Exam 1 Review

Acute Bacterial Rhinosinusitis (inflammation of paranasal sinuses)

• R/F: Smoking, pollution, anatomic abnormalities, asthma.

• Diagnostics: Gold standard is sinus aspiration and culture (rarely done due to invasiveness).

• S/S:

  • Pain in face/ cheeks.

  • Pressure above eyebrows/forehead.

  • Fever x 10 days.

  • Mucopurulent nasal discharge.

  • Bacterial vs. viral

    • Viral if s/s last longer than 10 days w/o improvement or improve then get worse (double sickening).

• Causes:

  • Haemophilus influenzae.

  • Streptococcus pneumonia (most common).

  • Moraxella catarrhalis (M cat)

  • Not usually staph.

• Treatment

  • 1^st line treatment: Amoxicillin/Clavulanate (Augmentin) because H.flu is lactamase-producing.

  • Regular amoxicillin is not used anymore.

  • Only use alternatives if penicillin allergy is present.

Acute Otitis Media

• S/S:

  • Pain/pressure in ear, may have reduced hearing.

  • Woke up with pain “shooting stabbing pain in ear.”

• Treatment:

  • Amoxicillin is the first line in adults and children.

    • Ceftriaxone can be used, but not first line because of the rise of resistance.

Blepharitis

• Inflammation involving structures of eyelid margin.

• Can be infectious and non-infectious.

• S/S:

  • Red, watery eyes.

  • Red, swollen eyelids.

  • Itching lids, crusted eyelashes.

  • Eyelids appear greasy, skin flaking.

  • Gritty, burning, stinging sensation.

• Types:

  • Seborrheic:

    • Irritants such as smoke & eye makeup.

    • “Red Rim” eyelids

    • Swollen, crusty.

    • Loss of lashes.

  • Ulcerative:

    • Underlying cause is staph aureus.

    • Burning and tearing with light sensitivity.

    • Feeling of foreign body in eye.

  • Both will have watery, mucous discharge; blurry vision, eye redness.

  • Anterior blepharitis is the outside of eyelid.

    • Caused by bacteria.

    • Associated w/ seborrheic dermatitis, eczema, psoriasis, allergy.

  • Posterior blepharitis is inner eyelid.

    • Caused by meibomian gland dysfunction.

    • Associated with same as above, plus acne rosacea.

• Treatment:

  • Throwing away older eye makeup.

  • Lid wash (diluted baby shampoo).

  • Warm moist compress.

  • Bacitracin or erythromycin eye ointment.

Cataracts

• Caused by buildup of protein in lens that causes cloudiness over time.

• R/F: Smoke, air pollution, lead exposure, excessive steroid use.

• P/E:

  • Visual acuity with/without glasses.

  • Confirm lens opacity with fundal exam.

    • Check for opacities in red reflex, concealment of ocular fundus).

  • Assess visual fields by confrontation.

• S/S:

  • Cloudy, blurry, foggy vision.

  • Glare from lights.

  • Sudden change in glasses prescription.

• Treatment: Ophthalmology referral for possible cataract surgery.

Glaucoma

• Inner eye pressure rises because fluid not draining properly 🡪 increased IOP.

• Open Angle glaucoma: 2^nd leading cause of blindness.

• Primary open angle glaucoma: drainage channels (trabecular meshwork) in the angle are partially blocked; fluid drains too slow causing fluid back up.

• R/F:

  • African American, family hx, eye injury hx, high myopia (nearsightedness), HTN, corneal thickness.

  • Meds: Steroid use, SSRI, SNRI, anticonvulsants, antihistamines, stimulants.

• S/S:

  • Primary Open Angle Glaucoma

    • Loss of peripheral vision.

    • Tunnel vision in advanced stages.

  • Acute Open Angle Glaucoma:

    • Cupping of optic disc with visual field loss.

    • Blurred vision.

    • Unilateral headache.

    • Photophobia.

    • Nausea.

    • Halos.

  • Acute is painful, chronic often asymptomatic (and has no night vision difficulty).

• P/E:

  • External eye exam for swelling, ptosis, conjunctival infection, corneal clarity.

  • Assess visual acuity and peripheral vision.

  • Measurement of IOP w/ Schiotz tonometer.

• Treatment: Referral to ophthalmology.

Glaucoma Screening

• Age 40-50 : Fundoscopic eye exam and intraocular measurement every 2-4 years (if no risk factors like DM, eye injuries, family hx).

