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503 Exam 2 Flashcards

1
Q

Refer to optho for 5 red eye complaints:

A
  1. Painful red eyes
  2. Photophobia
  3. Changes in vision
  4. Recent contact lens wear
  5. No improvement w/ tx
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2
Q

Some Painful Red Eye Differentials (8)

A
  1. Preseptal Cellulitis
  2. Orbital Cellulitis
  3. Episcleritis
  4. Scleritis
  5. Herpes Simplex
  6. Herpes Zoster
  7. Ulcerative keratitis
  8. Uveitis
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3
Q

Preseptal Cellutlitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Infection of soft eyelid tissue anterior to orbital eyelid septum (aka eyelid not eye ball)
  2. Redness to eyelid,
    NO PAIN w/ eye movement, no change in vision, eyes are not VERY red, no or very mild fever,
    optic nerve will not be swollen on fundus exam.
  3. Oral Augmentin or Keflex x 10 days &
    Warm compress.
    Hospitalize if: age < 5yo OR orbital cellulitis suspected!
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4
Q

Orbital Cellulitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammation of eye tissue behind orbital septum, EMERGENCY can lead to vision loss.
  2. Acute onset erythematous swollen eyelid w/ proptosis and eye pain. Pain with eye movement, abnormal EOM.
    May have had recent URI sx or hordeolum.
  3. Transfer to ED/Opho.
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5
Q

Episcleritis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammation in the episclera of eye, often in section or nodule formation.
  2. Mild pain and tenderness
    Redness WILL blanch w/ 10% topical phenylephrine and episcleral vessel will be mobile on palpation.
    Can be linked w/ systemic conditions such as I
    IBD (Crohns, UC), RA, SLE
    Often occurs unilaterally, if found bilaterally or recurrent do blood work.
  3. Idiopathic- comes and goes. Self resolving in 2-3 weeks. Topical steroid drops can help w/ comfort.
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6
Q

Scleritis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammation of sclera of eye. Can cause perforation of globe and vision loss!
  2. DULL Pain, MORE painful than episcleritis.
    Sclera will be dark red or blue.
    Redness doesn’t blanch w/ phenylephrine.
  3. Transfer to ED/Optho.
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7
Q

Herpes Simplex

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Viral infection of cornea.
  2. Painful dendritic ulcerations of cornea.
    Redness, irritation, aching pain, photophobia, increased tearing, may also have skin vesicles.
  3. Topical or oral antiviral therapy. Refer to optho.
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8
Q

Herpes Zoster

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Viral infection of cornea.
  2. Ocular lesions form 2-3 days after skin rash.
    Hutchinson’s Sign- skin lesion to base of nose when affecting the ophthalmic branch of trigeminal nerve.
    Conjunctivitis, pseudo-dendritic ulcers.
  3. Can cause necrotizing retinitis. Transfer to Optho.
    Oral antiviral therapy.
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9
Q

Ulcerative Keratitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Serious condition, causing inflammation to cornea of eye and corneal ulcers often after overnight wear of contact lenses.
  2. SEVERE ocular pain.
3. Needs ocular scraping to determine causative agent.
Often pseudomonas or strep.
Fungal infection (acanthamoeba) is most concerning.

Refer to ED/Optho
DON’t patch eye
Tx- abx every 30min - 1hr around the clock w/ daily follow ups.

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10
Q

Narrow Angle Glaucoma

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Serious and sudden increase in intra-ocular pressure 50-60mmHG (normal ocular pressure is 12-22mmHG)
    d/t anatomic barrier to flow of aqueous fluid.
  2. Occurs most often in dim light conditions (bc pups are dilating)
    Pain, photophobia, HA, N, V, redness, tearing, blurry vision, dilated pupil fixed and non-reactive.
  3. Transfer to ED, need to lower intra-ocular pressure immediately!
    IOP lowering agent such as beta blocker.
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11
Q

Open Angle Glaucoma

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Chronic condition where intra-ocular pressure slowly increases leading to loss of peripheral vision if untreated. Risk factor- blue eyes.
  2. Asymptomatic. Intraoccqular pressure >25mmHG
    Fundoscopic exam- will see excessive cupping of optic disk.
  3. Topical ocular agents such as beta blockers, alpha2 agonist, prostaglandin analogues.
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12
Q

Uveitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammation of middle layer of eye wall the UVEA. Can be acute, chronic or recurrent
  2. Dull pain, redness, photophobia, excessive tearing (epiphora), decrease vision, constricted pupil, nonreactive and irregularly shaped pupil.
    May have other symptoms such as back pain, joint pain, skin rash, diarrhea etc..
  3. Refer to optho for tx w/ steroid and cycoplegic agent.
    If recurrent, bilateral… PCP should do work up for:
    TB, sarcoidosis, IBD, syphilis, SLE, lyme dx, behcet dx, herpes, toxoplasmosis.
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13
Q

Blepharitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. AKA Meibomian Gland disease
    Inflammation of meibomian glands to inner eye lids.
    Blepharitis is the main cause of bacterial conjunctivitis in adults known as blepharoconjunctivitis

2.Flakes/heavy crusting on the lashes, lid redness and swelling.
Blocked meibomian glands causes thickened and telangiectasia lid margin.
Can be associated with acne rosacea.

