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NURP532 > Week 2 Ophthalmology & ENT > Flashcards

Week 2 Ophthalmology & ENT Flashcards

1
Q

Clinical manifestation of Herpes Zoster Opthalmicus

A

Hutchinson sign

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2
Q

Clinical manifestation of allergic conjunctivitis

A

Boggy conjunctiva

Bilateral eye itching

Tearing

Rhinitis

Family/ Current history Atopy

Follicular reaction of conjunctiva redness, swelling

Stringy, mucoid discharge

Vision screening is generally normal

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3
Q

Clinical manifestations of retinal detachment

A

Sudden onset visual field defect

Floaters

Photopsia “flashing lights”

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4
Q

Clinical manifestations of uveitis #5

A

Pain

Photophobia

Eye Redness

Irregular pupil shape & no pupil constriction

Ciliary flushing (ring of red around cornea)

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5
Q

Clinical manifestations of acute angle glaucoma

A

Eye pain

Eye redness

Halo around lights

N/V

Headache

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6
Q

Clinical manifestations of Chalazion

A

non painful nodule located away from the eyelid margin

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7
Q

clinical manifestations of hordeolum

A

painful nodule on eyelid margin

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8
Q

Clinical manifestations of viral conjunctivitis

A

Red eye watery discharge follicles on conjunctiva

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9
Q

Clinical manifestations of bacterial conjunctivitis

A

Conjunctiva injection purulent discharge gradual onset

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10
Q

Clinical manifestations of AMaurosis Fugax

A

Monocular vision loss lasting less than 30 mins

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11
Q

What eye problems require an urgent referral?

A

Keratitis

Herpes zoster opthalmicus

Acute angle glaucoma

Scleritis

Orbital cellulitis

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12
Q

A 6-year-old male presents with right ear pain of 2 days. He denies fever or recent upper respiratory symptoms. On exam, the nurse practitioner notes some tenderness with palpation of the tragus and mild erythema and edema of the ear canal. There is no discharge. The TM appears grey, intact, with a normal light reflex and visible bony landmarks. The nurse practitioner treats the patient with which of the following?

A

Neomycin, polymixin B, hydrocortisone (Cortisporin) otic solution

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13
Q

A 45-year-old male woke up 3 days ago with dizziness when turning over in bed. The dizziness has persisted, and he notes that it occurs with turning his head or position change. The episodes are brief, about 30 seconds, and are associated with mild nausea without vomiting. He denies headaches, hearing loss, tinnitus, ear pain, vision problems or weakness. His physical exam is normal. The nurse practitioner should next perform

A

Dix-Hallpike test

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14
Q

The nurse practitioner is seeing a 12-month-old female with fever of 101–102 degrees F and irritability for 2 days. She has a past medical history of left acute otitis media at 8 months of age; otherwise, she has only been seen in the clinic for her well-child visits. Her immunizations are up-to-date. On exam, the nurse practitioner notes erythema, bulging, and no visibility of the bony landmarks of both TMs. There is no drainage noted and the ear canal appears normal. The plan of care should include

A

treatment with amoxicillin.

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15
Q

Meniere’s disease is characterized by

A

hearing loss, tinnitus, & vertigo

*vertigo lasting at least 20 minutes associated with hearing loss.

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16
Q

A peritonsillar abscess should be treated with oral clindamycin and follow up with an otolaryngologist in 24 hours. True or false?

A

False. Send to ED for I&D and IV antibiotics

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17
Q

A 3-year-old male presents for rhinorrhea, sneezing, and watery eyes for 2 weeks. The parents reports that he has been afebrile and otherwise is active, playful, and has a good appetite. The child and parents deny pain, sore throat, cough, trouble breathing, or gastrointestinal symptoms. He does not attend daycare/preschool. First-line pharmacologic management of this patient should include…

A

Fluticasone Nasal Spray Allergic rhinitis

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18
Q

What pathogens commonly cause Acute Bacterial Rhinosinusitis?

A
  • Strep Pneumo
  • H. Flu
  • Moraxella Catarrhalis
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19
Q

An 8-year-old male presents for a sore throat and fever for 24 hours. His father reports that his temperature has been running about 101 degrees F and is reduced with ibuprofen. He has no rhinorrhea or cough. His exam shows erythematous tonsils with exudate that are 2+. He has swollen, tender, anterior cervical nodes. His centor score is

A

5

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20
Q

What are are a common lab findings in infectious mono?

A

Elevated Lymphocytes

Elevated LFTs

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21
Q

A patient with a centor score of 3 should receive empiric treatment with antibiotics. True or False?

A

A centor score >5 empiric antibiotics

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22
Q

What are possible causes for Ocular Pain and Photophobia?

A

Acute glaucoma

Corneal Trauma

Iritis/Uveitis

Scleritis

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23
Q

What are the causes of eye pain and N/V?

A

Acute glaucoma

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24
Q

What are the possible causes of eye pain and itching?

A

Chemical Injury

Severe dry eye

Allergy

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25
Q

What are the possible causes for pain on eye movement?

A

Optic Neuritis

Trauma

Orbital cellulitis

Trauma’

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26
Q

What are the possible causes of eye pain and foreign body sensation?

A

Corneal ulcer or abrasion

Conjunctivitis

Eyelid lesions

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27
Q

List the Centor Scores

A

Fever

Tonsillar Exudate

Tender anterior cervical lymph nodes

Absence of cough

<15 years old

>45 year old (-1)

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28
Q

Immediate referral is indicated for acute otitis media in children ____ months or younger, and in children who appear _____ .

A

Immediate referral is indicated for acute otitis media in children 6 months or younger, and in children who appear toxic .

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29
Q

What is the primary bacteria in a peritonsillar abscess?

