ENT and pumonary - PC 617 - Sheet1 Flashcards
C
Near vision card, penlight with blue filter, topical anestetic, fluorescein strips, topical mydriatic
Cranial nerves 2-7 control
Pupils, visual fields, EOMs, facial droop
Inspection/palpation of eye and surrounding structures
Assess for asymmetry, proptosis, enophthalmos, orbital rim
Slit lamp exam assess…
Anterior segment of the eye
Fundoscopy assesses….
Posterior segment of the eye.
Contraindication to dilation of eye
Significant head trauma, suspected rupture, history of glaucoma
Assessment of intraocular pressure
Goldman applanation tonometry, Tonopen
Exam of anterior segment of the eye
Perform at slit lamp - or ophthalmascope. Inspect conjunctiva, cornea, anterior chamber, iris, lens
Estimating anterior chamber depth of the eye
Shine a light from the temporal side of the head across the front of the eye parallel to the plane of the iris. Look at the nasal aspect of the iris. If two thirds or more of the nasal iris is in shadow, the chamber is probably shallow and the angle narrow.
Tonometry
Measures the intraocular pressure by calculating the force required to depress the cornea a given amount with a tonometer
Normal intraoccular pressure
10 - 20 is normal
IOP and chronic open angle glaucoma
Can be 20-30
IOP and acute angle closure glaucoma
Can be greater than 40
The swinging flashlight test
Measures both the direct and consesual response of pupil to light
Steps of the swinging flashlight test
- Shine light in right eye. This will cause BOTH pupils to constrict via CN III through Edinger-Westphal nucleus. 2. Then swing pen light to left and ensure the left eye CONSTRICTS. If it constricts, this means that the LEFT CN II is intact and is causing a direct pupillary reflex. If it dilates, then this is a sign that the LEFT retina or optic nerve is damaged and is called an Afferent pupillary defect (APD).
Assessment of posterior segment of the eye
Vitreous, optic disc, retinal vessels, macula
Key worrisome clinical findings - ophtho referral needed
Pain - pain in eye often indicates more serious intraocular pathology (iritis, glaucoma); Visual acuity - if decreased, usually more serious cause; Pupil - if sluggish, worry about acute glaucoma; Pattern of redness - ciliary flush (redness worse near cornea, usually serious intraocular cause: iritis or glaucoma)
Ciliary flush
Injection of deep conjunctival vesels and episcleral vessels surrounding the cornea. Seen in iritis or acute glaucoma. NOT seen in simple conjunctivitis
Iritis
Inflammation in the anterior chamber
Red eye - Key historical questions
Do you have any pain? Do you wear contacts? Do you have any associated symptoms
Pain in eye
Biggest distinguishing factor between emergent and non-emergent
Wearing contacts and eye history
Increased risk of keratitis-corneal infection
History of associated eye symptoms
Decreased vision, photophobia/diplopia, flashes/floaters, halos/N/V/abd pain. Any requires a referral
Main differential of red eye
Conjunctivitis (infectious/noninfectious), trauma - foreign body, subconjunctival hemorrhage, acute closure glaucoma, iritis/uveitis, keritits, scleritis - episcleritis
Ocular emergencies
Closed-angle glaucoma; retinal detachment; foreign body; orbital fractures; corneal abrasions; lacerations, ulcers; chemical burns; ruptured globe; CRAO; retrobulbar hematoma
Acute angle closure glaucoma (AACG) diagnosis
History - acute onset, higher risk in far-sighted; symptoms - pain, halos (around lights), visual loss (usually peripheral), nausea/vomiting; Signs - conjunctival injection, corneal edema, mid-dilated, fixed pupil, increased IOP
Pathophysiology of glaucoma
Aqueous humor produced by ciliary body, enters anterior chamber, drains via trabecular meshwork at angle to enter canal of Schlemm. In AACG, iris obstructs trabecular meshwork by closing off angle. Optic nerve damage secondary to increased IOP.