  1. Washlashes w/ baby shampoo or lid scrub, warm compress, artificial tears
    If the lid is VERY inflamed consider abx/steroids but most refer to optho to monitor pressures in the eye.
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14
Q

Hordeolum

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Small infection to glands around the eye, inside or external to eyelid, AKA “stye”
  2. Painful on palpation
  3. Warm compress
    if large & painful or spread causing cellulitis- oral abx.
    Oral doxycycline 100mg BID
    *COULD lead to orbital cellulitis= emergency.
    if failed tx or secondary infection refer to optho
    may need I & D
    no topical abx
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15
Q

Chalazion

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammation of glands around the eye, usually starts as a hordeolum.
  2. Nonpainful to palpation
  3. Same tx as hordeolum
    Warm compress
    if large & painful or spread causing cellulitis- oral abx.
    Oral doxycycline 100mg BID
    *COULD lead to orbital cellulitis= emergency.
    if failed tx or secondary infection refer to optho
    may need I & D
    no topical abx
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16
Q

Contact dermatitis to eyelid

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Irritation to eyelid surrounding eye often from makeup.
  2. Bilateral outside surface, itchy, red eyes

3.Find causative agent: preservative in topical agents, cosmetics, hair products, etc.
Stop causative agent, cold compresses, preservative free tears, topical/oral antihistamine.

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17
Q

Allergic Conjunctivitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammation of the conjunctiva d/t allergy. occurs often to children and young adults w/ a “trigger”
  2. Mild injection to eye with itching, conjunctival edema (chemosis) & papillary (cobble stone) on palpebral conjunctiva (clear membrane coats inside of eyelids).
  3. Topical antihistamine (alway, radiator, patanol) or nasal corticosteroid (Flonase) warm compress
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18
Q

Viral Conjunctivitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammation of the conjunctiva d/t virus.
  2. tearing and burning to eyes, usually one eye then spreads to the other eye, follicles on palpebral conjunctiva. Will usually have URI sx.
  3. Highly contagious- wash pillow cases, towels, cosmetics etc.
    Preservative free artificial tears and cold compresses: self-resolving in 2–3 weeks
    Refer to optho if vision is affected, pain w/ blinking
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19
Q

Bacterial Conjunctivitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammation of conjunctiva d/t bacteria.
  2. Beefy redness, major discharge, itching/irritation.
  3. Uncomplicated cases tx with topical abx,
    Treat with topical abx 2 days prior to return to school
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20
Q

Bacteria most likely to cause bacterial conjunctivitis

  1. Newborns
  2. School age children
  3. Adults
A

Newborns- gonorrhea & chlamydia
School age children- Strep, H Flu
Adults- Staph

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21
Q

Sub-conjunctival Hemorrhage

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Superficial blood vessel burst, very common and often benign.
  2. Blood vessel burst.
  3. Always check pt’s BP
    Avoid blood thinners, heavy lifting, strenuous activity.
    If recurring evaluate pt for coagulation problems.
    Self resolving
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22
Q

How to detect most corneal disease/conditions?

A

Slit lamp w/ cobalt blue light filter and fluorescein dye.

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23
Q

Kerato-conjunctivitis Sicca

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. AKA DRY EYE, Dry eye that occurs when tears aren’t able to provide adequate moisture.
    Affects 10-30% of ppl >40 yo
  2. burning, foreign body sensation in eye, itchiness, excessive tearing
  3. USE Schrimer’s test to diagnose and evaluate how much tear production.
    Prescribe artificial tears, if severe refer to optho.
24
Q

AOM

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Acute inflammation and effusion (fluid behind ear drum) of the middle ear.
  2. Otalgia, fever, conductive hearing loss, imbalance, vertigo, mild stuffiness, fullness or popping sensation in ear.
  3. 1st line therapy:High dose amoxicillin
    80-90mg/kg/day.
    Tx right away if >=102.2F (39C) or bilateral OM or perf (drainage).
25
Q

AOM tx allergy to PCN

A

3rd generation cephalosporin- cefdinir or azithromycin.