A

Group A Strep

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30
Q

What are DDx for peritonsillar abscess?

A

Infectious Mono

Tumors

Peritonsillar cellulitis

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31
Q

How would you tell the difference between infectious mono and peritonsillar abscess?

A

Serologic findings

In mono: headache, malaise, fatigue and anorexia are present before sore throat

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32
Q

Difference between viral and bacterial pharyngitis?

A

Viral

  • Sudden onset
  • Productive Cough
  • No lymphadenopathy
  • Conjunctivitis

Bacterial

  • Cough, conjunctivitis, and myalgia not present
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33
Q

Viral Conjunctivitis

Cause

S/S

How long until it resolves?

Management

A

Cause: Adenoviral Conjunctivitis; recent or concurrent viral URI

Symptoms:

  • Redness, tearing, watery discharge, itching, irritation
  • Eyelid Edema, injected conjunctiva, periauricular adenopathy
  • Starts unilateral moves to other eye

​Resolves: Lasts 5-14 days; improves in 1-2 weeks

Management:

  • Cool Compress
  • Lubricating drops
  • Transmission prevention education
  • Good hand washing, don’t share towels, wash pillowcases
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34
Q

Bacterial Conjunctivitis

Common causes:

  • which have gradual onset?*
  • Which have rapid onset?*
A

Gradual Onset

  • H. influenzae (most common in children Dec. – April)
  • Streptococcus pneumoniae
  • S. aureus

Rapid Onset

  • Gonorrhea (more purulent discharge, more severe infection) *neonate & adolescent
  • Chlamydia *neonate & adolescent
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35
Q

Bacterial conjunctivitis:

Adult Management

vs

Child Management

A

Adult Management

  • Tx healthy adults conservatively; may resolve spontaneously
  • Empiric topical for 1 week
  • Gentamycin, ciprofloxacin, azithromycin, erythromycin, sulfacetamide, trimetheoprim/polymyxinb
  • If chlamydia or gonorrhea = follow CDC guidelines

Child Management (treat empirically to cover H. influenzae; culture not necessary)

  • <12 months: 1st line Trimethoprim sulfate plus polymyxin B sulfate ophthalmic solution
    • 2nd line: Erythromycin 0.5% ophthalmic ointment (if sulfa allergy)
  • Over 12 months = Fluoroquinolone or Azithromycin (if sulfa allergy)
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36
Q

What would you prescribe a child with bacterial conjunctivitis with otitis media…

Usual infectious agent

Treatment

How long until it resolves?

What if there is no improvement?

A

Cause: H. Influenzae

Treatment: Augmentin

Resolves: 3 days

No improvement: Opthalmology referral

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37
Q

Allergic Conjunctivitis

Symptoms

Management

A

Symptoms:

  • Bilateral
  • Pruritis
  • Clear or White stringy discharge
  • Under eye dark circles “allergic shiners”
  • Boggy conjunctiva

Management

  • Avoid Allergen
  • Cold compress
  • Artificial tear
  • Oral antihistamines for systemic allergy symptoms
  • Eye drops: antihistamine, ocular mast cell stabilizer, dual
    • OTC: Ketotifen (antihistamine)
    • Prescription: Patanol or Olopatadine those >3 years (antihistamine)
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38
Q

Atopic Conjunctivitis

Who is this more common in?

S/S

Treatment

A

Adults >50 years with history of atopy

Symptoms: bilateral itching, burning, tearing

Treatment: mast cell stabilizer eye drop; Referral to ophthalmology

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39
Q

Dry Eye Syndrome

S/S #6

Diagnose

Differentials #3

Treatment

A

Cause: underlying autoimmune disease (Sjogren’s) or evaporative eye…due to lacrimal or meibomian gland dysfunction

Symptoms

  • Dry eye
  • Foreign body sensation
  • Scratchy gritty feeling
  • Burning
  • Stinging
  • Tearing (reflex from corneal irritation)

Diagnose: Schirmer test

Differentials

  • Trichiasis
  • Conjunctivitis
  • Corneal abrasion

Treatment

  • Avoid causative meds EX: anticholinergics or diuretics
  • Avoid AC or fans
  • Preservative-free lubricants
  • If no improvement, refer to Ophthalmologist for Cyclosporine eye drops
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40
Q

How would you diagnose dry eye syndrome?

How is this test performed?

A

Schirmer test: determines if evaporative dry eye VS lacrimal problem

  1. Filter paper on inferior cul-de-sac
  2. How wet is paper after 5 mins?
  3. <10mm without anesthesia= abnormal = aqueous-deficient dry eye
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41
Q

Subconjunctival Hemorrhage

What is it?

Causes

How long for it to resolve?

A

What: Bleeding between conjunctiva & sclera

Cause:

  • Increased pressure in capillaries: cough, sneeze, or straining
  • Medications: Blood thinners, HTN, DM

Resolves in 2 weeks

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42
Q

What are the ocular adnexal disorders?

A

Blepharitis

Hordeolum (stye)

Chalazion

Nasolacrimal duct obstruction

Preseptal and orbital cellulitis

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43
Q

Blepharitis

What is it?

Causes?