Treatment of acute angle closure glaucoma
Reduce production of aqueous humor - topical b-blocker (trimolol 0.5% - 1-2 gtt), carbonic anhydrase inhibitor (acetazolamide 500 mg IV or PO), systemic osmotic agent (mannitol 1-2 g/Kg IV over 45 min) OR increase outflow - topical a-agonist (phenylephrine 1gtt), miotics (pilocarpine 1-2%) ALSO topical steroid (prednisolone acetate 1%) 1gtt Q 15-30 min x 4 then q1h
Definitive treatment of acute angle closure glaucoma
Optho referral - laser peripheral iridectomy
Pathophysiology of retinal detachment
Separation of neurosensory layer of retina from underlying choroid and retinal pigment epithelium. Schaffer’s sign
Schaffer’s sign
Presence of vitreous pigment. Useful in that it has a NPV of 99% for detachment
Risk factors for retinal detachment
Increasing age, history of posterior vitreous detachment, myopia (nearsightedness), trauma, diabetic retinopathy, family history, cataract surgery
Signs and symptoms of retinal detachment
“black curtain coming down over visual field”, bright flashes of light (photopsia), increasing floaters, decreased visual acquity, distortion of objects (metamorphopsia), +APD on exam
Diagnosis of retinal detachment
If direct ophthalmoscopy is inconclusive, refer to ophtho for dilated fundux exam with indirect ophthalmoscope. Direct ophthalmoscopy is not very effective at visualizing periphery where most RD’s occur
Treatment of retinal detachment
Surgery to replace retina onto nourishing underlying layers. Surgical options include laser photocoagulation therapy, and scleral buckle with intraocular gas bubble to keep retinal in place while it heals
Key management point of retinal detachment
Know “classic” presentation so you can refer to an ophthalmologist quickly
Foreign body
Often metallic following work injury.
Signs and symptoms of foreign body
Foreign body sensation, tearing, red, or painful eye. Pain often relieved with the instillation of anesthetic drops.
Assessment of foreign body
Stain with fluorescein stain and illuminate under blue fluorescent light (Wood’s lamp) is effective to see corneal epithelial defects
Treatment of corneal foreign body
Apply topical anesthetic. Remove foreign body with sterile irrigating solution or moistened sterile cotton swab. Never use a needle. Apply antibiotic ointment. 24-hr follow-up is mandatory. Refer if foreign body cannot be removed.
Signs and symtpoms of orbital blowout fracture
Enophthalmos; diplopia; impairment of eye movement secondary to EOM entrapment; orbital hemorrhage or nerve damage; orbital emphysema; infraorbital n. anesthesia
Diagnosis of orbital blowout fracture
CT should include axial and coronal cuts
Disposition of orbital blowout fracture
If no diplopia, minimal displacement, and no muscle entrapment, discharge with ophthalmology follow up within a week
Treatment of orbital blowout fracture
Surgery - for enophthalmos, muscle entrapment, or visual loss
Management of orbital blowout fracture
Ice packs beginning in clinic/ED and for 48 hrs will help decrease swelling associated with injury. Elevate head of bed (decrease swelling). If sinuses have been injured, give prophylactic antibiotics and instruct patient not to blod nose. Treat nausea/vomiting with antiemetics.
Coroneal injuries
Abrasions, lacerations, ulcers
Symptoms of corneal injuries
Extreme eye pain, relieved with lidocaine drops. Visual acuity usually decreased, depending on location of injury in relation to visual axis. Inflammation leading to corneal edema can decrease visual acquity
Diagnosis of corneal injuries
Fluorescein staining to see epithelial defect. Seidel’s test for aqueous leakage to diagnose laceration.
Seidel’s test
Concentrated fluorescein is dark orange but turns bright green under blud light after dilation. This indicates aqueous leakage which is diluting the green dye.
Management of corneal injury
Topical antibiotics and follow up with ophthalmologist. For lacerations, 1cm, refer to ophthalmologist to rule out globe rupture and for possible suture placement. Avoid contact lenses. Avoid patching.