26
Q
  1. Unresponsive to initial AOM tx 48-72hrs from start what abx do you switch to?
  2. if allergy to PCN what abx?
A
  1. Amoxicillin-Clavulanate (Augmentin) - 90mg/kg/day / 6.4mg/kg/day
  2. clindamycin 20-40mg/kg/day in 3 divided doses (in combo w/ 3rd gen cephalosporin)
    OR
    Ceftriaxone 50mg/kg/day IM or IV
27
Q

3 common bacterial causes of AOM:

A
  1. H. influenza
  2. Strep. pneumonia
  3. M. catarrhalis
28
Q

Refer to ENT if:

1.

A
  1. Frequent ear infections 3x/6mo or 6x/12mo- ear tubes
29
Q

Consider need for audiology assessment if:

1.

A
  1. speech delay in child
30
Q

Ear infection prevention:

A

Breastfeeding, no 2nd hand smoke exposure, control allergies, avoid pacifiers, daycare attendance, flu vaccines.

31
Q

Non modifiable risk factors for AOM:

A

Male gender, low socioeconomics, down syndrome.

32
Q

Sinusitis can lead to ____?

A

Peri-orbital cellulitis

33
Q

Rhinosinusitis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. inflammation of nasal cavity and paranasal sinuses.

2.
Bacterial- 10 days sx, resickening syndrome, purulent nasal discharge, may have fever
Viral <10 days sx

  1. Bacterial- Augmentin Children: 10-14 days, Adults 5-7 days. NOT Z PAC!!!! (not azithromycin!!!)

If 2 rounds of abx and no improvement consider imaging for possible tumor!*****

34
Q

3 common bacterial causes of bacterial sinusitis:

A
  1. Strep pneumoniae
  2. H. Influenzae
  3. M. Catarrhalis.
35
Q

Centor Criterial

  1. What is it?
  2. What does 2-3 points indicate?
  3. What does 4-5 points indicate?
A
  1. set of criteria to identify likelihood of bacterial infection w/ sore throat complaint.
  2. 2-3 points = throat culture, treat with ABX if positive (15-32% chance of infx)
  3. 4-5 = throat culture, but treat empirically (56% chance of infx)
36
Q

Mononucleosis

  1. What is it?
  2. Signs/Symptoms?
  3. What labs do you draw?
  4. Treatment
A
  1. Ebsteinbarr Viral infection transmitted by saliva
  2. Fatigue, fever, rash, and swollen glands- anterior and posterior cervical, hepatomegaly, splenomegaly.
  3. Mono spot, CBC, CMP, LFTs
    If early diagnosis mono spot test may need to be repeated in 1 week as antibodies may not have developed yet.
  4. Supportive care, Rest, no Tylenol (d/t liver), no contact sports, no ETOH.

If LFTs are elevated you must recheck them in 1-2 mo to confirm they have returned to normal levels.

37
Q

What abx given w/ mono can cause a rash?

A

Amoxicillin

38
Q

Tx for streptococcal pharyngitis for pt with pcn allergy:

A

azithromycin, clarithromycin, clindamycin

39
Q

Pts w/ strep throat can be cleared to return to work or school after ___ hr abx.

A

24 hours tx

40
Q

Common causative organisms of peritonsillar abscess include what 4 organisms?

A
  1. Fusobacterium necrophorum
  2. Group C Strep
  3. Group G Strep
  4. GABHS (Group A streptococcus, S. Pyrogenes)
41
Q

When diagnosing scarlet fever what is important to tell the patient/parents?

A

rash will peel during recovery!

42
Q

Incubation period for M. Pneumoniae

A

3 weeks

43
Q

Incubation period for Strep Pyogenes (GABHS)

A

3-5 days

44
Q

What are the symptoms of a GABHS (S. Pyogenes, Group A strep) infection?

A

Exudate, palatal petechiae, fever, anterior cervical lymphadenopathy, beefy tonsils.

45
Q

Tx for scarlet fever in 19yo?

A

PCN, cefdinir, or cefpodoxime (cephalosporin).

46
Q

Does H. influenza produce beta lactase?

What abx do you tx w/?

A

Yes.

Augmentin or Cephalosporin (cefdinir/cefpodoxime)

47
Q

What are PTA red flags?

A

Hot potato voice, trismus (can’t open mouth)

Send to ED.

48
Q

Osteoarthritis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Erosion of cartilage and bone in joints- non inflammatory.
  2. Joint stiffness <30min, pain to base of thumb is common, unilateral, often in DIP joints, crepitus felt.
  3. 1st line tx: acetaminophen.
    Always check kidney functions prior to starting on NSAIDS.
49
Q

Rheumatoid Arthritis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Inflammatory synovitis with palpable synovial swelling
  2. Morning stiffness >1 hr, fatigue, symmetrical, (Must have 3 joints)- wrists, MCP, PIP, elbow, knee ankle. * (spares DIP and thoracolumbar spine, IP toes)
    Nodules seen at pressure points.
    Swan neck deformity, boutonniere deformity seen.