S/S #6

Treatment

Treatment if it’s d/t s. aureus

Treatment if it’s severe/persistent

A

What: Inflammation of eyelid

Cause:

  • S. aureus
  • Seborrheic dermatitis
  • Rosacea

Symptoms

  • Burning
  • Foreign body sensation
  • Tearing
  • Eyelid swelling
  • Itching
  • Discharge
  • Yellow scales along eyelid margin

Treatment (usually resolved on its own, can be recurrent)

  • Warm compress 10 mins, multiple times/day
  • Lid hygiene: dilute baby shampoo and cleanse daily
  • If d/t S. aureus: topical antibiotic
  • If severe/persistent: Doxycycline 50mg BID
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44
Q

Hordeolum

Cause

Symptoms

Treatment

Complications

A

Cause: Blocked meibomian gland = bacteria growth S. aureus

Symptoms:

  • Mild swelling, tender, warm inflamed nodule
  • Nodule on eyelid margin “pimple”
  • Tender
  • NO EYE INJECTION, NO DISCHARGE

Treatment

  • Lid hygiene
  • Warm, moist compress 10mins 4x/day
  • Referral for I&D if large, persistent
  • Resolves after 1-2 weeks

Complications: Preseptal cellulitis

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45
Q

Chalazion

What is it?

Cause

Symptoms

Treatment

How long to resolve?

A

What: Chronic, non-painful, non-infectious nodule

Cause:

  • Results from stye
  • From meibomian gland obstruction/inflammation

Symptoms

  • Located away from eyelid margin
  • more firm, chronic & non tender than stye

Treatment

  • Warm compress
  • Gentle Massage
  • If persistent: Referral for incision or steroid injection

Resolves weeks to months

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46
Q

Nasolacrimal duct obstruction

  • Symptoms
  • Treatment for child
  • Treatment for adult
  • Complication
  • DDx
A

Symptoms

  • Begin at 2-6 weeks; resolve at 6 months
  • Overflow of Mucoid discharge
  • Tearing
  • Dried mucus
  • Eyelid inflammation

​Child Treatment

Massage lacrimal duct daily

If not resolved by 12 months = referral for probing procedure

Adult Treatment

Surgery

Complications:

Dacryocystitis

Differential Diagnosis

  • Orbital cellulitis
  • Conjunctivitis
  • Neoplasm
  • Blepharitis
  • Chronic dry eyes
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47
Q

Dacryocystitis

Symptoms

Treatment

A
  • inflammation, redness, swelling of lacrimal sac
  • Fever & leukocytosis
  • Inferior to medial canthus

Treatment: systemic antibiotics (penicillinase-resistant), topical optic abx drops

If an abscess = referral for I&D

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48
Q

What are the usual causes of preseptal and orbital cellulitis?

A
  • Strep
  • Staph
  • anaerobic bacteria
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49
Q

Preseptal Cellulitis

What is it?

Symptoms

Treatment for <2 years

Treatment for >2years old

Treatment if the cause is MSSA/strep?

Treatment if the cause is MRSA?

When to follow up?

A

What: Superficial Infection

Symptoms:

  • • Eyelid Swelling & Warmth
  • • Erythema further beyond eyebrow
  • • NO PAIN W/EYE MOVEMENT

Treatment

  • <2 years: hospitalization w/IV abx
  • >2 years: outpatient tx
    • o 3rd generation cephalosporin (Ceftriaxone/Rocephin) or Augmentin
    • o MSSA/strep: dicloxacillin or cephalexin
    • o MRSA/strep: clindamycin
  • Follow up 12-24 hours
50
Q

What does a positive Shirmer test mean?

A

Aqueous duct defect

51
Q

Orbital Cellulitis

What is it?

Symptoms?

Treatment

DDx

A

What: Severe infection of soft tissue posterior to orbital septum

Medical Emergency that effects eye

Symptoms:

  • Erythema centered in middle of eye
  • Restricted & painful eye movements
  • Chemosis (eye tissue swelling)/increased intraocular pressure
  • Proptosis (late sign; “exopthalmus”)
  • Decreased Visual acuity & diplopia (shows optic nerve compromise)

Treatment

  • Emergency Room
    • CT scan
    • if untreated = vision changes

Differential diagnosis

  • Thyroid disease
  • Severe conjunctivitis
  • Idiopathic orbital inflammatory syndrome
52
Q

Uveitis

What is it?

S/S

Treatment

Who is most effected?

A

Uveitis *Painful Red Eye*

What: Inflammation of choroid, ciliary body or iris

Symptoms

  • Pain
  • Photophobia
  • Conjunctival hyperemia
  • Irregular Pupil shape & constriction/restriction DOES NOT REACT WELL
  • Ciliary flush (ring of red/violet spread around cornea of eye)
  • Blurred vision
  • Epiphoria (excessive watering)

Symptoms develop over 1-2 days; Uncomfortable patient

Treatment:

  • Same-day referral
  • Corticosteroid eye drops

Who:

  • Underlying inflammatory condition
  • Autoimmune disease EX: RA, IBD
  • HLA-B27 gene
53
Q

Keratitis

What?

Cause?

S/S

Treatment

Who is most commonly affected

A

Keratitis *Painful Red Eye*

What: Corneal epithelium defect = bacteria penetrate cornea = leads to ulcerations

Cause: Infectious (bacterial, viral or fungal) or noninfectious

Symptoms:

  • Very painful
  • Photophobia
  • Dry, Red eyes
  • Discharge
  • Difficulty keeping eyes open

Treatment

  • Same day referral

Who

  • Contact lenses wearers that sleep with their contacts
  • Dry eyes
  • Difficulty closing eye
54
Q

Herpes Zoster Opthalmicus

What

S/S

  • prodrome?
  • Unique symptoms? #2
  • other symptoms #5

Treatment

A

Herpes Zoster Opthalmicus

What: Vesicular eruption along trigeminal nerve & subsequent conjunctivitis

Symptoms

  • • Prodrome: malaise
  • • Pain along trigeminal nerve
  • • Hutchinson Sign*: lesion at tip, side or root of nose
  • • Red eye
  • • Foreign body sensation
  • • Tearing
  • • Blurred vision
  • • Photophobia

Treatment

  • • Same day referral
  • • Oral antivirals
  • • optic Corticosteroids
55
Q

Scleritis

What

Who

S/S

Treatment

A

Scleritis *Painful Red Eye*

What: Sclera inflammation

Who: Autoimmune disorders (lupus, scleroderma, IBD)

Symptoms:

  • Severe eye pain radiates to brow or jaw
  • Eye Tenderness
  • Blurred Vision
  • Inflamed Sclera
  • Tearing
  • Photophobia

Treatment

Same day referral

56
Q

Episcleritis

What?