Chemical burns
Constitutes an emergency. Every minute counts. Do not waste time on history or physical exam. Alkali burns more common and worse than acid
Alkali chemical burns to eye
Saponification - denatures collage, thromboses vessels - household cleaners, fertilizers, and drain cleaners
Acid chemical burns to eye
Coagulation, H+ perecipitates protein - barrier. Industrial cleaners, batteries, vegetable preservatives
Initial treatment of chemical burns to eye
Immediate copious irrigation - topcial anesthesia (tetracaine), can use NS, LR, irrigate at least 30 min; angiocath or irrigating lens can be used; lids should be retracted and fornices swabbed for particulate matter; check pH with litmus paper after initial irrigation - (7.0-7.3). Once pH stabilized - cyclopegic agent (0.25% scopolamine), broad-spectrum antibiotic (cipro, ofloxacin, gentamicin, or robramycin should be applied). Refer to ophtho immediately w/o stopping irrigation.
Ruptured globe
Penetrating trauma leads to corneal or scleral disruption and extravasation of intraocular contents. Can lead to: irreversible visual loss and endophthalmitis
Endophthalmitis
Inflammation of the intraocular cavities
Signs and symptoms of ruptured globe
Pain, decreased vision; hyphema; loss of anterior chamber depth; “tear-drop” pupil which points toward laceration; severe subconjunctival hemorrhage completely encircling the cornea.
Diagnosis of ruptured globe
Seidel’s test, clinical exam
Management of ruptured globe
Stop exam. Cover with metal eye shield or cup. DO NOT PATCH. Consult ophthamology immediately. Do not perform tonometry. CT head and orbit to evaluate for concomitant facial/orbital injury. NPO. Tetanus. Antibiotics - cefazolin + Cipro provides gooc coverage. Antiemetics and analgesics decreases risk of Valsalva or movement which could increase IOP.
Etiology of central retinal artery occlusion
Emboli-cardiac,atherosclerotic, fat; vasculitis, coagulopathy, sickle cell
Signs and symptoms of central retinal artery occlusion
Sudden onset severe monocular vision loss over seconds; usually preceded by amaurosis fugax; 90% will have visual acquity of counting fingers or less; after visual activity, do IOP, pupillary response (APD common); dilate pupils immediately and perform fundoscopic exam
Cranial retinal artery occlusion (CRAO)
Narrow arterioles, optic disc and retinal pallor, cherry red spot at fovea (due to maintained perfusion of cilio-retinal artery), emboli seen 20%
Treatment of cranial retinal artery occlusion (CRAO)
Must have VERY high index of suspicion, especially in patients with appropriate risk factors. Immediate referral. Retina can become irreversibly damaged in 100 min. Mannitol 0.25-2 g/Kg IV or acetazolamide 500 mg PO once to reduce IOP. Carbogen inhalation (95% O2 and 5% CO2). Oral nitrates. Lay pt flat on back. Massage orbit. This is thought to help dislodge clot from a larger to smaller retinal artery branch, minimizing area of visual loss. Ophthalmologist may perform paracentesis of aqueous humor to reduce IOP.
Retrobulbar hematoma
Acute orbital compartment syndrome secondary to blunt or penetrating trauma. Hemorrhage into closed space of orbit. Increased IOP leading to vision loss from optic nerve damage/retinal ischemia
Clinical diagnosis of retrobulbar hematoma
Ocular pain, APD, proprosis, ophthalmophegia, diminished vision, increased IOP. Immediate lateral canthotomy and cantholysis indicated if IOP > 40 mmHg or vision loss
What to do if fish hook in the eye
Stabilize hook. Brief exam to document visual acuity, pupillary responses, visual fields. Protect eye from further damage. NPO. Tetanus. IV antibiotics. Pain control. Antiemetics. Refer.
Blepharitis
Inflammation of the eyelids. 2 categories anterior and posterior. As a result of oil secretions or solidification of meibum, a chalazion or hordeolum may develop.
