Week 2 Ophthalmology & ENT Flashcards
1
Q
Clinical manifestation of Herpes Zoster Opthalmicus
A
Hutchinson sign
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
3
Q
Clinical manifestations of retinal detachment
A
Sudden onset visual field defect
Floaters
Photopsia “flashing lights”
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)
5
Q
Clinical manifestations of acute angle glaucoma
A
Eye pain
Eye redness
Halo around lights
N/V
Headache
6
Q
Clinical manifestations of Chalazion
A
non painful nodule located away from the eyelid margin
7
Q
clinical manifestations of hordeolum
A
painful nodule on eyelid margin
8
Q
Clinical manifestations of viral conjunctivitis
A
Red eye watery discharge follicles on conjunctiva
9
Q
Clinical manifestations of bacterial conjunctivitis
A
Conjunctiva injection purulent discharge gradual onset
10
Q
Clinical manifestations of AMaurosis Fugax
A
Monocular vision loss lasting less than 30 mins
11
Q
What eye problems require an urgent referral?
A
Keratitis
Herpes zoster opthalmicus
Acute angle glaucoma
Scleritis
Orbital cellulitis
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
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
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.
15
Q
Meniere’s disease is characterized by
A
hearing loss, tinnitus, & vertigo
*vertigo lasting at least 20 minutes associated with hearing loss.
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
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
18
Q
What pathogens commonly cause Acute Bacterial Rhinosinusitis?
A
- Strep Pneumo
- H. Flu
- Moraxella Catarrhalis
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
20
Q
What are are a common lab findings in infectious mono?
A
Elevated Lymphocytes
Elevated LFTs
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
22
Q
What are possible causes for Ocular Pain and Photophobia?
A
Acute glaucoma
Corneal Trauma
Iritis/Uveitis
Scleritis
23
Q
What are the causes of eye pain and N/V?
A
Acute glaucoma
24
Q
What are the possible causes of eye pain and itching?
A
Chemical Injury
Severe dry eye
Allergy
25
What are the possible causes for pain on eye movement?
Optic Neuritis
Trauma
Orbital cellulitis
Trauma'
26
What are the possible causes of eye pain and foreign body sensation?
Corneal ulcer or abrasion
Conjunctivitis
Eyelid lesions
27
List the Centor Scores
Fever
Tonsillar Exudate
Tender anterior cervical lymph nodes
Absence of cough
\<15 years old
\>45 year old (-1)
28
Immediate referral is indicated for acute otitis media in children ____ months or younger, and in children who appear _____ .
Immediate referral is indicated for acute otitis media in children _6 months_ or younger, and in children who appear _toxic_ .
29
What is the primary bacteria in a peritonsillar abscess?
Group A Strep
30
What are DDx for peritonsillar abscess?
Infectious Mono
Tumors
Peritonsillar cellulitis
31
How would you tell the difference between infectious mono and peritonsillar abscess?
Serologic findings
In mono: headache, malaise, fatigue and anorexia are present before sore throat
32
Difference between viral and bacterial pharyngitis?
Viral
* Sudden onset
* Productive Cough
* No lymphadenopathy
* Conjunctivitis
Bacterial
* Cough, conjunctivitis, and myalgia not present
33
Viral Conjunctivitis
## Footnote
Cause
S/S
How long until it resolves?
Management
**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
34
**Bacterial Conjunctivitis**
_Common causes:_
* which have gradual onset?*
* Which have rapid onset?*
*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
35
Bacterial conjunctivitis:
Adult Management
vs
Child Management
**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)
36
**What would you prescribe a child with bacterial conjunctivitis with otitis media...**
## Footnote
Usual infectious agent
Treatment
How long until it resolves?
What if there is no improvement?
**Cause**: H. Influenzae
**Treatment**: Augmentin
**Resolves**: 3 days
**No improvement:** Opthalmology referral
37
**Allergic Conjunctivitis**
## Footnote
Symptoms
Management
**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)
38
**Atopic Conjunctivitis**
## Footnote
Who is this more common in?
S/S
Treatment
Adults \>50 years with history of atopy
**Symptoms:** bilateral itching, burning, tearing
**Treatment:** mast cell stabilizer eye drop; Referral to ophthalmology
39
Dry Eye Syndrome
S/S #6
Diagnose
Differentials #3
Treatment
**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
40
How would you diagnose dry eye syndrome?