Symptoms

Treatment

A

What: Self-Limited; Superficial inflammation

Symptoms:

  • Painless
  • Localized injection of sclera

Treatment

  • None; resolved 1-2 weeks
  • Lubricating eye drops
  • Patient Education: pain develops = scleritis = Same Day Referral
57
Q

Corneal Abrasion

Cause

Who is most affected

Symptoms

Diagnosis

Differentials

Treatment

Education

A

Cause: Eye trauma

Who: contact lens wearers; carpenter; metal worker

Symptoms:

  • Severe sudden onset pain
  • Tearing
  • Redness

Diagnosis

Fluorescein stain

Differentials

  • Corneal Ulcer
  • Herpetic keratitis
  • Dry eye syndrome

Treatment

  • Topical abx ointment (preferred over drops because more lubrication)
  • Lubricating drops
  • Ibuprofen
  • (contraindications = steroids because inhibit healing)

Education

Heal 1-3 days

If no improvement: same day referral

Worsening symptoms: eye pain, photophobia…

58
Q

Acute Angle Closure Glaucoma

What?

Symptoms

Risk factors

A

Ophthalmic Emergency

What: Abrupt Increase in intraocular pressure; Increased resistance to aquous humor outflow from posterior into the anterior chamber = increased pressure = optic nerve damage

Symptoms:

  • Pain
  • Redness
  • Blurred vision “halos” around lights
  • Headache
  • N/V

Risk Factors

  • >50 years
  • Family history
  • PMH acute angle glaucoma in other eye
59
Q

Retinal Detachment

What

Symptoms

Exam findings

Risk factors

DDx

Treatment

A

_Medical Emergency *Decreased Vision*_

What: Inner layer of retina separation from choroid and retinal pigment epithelium

Symptoms:

  • Sudden onset visual field defect
  • Floaters
  • Photopsia “Flashing lights”

Exam Findings

Retina Elevation “gray w/ dark blood vessels”

Risk Factors:

  • High myopia “very nearsighted”
  • Trauma
  • Vascular Disease
  • History of vitreous disease/degeneration

Differential Diagnosis

  • Migraine with aura
  • Vitreous detachment
  • Retinal artery or vein occlusion

Treatment

  • Emergency room
  • NPO (surgical treatment)
60
Q

Optic Neuritis

What?

Risk Factors #3

S/S #5

Exam findings #4

Treatment

What illness is this consistent with?

A

What: Demyelinating inflammation of optic nerve

Risk Factors:

  • Multiple Sclerosis
  • Young females
  • Preceding Viral infection

Symptoms

  • Unilateral (sometimes bilateral)
  • Dyschromatopsia (change in color perception)
  • Pain with eye movement
  • Vision loss with exercise & heat
  • Objects appear distorted/curved

Exam Findings

  • Decreased Pupil light reflex
  • Decreased visual acuity
  • Central scotoma
  • Swollen optic disc

Treatment

  • Emergency room
  • IV steroids then oral steroids
  • Brain MRI (look for demyelinating lesions consistent with MS)
61
Q

Amaurosis Fugax

What?

Cause

Symptoms #3

Risk Factor

Treatments

DDx

A

Amaurosis Fugax *Decreased Vision*

What: Transient monocular loss of vision; sub-form of TIA; loss blood flow

Cause: Retina choroid & optic nerve ischemia from plaque build up in eye; Giant Cell Arteritis

Symptoms:

  • Gray curtain moving from the periphery into center of visual field
  • “Brief” seconds up to 30mins.
  • Unilateral

Risk Factors

>45 years

Treatment

  • Neurological & Cardiologic exam
  • Hypercoagulability
  • Assess for TIA
  • Same Day Referral
  • Carotid US
  • If concerned giant cell arteritis, check inflammatory markers

Differential diagnosis

Retinal Artery Occlusion (but more persistent symptoms) = Emergency

62
Q

What are causes of Otitis Media?

A

Cause: Bacteria & Virus (S. pneumoniae, H. influenzae, Moraxella catarrhalis, and S. pyogenes)

63
Q

Acute otitis media

Symptoms

Diagnostic criteria #5

A

Symptoms

  • Ear pain
  • Ear pulling
  • Otorrhea
  • Pain worse with lying down

Diagnosis

  • Recent onset middle ear inflammation
  • Bulging/painful/red TM
  • Decreased mobility of air-fluid levels
  • Needs presence of effusion for diagnosis**
  • Pneumatic otoscopy to determine TM mobility
64
Q

How would you manage Acute Otitis Media?

Non Pharmacologic options

When would you prescribe antibiotics?

When would you only observe?

A

Nonpharmacologic

  • Pain Control
  • Heat/Cold Compress
  • Distraction

Antibiotic therapy if…

  • <6 months old
  • <12years old with underlying condition
  • >6 months old with severe infection, pain >48 hours

Observation only if…

  • 6-23 months non severe, unilateral AOM
  • >24 months
65
Q

When would someones AOM symptoms get better?

A

in 3 days

66
Q

What are some complications of Acute Otitis Media?

A
  • Mastoiditis
  • Peforation
  • Effusion
  • Cholesteatoma
67
Q

What is Mastoiditis?

