></br>-Topical miotic (pilocarpine)
<p>What clinical signs would support temporal arteritis?</p>
<ul> <li>1. Retinal appearance</li> <li>2. Temporal artery tender</li> <li>3. Relative afferent pupillary defect (Marcus Gunn defect)</li> </ul>
“<img></img>”
“<img></img>”
“<img></img>”
<ul> <li>1. Macular Cherry red spot</li> <li>2. Retinal Pallor</li> </ul>
<p>Central retinal artery occlusion</p>
Rx of CRAO
<p>1.Consider Orbital massage (.5)</p>
<p>2.Emergent (immediate) Opth consult (1)</p>
<p>3.Lower IOP if increase (.5)</p>
<p>4.Consider intraarterial thrombolysis with IR(.5)</p>
“Describe<br></br><img></img>”
“<img></img>”
Optic Neuritis
“<img></img>”
“<img></img>”
Perilimbal Flush<br></br>Hypopyon<br></br><br></br>Most likely due to Iritis/uveitis
Iritis/uveitis, what to ask further in Hx?
Arthritis<br></br>Urethritis<br></br>GI sym (IBD)
Iritis/uveitis, what are other signs?
Contralateral photophobia<br></br>Cell in ant chamber by slit lamp
Iritis/uveitis, Treatment
Cycloplegia/mydriatic<br></br>Topical steroids<br></br>Urgent ophth consult within 24 hrs
What historic features are important in orbital cellulitis?
<b><u>Hx of:</u></b><br></br>URTI (sinusitis)<br></br>Trauma<br></br>Pain<br></br>Fever<br></br>
What physical features are important in orbital cellulitis?
VA<br></br>EOM (painful)<br></br>Proptosis
“<img></img>”
Teardrop sign (orbital floor #)<br></br>Air/fluid level in lt max sinus<br></br>Maxillary wall #
Orbital wall #, Describe 2 important physical exam that should be performed and why
1.Assess EOM specifically upper gaze(1) (entrapment of inferior rectus muscle)
2.Visual acuity (.5)
3.Slit lamp to rule out Hyphema (.5)
1.Apply Protective Fox eye shield (1)
2.IV broad spectrum ABTS(.5)
3.Emergent OPTH consult (1)
- Imaging of globe (CT or plain films)
5.Assess Tetanus status, if unknown give TD (.5)
"Check IOP
Dilate the pupil
Urgent cons
Hyphema treatment
- 1 drop of 1% atropine
- 1 drop of 1% prednisolone
- Fox shield
- If globe intact and Pressure>30 Timolol
- Acetazolamide ( exception sickle cell)
- If no response Mannitol
- Sickle Cell keep pressure<24
- Emergent Opth consult
- If 1/3< may be tx as outpatient
Tumor
DM
Mydriasis
Failure of adduction and upward gaze (Down and out)
-Environmental: dry cold conditions, prolonged inhalation of dry air (e.g. nasal cannula)
-Latrogenic: e.g. NG insertion
-Medicinal: topical steroids, antihistamines, solvent inhalation (huffing), snorting cocaine
-Coagulopathies
-Vascular anomalies: e.g. neoplasms
-Cannot directly visualize source of bleeding
-++ fresh blood in posterior pharynx
-Ongoing bleeding despite bilateral anterior packing
-Hemodynamic instability
-Administration of PRBC
-Administration of FFP (for resus and reversal of DOAC)
-Consider platelet infusion
-Consider PCC/octaplex
-Consider securing the airway
-Consider small IVF bolus (blood is better)
ENT consultation
Provide a differential diagnosis of painless vision loss
Central retinal artery occlusion
Central retinal vein occlusion
Vitreous detachment/hemorrhage
Retinal detachment
Pre-chiasmal space occupying lesion
Macular degeneration
Amarosis fugaux
Malingering
Conversion disorder
- Vitreous hemorrhage
- Retinal detachment
- Retinal ischemia
- Optic neuritis
- Acute angle-closure glaucoma
- Open-angle glaucoma
- Vitreous hemorrhage
- Orbital cellulitis/abscess
- Retrobulbar hemorrhage
- Hyphema
- Iritis with hypopyon
- Chronic steroid eye drop use
- Enopthalmitis
- Incorrect measurement technique
- Ocular malignancy
- Vomiting
- Ocular trauma
- Blunt or penetrating trauma
- Previous surgery
- Synechiae from prior iritis or other inflammatory conditions
- Acute angle‐closure glaucoma
- severe uveitis
- acute loss of vision (from CRAO, temporal arteritis, retinal detachment or optic neuritis)
- significant corneal ulceration of >1mm in length