Anterior blepharitis
Involves the anterior lid margin surrounding the lid margin and is usually associated with Staph infection or seborrhea.
Anterior staphylococcal blepharitis
A cell mediated response resulting in lid margin inflammation
Anterior seborrheic blepharitis
Often associated with generalized seborrhea
Posterior blepharitis
Caused by meibomian gland dysfunction and an alteration in meibomian gland secretions
History and clinical presentation of blepharitis
Burning, tearing, or foreign body sensation. Itching, redness, discharge. Absent lashes. Lashes crusted with meibum. Seborrheic blepharitis may have greasy scales along the lid margins with foamy tears, diffuse seborrhea or the scalp and ears. Rosacea is related to meibomian gland dysfunction. Patients may have erythema or telangiectasia over the cheeks and nose or pustular skin eruptions.
Management of blepharitis
Lid hygiene - warm, moist compresses for 5-10 minutes; lid scrubs with Q-tip and baby shampoo. Antibiotic ointment - E-mycin or bacitracin. Artificial tears. Referral to ophthalmologist for corticosteroids
Hordeolum
An acute infection of a gland in the eyelid. Inflammed area or eyelid where eyelashes meet eyelid. Bacteria (usually staph) gets into the oil gland that lubricates the eye. Similiar process to a pimple.
History and clinical presentation of hordeolum
Swollen single gradually emerging red bump on the eyelid, gritty scratchy sensation, sensitivity to light, tearing, tenderness on the eyelid.
Management of hordeolum
Usually self-limited. Spontaneous improvement in 1-2 weeks with conservative treatment. Frequent warm, moist compresses. Teaching light and gentle massage, lid hygiene with lid scrubs. Refer if I&D needed
Chalazia
Chronic, sterile lipogranulomatous inflammatory lesion of the meibomian gland.
Lipogranuloma
Caused by a blockage in the Meibomian gland or oil gland that lubricates the eye. A gradually localized enlarging nodule where glands are located near the eyelashes.
History and clinical presentation of chalazia
Hard, non-tender module found on the mid-portion of the eyelid away from the lid border. May develop on lid margin with lid tenderness, pain, and swelling. Eyelid tenderness, increased tearing. Gradually enlarging nodule on the eyelid, sensitivity to light, pain, or pressure if pressing against the cornea.
Management of chalazion
Usually self-limiting in 25-50% of cases. Spontaneous improvement in 1-3 months with conservative treatment. Frequent warm, moist compresses to liquify glandular secretions. Teaching: gentle massage to express impacted secretions. Referral for corticosteroid injections or I&D if necessary.
Viral conjunctivitis
Inflammation of the conjunctiva or the transparent mucosal tissue than lines the eye and inner surface of the eyelids. Generally caused by adenovirus. Highly contagious
History and clinical presentation of viral conjunctivitis
Red eye (from corners inward). Excessive watering. Itching. Watery discharge. Photophobia. Foreign body sensation. Begins in one eye and spread to the other. Abrupt onset. 50% may have tender preauricular lymph nodes.
Management of viral conjunctivitis
Self-limiting usually 5-14 days. Treatment is supportive. Artificial tears. Cool compresses. Teaching: good hand hygiene, don’t share towels, avoid contact lens use until resolved and discard used lenses.
Allergic conjunctivitis
Airborne allergen comes in contact with the ocular surface. Inflammatory response occurs. IgE mast cell-mediated response and hypersensitivity
History and clinical presentation of allergic conjunctivitis
Allergic rhinitis, headache, fatigue, often have a positive family history of hay fever or atopy, generally begins simultaneously in both eyes, itching, periocular skin discoloration, thickening erythema
Management of allergic conjunctivitis
Cool compresses. Teaching: remove irritants. Oral/systemic antihistamines. Ophthalmic antihistamines - Naphcon A Vasocon (otc)
Bacterial conjunctivitis
Bacterial infection of the conjunctiva-membrane lining the eyelid by a wide range of gram-positive and gram-negative organisms. Staph aureus is most common. Tears contain enzymes and antibiotics that kill bacteria.