Management plan?

A
  • Rare; complication of AOM

Symptoms

  • Ear pain
  • Posterior ear & mastoid process swelling

Management

  • Urgent referral
68
Q

What is a Tympanic Perforation?

S/S

Treatment

How long to resolve?

A

Pain suddenly disappears and otorrhea

Treatment

Cipro dops & Oral antibiotics

Resolution

Mild = resolves in weeks

69
Q

What is an effusion?

S/S

Management if the effusion lasts more than 3 months?

What if it lasts more than 6 months?

A

Persistent fluid behind ear

S/S

Pressure sensation

Hearing Loss

Effusion Lasts >3 months = hearing testing

Hearing loss or Effusion lasts >6 months = ENT referral for T-tube

70
Q

What is a Cholesteatoma?

Cause

S/S

Exam Findings

Tx

A

middle ear epidermal inclusion cyst

Cause: AOM or congenital

S/S: hearing loss, vertigo, asymptomatic

Exam Findings: Pearly white lesion on TM

Tx: ENT referral

71
Q

What is antibiotic therapy for AOM in children?

What is 1st line?

What if they have a non type 1 allergy?

What if they have received Amoxicillin in last 30 days?

What if they’re vomiting?

A

1st line: Amoxicillin

2nd line:

  • If allergic, give Cephalosporin
  • If received Amoxicillin in last 30 days, give Amoxicillin clavulanate
  • If vomiting, Ceftriaxone (can be given as 1 dose)

*Azithromycin (macrolides) high resistance rate

72
Q

Otitis Externa causative agents

A

S. aureus

Pseudomonas

Candida

73
Q

Otitis Externa

Symptoms #4

Exam Findings #3

Treatment

A

Symptoms

  • Pain with palpation
  • Drainage
  • Fullness/clogged/itchy feeling
  • Hearing Loss

Exam Findings

  • Tenderness with tragus palpation or auricle manipulation
  • Otoscope shows: edema, ear canal erythema, canal discharge/debris
  • NORMAL TM

Treatment

  • Topical abx: fluoroquinolone (Cipro or Acetic acid)
  • If no improvement, fungal infection esp if DM or immunocompromised
  • Systemic abx only if AOE spreads outside ear
  • Reassess in 48-72 hours
74
Q

Tinnitus and the quality of its pitch

High-pitched =

Low-pitched =

Pulsating =

Ocean =

Clicking =

A

o High pitched->sensorineural hearing loss

o Low pitched->idiopathic or Meniere disease

o Pulsating->vascular origin

o Ocean->eustachian tube dysfunction

o Clicking->TMJ

75
Q

Vertigo & Hallmark signs of peripheral lesions #3

A

Nausea

Normal Neurologic findings

Symptoms that are position related

76
Q

List Peripheral causes of vertigo

A
  1. Benign Positional Paroxysmal Vertigo #1 Cause
  2. Vestibular Neuritis #2 cause
  3. Bacterial labyrinthitis
  4. Viral Infections
  5. Meniere’s disease
  6. Neuroma
77
Q

Benign Positional Paroxysmal Vertigo

Cause

S/S

How to diagnose

Treatment

A

Cause: Crystal in ear that maintains balance in wrong place (Dix-Hallpike Maneuver tests this crystal)

Symptoms: Episodic vertigo <30 seconds, nystagmus with Dix-Hallpike Maneuver

Diagnosis: History & Dix-Hallpike Maneuver (Affected Ear will be down)

Treatment: Epley maneuver, surgery, Vestibular rehab

78
Q
A
79
Q

Vestibular Neuritis

A

Cause: inner ear nerve inflammation; usually viral or AOM “had a cold 1 week ago”

Symptoms:

  • Sudden onset of continuous vertigo
  • Persistent, Severe spinning,
  • Horizontal nystagmus
  • Gait instability
  • VERY nauseous,
  • lasts for 5 days or resolved in 2 weeks;
  • aggravated w/movment

Diagnosis: Dix-Hallpike maneuver will be positive, Romberg test

Treatment: antihistamine (Meclizine); anticholinergics; antiemetic (only for 3 days); hydration; no driving; vestibular rehab

If it doesn’t resolve in 4-6 weeks refer to ENT*

Resolves: can last up to 5 days

80
Q

Meniere’s disease

Cause

Symptoms

Treatment

Education

Differentials

A

Cause: Excessive fluid in the inner ear

Symptoms:

  • Sensorineural Hearing loss (AC>BC);
  • tinnitus (usually unilateral);
  • recurrent vertigo;
  • feeling of fullness/ringing in affected ear

Vertigo lasting at least 20 mins associated w/hearing loss

Treatment: No cure;

  • Referral ENT;
  • antiemetics, antihistamine, H1 receptor agonist, diuretics

Education: Low sodium, low caffeine, low alcohol

Differentials: TIA, neuroma, tumor, syphillis

81
Q

What are the hallmarks of central lesion etiologies for vertigo?

A

Spontaneous vertigo (NOT POSITION RELATED)

Focal neurologic findings

No significant nausea or imbalance

82
Q

Vestibular migraine

Describe the vertigo

What are the associated symptoms?

A

Vertigo: Severity and Duration Varies

*Similar triggers as migraine like stress*

Associated S/S: migraine headache, photophobia, nausea, phonophobia

83
Q

How is Recurrent AOM defined?