• 55-64: 1-3 years.

• 65 and over: 1-2 years.

Cerumen impaction

• Light, yellow cerumen is easier to get out.

• Black is hardened, more difficult. May need to soften for a few days first.

• NO ear lavage with TM perforation (risk serious infection to middle ear).

Cervical Lymphadenitis

• Enlarged lymph node, frequently seen after dental work.

  • May also get fatigue.

• Treatment: Cefalexin (Keflex) 500 mg BID or Augmentin 500 mg BID

Conjunctivitis (pink eye)

• Allergic:

  • Itching, tearing, nasal congestion, discharge.

  • Seasonal allergies.

  • Tx: Antihistamines (Zyrtec, Claritin, Allegra), artificial tears. Mast cell stabilizer if allergic to options.

• Bacterial:

  • Mucopurulent or purulent discharge, matted/swollen eyelids.

  • Tx: Erythromycin ointment, trimethoprim/polymyxin drops, azithromycin solution, bacitracin ointment, ciprofloxacin drops.

• Viral:

  • Gritty sensation, edema of lids, watery discharge.

  • No tx.

Corneal abrasion

• Must use a fluorescein stain and Wood’s lamp to see abrasion.

• S/S: Intense watering and pain. **Assess visual acuity

• If you see a foreign body imbedded, send to ER.

• Treatment:

  • Normal saline to irrigate eye, analgesics for pain, tetanus prophylaxis. Avoid eye patch.

  • Antibiotics 3-5 days.

    • Erythromycin ointment or sulfacetamide ointment.

    • For contact lens users, ciprofloxacin, tobramycin, or ofloxacin ointment/solution.

Epistaxis

• Anterior or posterior bleed.

  • Anterior more common. Less severe. Starts at lower part of septum. Usually unilateral, continuous bleeding.

  • Posterior starts deeper, can’t see the bleed. Heavier flow, going into lungs and pharynx. Send to ER.

Hordeolum & Chalazion

• Hordeolum (stye)

  • Painful abscess on interior or posterior (conjunctival side of lid).

  • Thickening/stasis of gland secretions lead to secondary infection, usually staph aureus.

  • Chronic may indicate IgM deficiency.

  • R/F: blepharitis, ocular rosacea, meibomian gland dysfunction, elevated lipids.

  • Treatment: May need to lance. May need antibiotic ointment.

• Chalazion

  • Firm, non-tender bump on eyelid.

  • Swelling, blurry vision, light sensitivity.

  • Caused by inflammation of the lid and blockage of meibomian gland.

  • R/F: Prior hx of chalazion, acne rosacea, oily skin, mite species residing in lash follicles.

  • Treatment: Watch and wait. Warm compresses. Refer to ophthalmology if fever, headache, visual changes, painful drainage, both eyes swollen. May need I&D.

Mononucleosis

• Causes: Epstein-Barr virus, incubation 30-50 days.

• Diagnostics:

  • Monospot in office.

  • CBC with diff.

  • Heterophile antibody test is best. 70 to 90% accuracy, EXCEPT during first week of illness (25% false negative rate).

  • Can remain positive for up to a YEAR.

• S/S:

  • Triad: Fever, posterior cervical lymphadenectomy, exudative pharyngitis.

  • Hepatosplenomegaly, atypical lymphocytosis, abnormal LFT’s.

• Treatment: Tylenol and NSAIDs for fever/pain. Steroids only for obstructive tonsillar enlargement.

• Pt Education: No contact sports, heavy lifting; follow up 1-2 weeks.

Otitis Externa (swimmer’s ear)

• HPI is crucial, ask about swimming.

• Pseudomonas most common gram negative pathogen.

• S/S: Crusty discharge, itching, pain with ear movement. Rapid onset of ear pain.

• Treatment:

• If perforated TM, need sterile med.

  • Sterile: Ofloxacin & ciprodex.

  • Non-sterile: Cipro w/ hydrocortisone, neomycin w/ hydrocortisone.

• Cultures/ not usually necessary. Irrigation only if can visualize TM.

• Avoid swimming for 10 days, prolonged exposure to moisture, qtips.

• AVOID irrigating ears on pts with DM because you risk of emergency called malignant otitis externa.

Otitis Media with Effusion (no s/s of acute infection)

• S/S:

  • Shooting stabbing pain.

  • Cracking/popping when opening mouth.

  • Pressure in ear.