History and clinical presentation of bacterial conjunctivitis
Red eye (corners inward). Blurred vision, crust or matted discharge forming on eyelid overnight. Early morning glued eyes. Thich mucoid discharge. Absence of itching.
Management of bacterial conjucntivitis
Antibiotic drops or ointment - tobramycin, fluoroquinolone trimephoprim-polymixin B. Warm compresses frequently. Teaching should include changing pillowcases daily, dispose of eye cosmetics. Do not share towels or hankerchiefs. Good hand hygiene. Contact lens clearning and/or disposal.
Pathophysiology and clinical presentaiton of corneal abrasion
A cut, scratch or abrading of the thin, clear, protective coat of the anterior portion of the ocular epithelium often the result of trauma. Pain (sand or grit), tearing, photophobia, history of event, contact lenses? Photophobia. Known or suspected foreign body.
Management of corneal abrasion
Visualize eye structures. Observe for foreign body, perform a visual acuity. EOM. Fluorescein staining-visualize with cobalt blue light. Do not patch. Symptoms should resolve in 24-72 hrs. Teaching - do not rub. Refer if pain worses or persists.
Glaucoma-angle closure
Increased pressure occurs when the exit of aqueous humor fluid is suddenly blocked and results in quick, severe pain
History and clinical presentation of glaucoma-angle closure
Sudden and severe pain. Cloudy vision. N/V. Red eye. Rainbow-like halos around lights. Oval pupil from bowed iris. Cloudy cornea. May have history of recent eye dilation.
Management of glaucoma-angle closure
This is a medical emergency. Immediate referral.
Uveitis
Inflammation of the uvea or the middle portion of the eye. Involves the middle, pigmented vascular structures. Includes the ciliary body, chorioid. Noninfectious, autoimmune or infectious causes. May be isolated to the eye or be associated with systemic diseases.
History and clinical presentation of uveitis
Redness of eye (from center outward), blurred vision, photophobia, eye pain, floaters, headaches
Management of uveitis
Treatment of underlying condition. Immediate and emergent referral. Dark glasses. Steroid eye drops managed by ophtho
Allergic rhinitis
Allergic inflammation of the nasal membranes generally caused by breathing in pollen, dust, dander, or insect venom. Allergic triggers the production of IgE. When caused by pollens of plants it is called pollinitis. When caused by grass it is caused hay fever.
Hisotry and clinical presentaiton of allergic rhinitis
Rhinorrhea - generally clear. Pale, boggy nasal mucosa. Itching watery eyes. Nasal congestion. Swollen nasal turbinates. Eyelid swelling. Lower eyelid venous stasis (allergic shiners). Sneezing. No fever.
Management of allergic rhinitis
1 - Avoid irritants- pt teaching. Saline nasal spray ( can use with pregnancy). Intranasal corticosteroids - benclomethazone (may be used with pregnancy). Antihistamines - 1st generation - sedating; second generation - 1st line chlorpheniramine (may use with pregnancy). Decongestants (not for use in pregnancy), limit to 3 days or less.
Epistaxis
Bleeding that occurs from broken capillaries in the nose. Most occur in the front of the nasal septum. May result from some kind of trauma. May have history of allergies, snoring, HTN, headaches, foreign object. Lesion on nasal mucosa.