A

3 separate bouts of AOM within a 6 months period

OR

4 within a 12-month period

Usually a family history of AOM and other ENT disease

84
Q

2-year-old female

CC: Irritable, temp 99 and rhinorrhea for 24 hours

PMH: healthy, Imm UTD, no hx of ear infection

NKDA

Exam: temp 100, irritable, clear rhinorrhea. Ear canals are clear. Right TM: as pictured with minimal movement with insufflation

  1. What is your diagnosis? Why is this only mild AOM? What would you recommend to treat this child?
  2. Child returns at 48 hours, no improvement. What do you do?
  3. Child returns 3 days later, no improvement. What do you do?
A

Mild: Temp only 99 & less than 48 hours of pain

Management: Monitor & pain control. Most get better in 3 days

No Improvement at 48 hours =

  • 1st line: High dose Amoxicillin
  • 2nd line
    • If allergy, 3rd gen cephalosporin
    • If anaphylaxis, azithromycin
    • If accompanied with conjunctivitis (need H. influenzae coverage) or already received amoxicillin, Augmentin

If no improvement at 3 days =

  • Switch to Augmentin or ENT referral
85
Q

Three most common organisms that cause bacterial conjunctivits

A
  • H. Influenzae
  • Strep pnuemo
  • Moraxella species
86
Q
A
87
Q

A 19-year-old woman presents to her primary care clinic complaining of a sore throat for 2 days. She also reports a fever that reached 100.5 degrees Fahrenheit the previous day. She denies cough. A friend at her place of employment also had similar symptoms. On physical examination, her neck reveals tender anterior cervical lymphadenopathy, and her tonsils are inflamed and without exudate. What should the nurse practitioner do next?

Select one:

a. Treat empirically with antibiotics to cover group A strep pharyngitis
b. Perform a rapid strep test and treat with antibiotics if positive
c. Order a mono test and follow up via phone tomorrow
d. Review treatment for viral pharyngitis with analgesics and fluids

A

b. Perform a rapid strep test and treat with antibiotics if positive

88
Q

A 25-year-old man presents to the primary care clinic with 3 weeks of facial pain and pressure. He describes a right-sided fullness and tenderness over his cheek. He has also had yellow-green drainage from his nose along with subjective fever, halitosis, and malaise. He felt as though he was getting better 1 week ago, but then his symptoms returned worse than ever. On physical examination, his right maxillary sinus is tender to palpation and percussion. Which of the following should be included in the management plan?

Select one:

a. Treat with amoxicillin or amoxicillin-clavulanate
b. Refer for a CT scan of the sinuses
c. Refer to an ENT specialist
d. Treat with an intranasal decongestant

A

a. Treat with amoxicillin or amoxicillin-clavulanate

89
Q

A 10-year-old female presents to the primary care clinic with complaints of a runny nose, sneezing, and watery eyes. Her mother reports that she always seems to have a cold. She is always sniffling and rubbing her nose. Her mother has noticed that she has developed a crease on the bridge of her nose. She looks fatigued to her mother and has dark circles under her eyes. Based on the suspected diagnosis, what should be included in the management plan?

Select one:

a. Oral antibiotics to cover strep pneumoniae
b. Oral decongestant
c. Intranasal corticosteroid
d. Referral for immunotheraphy

A

C. intranasal corticosteroid

90
Q

A 30-year-old with inflammatory bowel disease presents with redness, pain, photophobia, blurred vision and tearing in the right eye. The nurse practitioner notes a constricted pupil on exam and conjunctival hyperemia of the right eye. What diagnosis is most likely?

Select one:

a. Acute angle closure glaucoma
b. Episcleritis
c. Uveitis
d. Retinal detachment

A

c. Uveitis

91
Q

A 5-year-old child presents with swelling around the right eye for 2 days. The parents report that the child has been afebrile, but is complaining of pain in the eye. On examination, there is erythema and edema surrounding the eye and chemosis. The child has difficulty and pain when moving the eye. What is the best management plan for this presentation?

Select one:

a. Refer to the emergency room
b. Treat with an antibiotic that will cover staph aureus
c. Treat with warm compresses and lid hygiene
d. Place an urgent referral to ophthalmology

A

a. Refer to the emergency room

92
Q

A 48-year-old male presents for intermittent dizziness for 3-4 days associated with decreased hearing in the left ear. The patient denies ear pain, tinnitus, or recent upper respiratory infection. He reports that he feels like he is spinning. The episodes are not triggered and they last 2-3 hours. He denies nausea or vomiting. He has a normal neurological exam. The weber exam lateralizes to the right ear and the Rinne reveals air conduction is greater than bone conduction in the left ear. Which of the following should be part of the management plan?

Select one:

a. Perform a canalith repositioning maneuver
b. Referral to the emergency department
c. Prescribe a LOOP diuretic
d. Referral to otolaryngology

A

d. Referral to otolaryngology

93
Q

Acute Bacterial Rhinosinusitis

Symptoms

A

Symptoms

  • URI >10 days
    • Or acute symptoms in 1st 4 days
  • Severe sinus pain, pressure, fever
  • Nasal congestion
  • Purulent mucus
  • Facial pain/ pressure/headache that’s worse when patient bends over
  • Decreased hearing w/ eustachian tube dysfunction
94
Q

Acute Bacterial Rhinosinusitis

How to diagnose? #3

A
  • Persistent symptoms >7 days
  • Severe onset or high fever (>39C or 102F) & purulent nasal discharge or facial pain lasting 4 days at beginning of illness
  • Worsening symptoms (new onset fever, h/a, or increased nasal discharge)
95
Q

How to treat Acute Bacterial Rhinosinusitis

Adult

  • 1st line
  • 2nd line

Child

  • 1st line
  • 2nd line
    • with anaphylaxis allergy to 1st line =
    • with allergy to 1st line =
A

Adult

  1. Augmentin 7-10 days
  2. Doxycycline

Child

  • 1) Augmentin 10-14 days
  • 2.a.) Levofloxacin
    1. b) Clindamycin AND 3rd gen cephalosporin
96
Q

What is allergic rhinitis?