  • Decreased hearing.

  • Exudate.

  • Bubbles behind ear drum, possible bulging membrane.

• Treatment:

  • Pseudoephedrine, Afrin or Astelin nasal spray, OTC Claritin or Zyrtec.

  • ENT if no resolution in 12 weeks.

• Otitis Media WITH s/s of infection:

  • 1^st line treatment: Amoxicillin/Clavulanate 875 mg x 10days or Amoxicillin 500mg q12.

  • If PCN allergy: Cephalosporins or Macrolides.

  • If PCN & Cephalosporin allergy: Doxycycline & Azithromycin or Clarithromycin.

  • NSAIDs for pain.

  • Non-pharm: Local heat, myringotomy, swallowing to ventilate eustachian tube

Parotitis

• Painful swelling of parotid glands.

• Seen post-op hip or major abdominal surgery.

• Or after virus, like EBV or HSV.

• Swelling in jaw, by ear.

• Sometimes resolves on own, sometimes need antibiotics or surgical intervention.

• 20% mortality rate of patients who develop this after surgery.

Patient-centered care and shared decision making

• Basically just include patients in care and respect their decisions.

• Increases compliance.

Peritonsillar abscess

• S/S:

  • Infection in 1 or both tonsils.

  • Fever chills.

  • Trouble swallowing pain when opening mouth.

  • Sore throat.

  • Foul breath.

  • Trismus (trouble opening mouth).

  • Muffled, “hot potato” voice.

• Labs/Diagnostics: CT, physical exam, CBC, monospot to r/o infectious mono, culture abscess.

• Treatment: Antibiotics, requires I&D or tonsillectomy, pain management, IV hydration.

  • IV antibiotics w/ single high dose of IV steroids is superior.

  • Fatal if ruptures!

Pterygium

• Wing-shaped fibrovascular tissue growth.

• Abnormal growth of conjunctival tissue.

• S/S: Eye redness and irritation, blurred vision, thickening in corner of eye, burning or gritty sensation, feeling like foreign object in eye.

• Causes: Too much exposure to UV light.

• Can encroach on cornea.

• Refer to ophthalmology.

Rhinitis Medicamentosa

• Chronic nasal congestion from meds.

• Causes: AFRIN nasal spray (shouldn’t use more than 2 days!).

• After using 4-5 days they get rebound congestion.

• Will need a steroid intranasal corticosteroid nasal spray to get them off it.

  • Maybe medrol dose pack.

• Different than nasal polyps or deviated septum that causes congestion due to obstruction.

Sensory neural hearing loss

• Effects 8th cranial nerve.

  • Permanent, effects balance and sound from inner ear.

• Cause:

  • Aging process.

  • Loud noise.

  • Infections or head/acoustic trauma.

  • Tumors.

  • NSAIDs, Chemo, ABX.

• Refer to ENT.

Strep Pharyngitis

• S/S:

  • Throat pain.

  • Fever over 100.

  • Exudative pharyngitis.

  • ANTERIOR cervical lymphadenopathy (remember mono is posterior).

• Risks

• Dx

• Treatment: Based on Centor score

  • 4 criteria: fever, tonsillar exudate, tender anterior cervical adenopathy, absence of cough.

  • Under 15 years add a point and over 44 subtract a point.

    • -1 to 0: No treatment or test.

    • 1: Unlikely.

    • 2: Strep test positive 🡪 treat.

    • 3-4: Treat.

• 1st line: PCN or amoxicillin (unless allergy).

  • If PCN allergy, use cephalosporin, clindamycin, azithromycin, or clarithromycin.

Subconjunctival hemorrhage

• Resolves on own, educate.

• Scary looking but NOT an emergency.

• Turn yellow, will heal within a few weeks.

• Broke a blood vessel in eye, from pressure like Valsalva maneuver.

Tinnitus

• Causes: Impacted cerumen, TM perforation, excessive use of steroids, NSAIDs, or ASA.

• Thorough HPI is crucial.

• Chronic tinnitus.

• CBD doesn’t work.

• Lab studies to confirm underlying issues: CBC to r/o anemia or infection, thyroid studies, lipid panel & Vit B12.

• Diagnostics: Audiogram & MRI.

• Treatment:

  • Priority: ELIMINATE ASA or NSAIDS.

  • Must learn to cope—may need oral antidepressants.

  • Hearing aid.

  • Referral to audiologist is essential when conductive hearing loss is present.