How is this test performed?
**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
41
Subconjunctival Hemorrhage
What is it?
Causes
How long for it to resolve?
**What**: Bleeding between conjunctiva & sclera
**Cause**:
* Increased pressure in capillaries: cough, sneeze, or straining
* Medications: Blood thinners, HTN, DM
**Resolves in 2 weeks**
42
What are the ocular adnexal disorders?
Blepharitis
Hordeolum (stye)
Chalazion
Nasolacrimal duct obstruction
Preseptal and orbital cellulitis
43
**Blepharitis**
## Footnote
What is it?
Causes?
S/S #6
Treatment
Treatment if it's d/t s. aureus
Treatment if it's severe/persistent
**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
44
**Hordeolum**
## Footnote
Cause
Symptoms
Treatment
Complications
**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
45
**Chalazion**
## Footnote
**What is it?**
**Cause**
**Symptoms**
**Treatment**
**How long to resolve?**
**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**
46
Nasolacrimal duct obstruction
* Symptoms
* Treatment for child
* Treatment for adult
* Complication
* DDx
**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
47
**Dacryocystitis**
## Footnote
Symptoms
Treatment
* 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
48
What are the usual causes of preseptal and orbital cellulitis?
* Strep
* Staph
* anaerobic bacteria
49
**Preseptal Cellulitis**
## Footnote
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?
**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
What does a positive Shirmer test mean?
Aqueous duct defect
51
**Orbital Cellulitis**
## Footnote
What is it?
Symptoms?
Treatment
DDx
**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
**Uveitis**
What is it?
S/S
Treatment
Who is most effected?
**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
**Keratitis**
## Footnote
**What?**
**Cause?**
**S/S**
**Treatment**
**Who is most commonly affected**
**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
Herpes Zoster Opthalmicus
## Footnote
**What**
**S/S**
- prodrome?
- Unique symptoms? #2
- other symptoms #5
**Treatment**
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
Scleritis
## Footnote
What
Who
S/S
Treatment
**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
Episcleritis
## Footnote
What?
Symptoms
Treatment
**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
**Corneal Abrasion**
## Footnote
Cause
Who is most affected
Symptoms
Diagnosis
Differentials
Treatment
Education
**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
**Acute Angle Closure Glaucoma**
## Footnote
What?
Symptoms
Risk factors
**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
**Retinal Detachment**
## Footnote
What
Symptoms
Exam findings
Risk factors
DDx
Treatment
_**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
**Optic Neuritis**
## Footnote
What?
Risk Factors #3
S/S #5
Exam findings #4
Treatment
What illness is this consistent with?
**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
**Amaurosis Fugax**
## Footnote
What?
Cause
Symptoms #3
Risk Factor
Treatments
DDx
**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
What are causes of Otitis Media?
**Cause**: Bacteria & Virus (S. pneumoniae, H. influenzae, Moraxella catarrhalis, and S. pyogenes)
63
**Acute otitis media**
Symptoms
Diagnostic criteria #5
**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
**How would you manage Acute Otitis Media?**
## Footnote
Non Pharmacologic options
When would you prescribe antibiotics?
When would you only observe?
**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
When would someones AOM symptoms get better?
in 3 days
66
What are some complications of Acute Otitis Media?
* Mastoiditis
* Peforation
* Effusion
* Cholesteatoma
67
What is **Mastoiditis**?
Management plan?
* Rare; complication of AOM
**Symptoms**
* Ear pain
* Posterior ear & mastoid process swelling
**Management**
* Urgent referral
68
What is a **Tympanic Perforation**?
S/S
Treatment
How long to resolve?
Pain suddenly disappears and otorrhea
**Treatment**
Cipro dops & Oral antibiotics
**Resolution**
Mild = resolves in weeks
69
What is an effusion?
S/S
Management if the effusion lasts more than 3 months?
What if it lasts more than 6 months?
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
What is a **Cholesteatoma**?