Hallmark symptoms

1st line treatment & how long does it take for full effect?

Severe symptoms Tx

Persistent severe symptoms Tx

Still persistent severe symptoms TX

A

IgE mediated; Causes include dust, dander, pollens

Hallmark symptoms = Sneezing & itching

1st line treatment = Intranasal corticosteroid (takes a few days for full effect)

Severe symptoms Tx = Intranasal corticosteroid & antihistamine

Persistent severe symptoms Tx = receptor antagonist

Still persistent severe symptoms TX = Immunotherapy

97
Q

Viral Pharyngitis

Cause:

Symptoms #6

Exam findings #2

Treatment

A

Cause *Viral pharyngitis is the most common*

  • EBV, HSV, CMV, adenovirus, rhinovirus

Symptoms

  • Runny nose/Nasal Congestion
  • Low grade fever
  • Cough
  • Malaise
  • Throat: scratchy & painful swallowing

Exam findings

  • Pharynx: mild erythema
  • NO PAINFUL LYMPH NODES OR EXUDATE

Treatment

  • Symptomatic
  • Resolves in 5-7 days
98
Q

What is Scarlet Fever?

A

D/t Group A Beta-Hemolytic Strep

Sore throat

5 days later…find sandpaper rash throughout body; circumoral pallow & strawberry tongue

99
Q

What are Pastia Lines?

What causes them?

A

Red lines in skin folds like inguinal or axillary

Cause: Group A Beta-Hemolytic Strep infection

100
Q

What ages are Group A Beta-Hemolytic Strep common in?

A

Ages 5-15 years

101
Q

What are some exam findings for Group A Beta-Hemolytic Strep?

What are some subjective findings?

A

Exam Findings

Tonsil inflamed, red, WITH EXUDATE

Anterior cervical lymphadenopathy

Soft palate petechiae*** suggests Group A strep

Scarlet Fever: Sore throat then 1-5 days later fine sandpaper rash throughout body; circumoral pallor & strawberry tongue (only w/scarlet fever)

Pastia lines: Red lines in skin folds like inguinal area or ancillary

Malodorous

Subjective Findings

  • Abrupt onset sore throat
  • Painful to swallow
102
Q

Group A Beta-Hemolytic Strep

Treatment

1st line:

2nd line:

a) PCN allergy
b) PCN anaphylaxis allergy

A

Treat 10 days

1st line: Penicillin or Amoxicillin

2nd line:

If allergy to PCN, Cephalexin or Cefadroxil

if anaphylaxis to PCN, Clindamycin or any macrolide

103
Q

Group A Beta-Hemolytic Strep

Education​

When would you recommend a Tonsillectomy?

A

Rash may peel 5-7 days later

Finish course of antibiotics to prevent rheumatic fever, glomerulonephritis & reactive arthritis

Feel better in 1-2days

Prevent transmission

Tonsillectomy

  • if 7+ sore throat episodes in year OR 5+ sore throat in 2 years
104
Q

Infectious Mononucleosis

What is the cause?

Symptoms?

Treatment?

Education?

A

Cause: EBV (HSV4)

Symptoms

  • Fever
  • Sore Throat
  • Lymphadenopathy *posterior cervical adenopathy most common*
  • Petechiae on soft palate
  • Splenomegaly
  • Hepatomegaly

Treatment

  • Hydration
  • OTC pain relievers
  • Avoid alcohol d/t liver inflammation
  • Avoid strenuous exercise d/t splenomegaly and possible spleen rupture
  • Follow up 2 weeks

Education

  • Acute symptoms resolve after 1-2 weeks
  • Persistent fatigue 2+ months
105
Q

What infection has a Prodrome, Acute and Resolution phase?

Describe each

A

Infectious Mononucleosis

Prodrome phase (mild symptoms): malaise, fever (maybe)

Acute Phase: (lasts 1-2 weeks)

  • Fever, pharyngitis, malaise,
  • discrete non-tender lymphadenopathy
  • Tonsillopharyngitis (exudative in 1/2)
  • Hepatosplenomegaly

Resolution Phase: (up to 4 weeks later) symptoms resolve & organomegaly takes up to 2 months to resolve

106
Q

How do you “work up” infectious mono? #6

A
  • Rapid strep test (strep is concurrent with mono usually)
  • Mono Spot(heterophile test) (2 weeks after symptoms to show positive test; usually negative for pts <4 years old)
  • CBC w/diff: atypical lymphocytes
  • LFTs: usually elevated

Used when primary screening results are negative

  • EBV capsid antigen
  • IgM early antigen
107
Q

What would you prescribe if someone had strep with mono?

A

Clindamycin or Azithromycin

(amoxicillin with mono = rash)

108
Q

Peritonsillar abscess

Cause

Differentials?

How to diagnose

A

Deep infection of head and neck. Collection of pus between palatine tonsil and muscles

Cause: Aerobic & anaerobic bacterial infection. Usually: Group A strep, S. aureus & Fusobacterium

Differential Diagnosis

  • Peritonsillar Cellulitis (can’t drain cellulitis)
  • Retropharyngeal or tetromolar abscess
  • Epiglottitis
  • Neoplasm

How to diagnose

  • Based on clinical presentation & exam findings
  • CT scan to see if infection has spread
109
Q

Peritonsillar Abscess

Symptoms

Exam Findings

A
  • Throat pain that’s worse on one side
  • Pain radiates to ear
  • Dysphagia or Odynophagia
  • Fever, Malaise
  • Trismus (inability to open mouth) painful spasm in neck/masseter muscle
  • Drooling
  • “hot potato” voice
  • Anterior Cervical Adenopathy more pronounced on affected side

Exam Findings

  • Deviated Uvula
  • Difficulty opening mouth
110
Q

What is the treatment plan for peritonsillar abscess?