Systemic manifestations: Fatigue, raynaud’s phenomenon, dry eyes, dry mouth (2ndary Sjogren’s syndrome to RA), interstitial lung disease, pleuritis, pericarditis, vasculitis.

  1. Confirm dx and refer to rheumatology ASAP
    Need aggressive tx, see pt q 2 mo. it is very important to to limit disability from dx.
    Exercise, ROM,
    NSAIDS
    DMARDS- Methotrexate (gold standard) *Monitor kidney function, LFT, CBC every 2-4 weeks, if stable after a year then ever 3mo.
50
Q 
2010 ACR RA Criteria: 
A.
B.
C.
D.
A 
A Joint involvement:
0 Points : - 1 large joint
1 Points: 2-10 large joints
2 Points: 1 -3 small joints
3 Points: 4 -10 small joints 
5 Points: < 10 joints (at least 1 small joint)

B Serology:
0 Points: - RF, -ACPA
2 Points: Low + RF, Low+ ACPA
3 Points: High + RF, High + ACPA

C Acute phase reactants (need atleast 1 +) :
0 Points: Normal CRP, Normal ESR
1 Point: Abormal CRP & Abnormal ESR

D Duration of symptoms:
0 Points: <6 weeks
1 Point: >= 6 Weeks

51
Q

In RA both the RF and ACPA (anti-ccp) are positive there is a ____ correlation with erosive disease.

A

HIGH

52
Q 
PMR Polymyalgia Rheumatica
Rheumatoid Arthritis
1. What is it?
2. Signs/Symptoms?
3. Treatment
A
  1. An inflammatory disorder causing muscle pain and stiffness around the shoulders and hips. >50 yo more often > 70yo
  2. Affects 2 or more axial areas- neck, shoulders, pelvic girdle, morning stiffness >/= 1 hr, ESR 40 or higher,
  3. Low dose prednisone- start 15-20 mg taper down to lowest tolerated dose tx for >1 yr 30% recurrence, tx <1y 70% recurrence.

Recommended taper: 20 mg prednisone 2 mo, decr by 5mg every 2 mo until 5mg/day for 1 yr then decr 1mg/mo until complete.

VERY SLOW TAPER OFF OF PREDNISONE!!!!
Associated w/ giant cell arteritis = ED EMERGENCY!

53
Q

Symptoms of Giant Cell Arteritis-

A

Associated w. PMR.

visual changes, jaw pain or scalp tenderness. EMERGENCY! Steroids required to prevent blindness!

54
Q

Psoriatic arthritis

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. Psoriatic arthritis is a type of inflammatory arthritis occurs in ppl w/ psoriasis.
    POSITIVE HLA-B27
  2. Symptoms include joint pain, stiffness, and swelling, which may flare and subside.
    DIP joints, nail pitting, dactylics (sausage fingers), tenosynovitis (inflammation of tendons), asymmetric oligo-arthritis (1-2 joints), may have overlapping joint disease. 15-30% will active active psoriasis.

POSITIVE HLA-B27

  1. If untreated arthritis mutilans can occur (pencil in cup deformity)
    NSAIDS, steroid injections, methotrexate, anti-TNF (adalimumab, etanercept, golimumab, infliximab). Motrin- helps sx. Pred can cause psoriasis flares.
55
Q

Systemic LUPUS Erythematosus (SLE)

  1. What is it?
  2. Signs/Symptoms?
  3. Treatment
A
  1. SLE is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels.
    Female 9: Male 1
    Onset- reproductive years
    Minorities
    Triggers: recent sun exposure, emotional stress, infection, meds- sulfonamides, hydralazine, sx etc…
  2. Fatigue, fever, wt loss, vasculitis like rash.
    mucocutaneous : malar rash, discoid lesions, photosensitivity, oral ulcers,
    Arthritis, serositis, neuropsychiatric, renal dx
  3. ANA is not specific for SLE (if + ANA doesn’t mean pt always has lupus, but must be positive in lupus)
    An Anti-smith (positive for lupus)!!!!***
    Think about lupus in women with recurrent fetal loss d/t antiphospholipid antibodies!

SUN BLOCK!!!!! Is super important! Sunlight activates lupus!
NSAIDS- alleviate pain (caution w/ kidney)
Plaquenil - all patients should be on this if tolerated. Safe. monitor retinal toxicity prior to start do retinal exam and 6mo, 12mo. Check for plaque deposits on back of retina.
Corticosteroids- topical and systemic (don’t use on face unless presc by derm)
Immunosuppressants to spare steroids. Severe lupus w/ nephritis. Methotrexate, cellcept, azathioprine, cytoxan- nephritis pt.
Belimumab- new drug. BLYS. 50% response rate.
ANA- nonspecific.

56
Q

What is the HEADSS exam?

A

Used to assess adolescents:

Home
Edu, employment
Activities
Drugs/Alcohol
SEX
SUICIDE

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