## Footnote
Cause
S/S
Exam Findings
Tx
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
**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?
**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
Otitis Externa causative agents
S. aureus
Pseudomonas
Candida
73
**Otitis Externa**
## Footnote
Symptoms #4
Exam Findings #3
Treatment
**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
**Tinnitus and the quality of its pitch**
High-pitched =
Low-pitched =
Pulsating =
Ocean =
Clicking =
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
Vertigo & Hallmark signs of peripheral lesions #3
Nausea
Normal Neurologic findings
Symptoms that are position related
76
List Peripheral causes of vertigo
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
**Benign Positional Paroxysmal Vertigo**
Cause
S/S
How to diagnose
Treatment
**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
79
**Vestibular Neuritis**
**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
**Meniere's disease**
## Footnote
Cause
Symptoms
Treatment
Education
Differentials
**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
What are the hallmarks of central lesion etiologies for vertigo?
Spontaneous vertigo (NOT POSITION RELATED)
Focal neurologic findings
No significant nausea or imbalance
82
**Vestibular migraine**
## Footnote
Describe the vertigo
What are the associated symptoms?
**Vertigo**: Severity and Duration Varies
\*Similar triggers as migraine like stress\*
**Associated S/S:** migraine headache, photophobia, nausea, phonophobia
83
How is Recurrent AOM defined?
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
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?**
**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
Three most common organisms that cause bacterial conjunctivits
- H. Influenzae
- Strep pnuemo
- Moraxella species
86
87
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
b. Perform a rapid strep test and treat with antibiotics if positive
88
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. Treat with amoxicillin or amoxicillin-clavulanate
89
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
C. intranasal corticosteroid
90
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
c. Uveitis
91
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. Refer to the emergency room
92
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
d. Referral to otolaryngology
93
**Acute Bacterial Rhinosinusitis**
Symptoms
**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
Acute Bacterial Rhinosinusitis
How to diagnose? #3
* 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
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 =
Adult
1. Augmentin 7-10 days
2. Doxycycline
Child
* 1) Augmentin 10-14 days
* 2.a.) Levofloxacin
* 2. b) Clindamycin AND 3rd gen cephalosporin
96
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
**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
**Viral Pharyngitis**
## Footnote
Cause:
Symptoms #6
Exam findings #2
Treatment
**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
What is Scarlet Fever?
D/t Group A Beta-Hemolytic Strep
Sore throat
5 days later...find sandpaper rash throughout body; circumoral pallow & strawberry tongue
99
What are Pastia Lines?
What causes them?
Red lines in skin folds like inguinal or axillary
Cause: Group A Beta-Hemolytic Strep infection
100
What ages are Group A Beta-Hemolytic Strep common in?
Ages 5-15 years
101
What are some exam findings for Group A Beta-Hemolytic Strep?
What are some subjective findings?
**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
**Group A Beta-Hemolytic Strep**
**Treatment**
_1st line:_
_2nd line:_
a) PCN allergy
b) PCN anaphylaxis allergy
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
**Group A Beta-Hemolytic Strep**
_Education_
When would you recommend a Tonsillectomy?
_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
**Infectious Mononucleosis**
What is the cause?
Symptoms?
Treatment?
Education?
**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
What infection has a Prodrome, Acute and Resolution phase?
Describe each
**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
How do you "work up" infectious mono? #6
* _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
What would you prescribe if someone had strep with mono?
Clindamycin or Azithromycin
| (amoxicillin with mono = rash)
108
Peritonsillar abscess
## Footnote
Cause
Differentials?
How to diagnose
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
**Peritonsillar Abscess**
Symptoms
Exam Findings
* 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
What is the treatment plan for **peritonsillar abscess**?
**_Emergency room!!!!_**
* Drain & monitor for 4 hours
* IV Abx: PCN & Flagyl together. Augment & Clindamycin
* Pain control
* Hydration
* Corticosteroids: Dexamethasone 1x dose
111
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?
**Cause**
H. Influenzae
S. pneumoniae
**Treatment**
Trimethoprim sulfate plus polymyxin B sulfate ophthalmic solution
112
What are the diagnostic criteria for acute otitis media?
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
Which children can be safely managed with observation with AOM?
* 6 to 23 months old with non-severe unilateral AOM
* \>24 months with non-severe bilateral or unilateral AOM
114
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?
**Diagnosis**:
Retinal Detachment
**Management**:
Emergency room & NPO for surgery
115
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
Ofloxacin ear drops
116
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
Cholesteatoma
117
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
Prescribe ophthalmic topical antibiotic eye drops to be applied in each eye for 7 days
118
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
Viral conjunctivitis
119
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
Subconjunctival hemorrhage
120
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
3 bullous myringitis
121
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
mono