A

Emergency room!!!!

  • Drain & monitor for 4 hours
  • IV Abx: PCN & Flagyl together. Augment & Clindamycin
  • Pain control
  • Hydration
  • Corticosteroids: Dexamethasone 1x dose
111
Q

You are seeing a 4-year-old child in the clinic for a painless, red eye with purulent drainage. What do you suspect is the causative organism and how would you treat this patient?

A

Cause

H. Influenzae

S. pneumoniae

Treatment

Trimethoprim sulfate plus polymyxin B sulfate ophthalmic solution

112
Q

What are the diagnostic criteria for acute otitis media?

A

Moderate to severe bulging tympanic membrane with obscured landmarks

New onset otorrhea not caused by AOE

Decreased/absent motility of TM using pneumatic otoscopy

Recent onset (<48 hours) of ear pain and erythema

113
Q

Which children can be safely managed with observation with AOM?

A
  • 6 to 23 months old with non-severe unilateral AOM
  • >24 months with non-severe bilateral or unilateral AOM
114
Q

A 56-year-old patient c/o sudden onset of floaters and photopsia in the left eye which are increasing over the past 36 hours. The patient denies eye pain or redness. Based on this history, what diagnosis do you suspect and how will you manage it?

A

Diagnosis:

Retinal Detachment

Management:

Emergency room & NPO for surgery

115
Q

A 4 year old boy diagnosed with AOM returns in 48 hours with a possible rupture of the tympanic rmembranes of the right ear. The mother reports seeing pus and a smal amount of blood on teh pillow that morning. The child states that his ear is no longer painful. During the ear exam, the otoscope is used to visualize the tympanic membrane, which has aperforation on the lower edge that is draining a small amount of purulent discharge. All fo the follow topical ear medications should be avoided in patients with perforation except:

  1. Gentamycin ear drops
  2. Ofloxacin ear drops
  3. Tobramycin ear drops
  4. Neomycin sulfate ear drops
A

Ofloxacin ear drops

116
Q

A cauliflower like growth with foul smelling discharge is seen during an otoscopic exam of the left ear of an 8 year old boy with a history of chronic otitis media. The tympanic membrane and ossicles are not visible , and the patient seems to have difficulty hearing the NP’s instructions. Which condition is most likely?

  1. Chronic perforation of the tympanic membrane with secondary bacterial infection
  2. Chronic mastoiditis
  3. Cholesteatoma
  4. Cancer of the middle ear
A

Cholesteatoma

117
Q

A 6 y/o girl who attends preschool PT is brought to the clinic by her mother as a walk in patient. The mother reports that her daughter has recently begun swim lessons. The symptoms began as redness on the Left eye and spread to the 2nd eye within 2 days. The child’s eyes are watery and crusted in the morning when she wakes up. Her vitals are 98.8F HR 90 & RR 16. The eye exam reveals bilateral injected conjunctiva. When the lower eyelid is examined, the NP notes that it is pink with a cobblestone appearance. There is ipsilateral preauricular adenopathy. All of the follow treatment measures are appropriate, except:

  1. Prescribe a topical ophthalmic vasoconstrictor to be used 2x BID PRN up for 3 days to reduce redness
  2. Write a note excusing the child from school because she should not attend until the symptoms resolve
  3. Prescribe ophthalmic topical antibiotic eye drops to be applied in each eye for 7 days
  4. Advise use of cool compress over closed eyes PRN comfort, washing hands often
A

Prescribe ophthalmic topical antibiotic eye drops to be applied in each eye for 7 days

118
Q

The mother of a 4 year old daughter who just started attending preschool to the health clinic. She tells the nurse practitioner that her daughter is complaining of burning and itching that started in the left eye. Within two days it involved both eyes and the child developed a runny nose and sore throat. During the physical exam the child’s eyes appear injected bilaterally with no purulent discharge. The throat is red, the inferior nasal turbinates are swollen and lymph nodes are palpable in front of each year. Which diagnosis is most likely?

  1. Herpes keratitis
  2. Corneal ulcer
  3. Viral conjunctivitis
  4. Bacterial conjunctivitis
A

Viral conjunctivitis

119
Q

A 70-year old male patient complains of a bright red colored spot in his left eye for 2 days. He denies eye pain, visual changes or headaches. He has a new onset cough from a recent viral upper respiratory infection. The only medicine he is taking is aspirin one tablet daily. Which of the following is most likely?

  1. Corneal Abrasion
  2. Acute bacterial conjunctivitis
  3. Acute uveitis
  4. Subconjunctival hemorrhage
A

Subconjunctival hemorrhage

120
Q

A nurse practitioner assesses a child who is experiencing severe otalgia and has a temperature of 100.7 degrees. The Rinne Test shows BC > AC and the Weber Exam shows lateralization in the affected ear. The nurse practitioner notes blisters on an erythematous tympanic membrane. Which of the following conditions is most likely?

  1. AOM
  2. Otitis media w/effusion
  3. Bullous myringitis
  4. Otitis externa
A

3 bullous myringitis

121
Q

An 84 year old female presented to the clinic 2 weeks ago with vague reports of fatigue, red maculopapular rash, and low grade fever. Upon examination, there was no lymphadenopathy, sore throat, a typical white blood cells, or splenomegaly. During a follow-up exam 2 weeks later, the patient is diagnosed with Guillain-Barre syndrome. What was the original diagnosis?

  1. Mononucleosis
  2. Influenza
  3. Meningitis
  4. Measles
A

mono

NURP532 (11 decks)

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