Clinical presentation of epistaxis
Bloody nasal discharge. Damage to nasal mucosa from foreign object or lesion. HTN
Management of epistaxis
Pinch lower part of nose to apply direct pressure. Lean forward to facilitate clot formation and avoid post-nasal drainage. Cautery or packing may be required. C&S is lesion is present. Treat underlying cause. Teaching - no foreign object in nose, including fingers
Acute sinusitis
Obstruction of the sinus ostia which is a small opening in which the maxillary, frontal, ethmoid and sphenoid sinuses drain into the nasal cavity. Mucous stasis may allow pathogens to grow. Can be viral or bacterial
History and clinical presentation of acute or chronic sinusitis
Facial pain. Headache teeth pain. Ear pain/pressure. Cough. Increased pressure above, below or behind eyes on leaning forward. Social history smoking or second hand smoke. Environmental exposures. Tenderness over sinus cavity. Acute symptoms: fever and purulent nasal discharge, presistant >10 days
Management of acute or chornic sinusitis
Most cases resolve without treatment. Saline, decongestant, or corticosteroid nasal spray. Analgesic and antipyretic - tylenol and NSAID. For symptoms greater than 10 days - amoxil, doxy, trimethoprim/sulfamethoxazole
Auricle disorders
The skin over cartilage. Most are dependent on problem such as: rheumatoid nodules, tophi, hematoma, carcinoma, infection
History and clinical presentation of auricle disorders
Deformity of auricle. Discharge - drainage. Lesion
Management of auricle disorders
Specific to the problem. Biospy lesions - basal cell (pearly borders with ulcerated center) and squamous cell (rough, scaly surface). Pressure dressings for trauma cauliflower ear. Piercings - alcohol for clearning, oral/systemic antibiotics such as cephalexin or dicloxacillin or cefriaxone or cephalexin IM/IV
Otitis externa
Inflammation of the ear canal. Usually bacterial or fungal. Most often caused by - S. aureus (MRSA), pseudomonas, candida, aspergillus. Cerumen impaction
History and clinical presentation of otitis externa
Pain and tenderness on palpation of traugus. Social history - swimming. History of clearning ear with a Q-tip. Allergies. Hearing aids.
Management of otitis externa
Cerumen removal if impacted. Teaching - no Q-tip in ears. Antibiotic/steroid ear drops - ciprodex, cortisporin otic. Keep ear canals dry for 7-10 days. Alcohol or vinegar drops. Limit use of ear plugs/phones and hearing aids until resolved. Antifungals for fungal infections - fluconozole
Pathophysiology of otitis media
Infection of the middle ear causing inflammation and pain which may be fungal, bacterial, or viral. Bacteria most often associated are S. pneumoniae, H. influenzae introduced in the eustacian tube through the nasopharynx following an upper respiratory infection or allergies
History and clinical presentation of acute otitis media
Earache, lymphadenopathy, headache, fever, upper respiratory symptoms, N/V, dizziness, sore throat, cough
Management of otitis media
Analgesica - topical (antipyrine/benzocaine) and oral (tylenol or ibuprofen). Antibiotics - amoxil, amoxicillin clavulanate, azithromycin. Antihistamines - second generation
Aphthous stomatitis
Chronic inflammation of the oral mucosal tissue with ulcers. Painful, shallow, recurrent ulcers of the oral mucosa. May be caused by direct trauma, vitamin deficiency, anemia, allergies
History and clinical presentation of aphthous stomatitis
Circular shallow ulcers covered by a gray membrane and raised border that is inflammed. Minor occurrence - 1-5 ulcers. Major recurrent 2 or more large ulcers. Herpetiform-recurrent with 5-100 ulcers.
Management of aphthous stomatitis
Self-limiting, correct vitamin deficiency. Teaching - eliminate causes. Magic mouthwash - benadryl, maalox or mylanta; may include nystatin if fungal etiology is suspected; swish and swallow
Glossitis
Inflammation and depapillation of the doral side of the tongue
History and clinical presentation of glossitis
Finger-like bumps on the surface of the tongue may be missing. Swollen, tender tongue, smooth surface, pale or fire red. Dry mouth. Recent infection. Injury. Low iron, skin condition, yeast, sore tongue. Difficulty chewing, swallowing, or speaking. Swollen tongue.
Management of glossitis
Good oral hygiene. Magic mouthwash. Teaching - avoid irritants - food, beverage. Correct dietary/vitamin deficiencies. Antibiotics/antifungals
Thrush
Skin and mucous membrane infections caused by Candida albicans. Yeast infection of the mucus membrane lining the mouth and tongue.
History and clinical presentation of thrush
White, velvety sores over red tissue that may bleed easily
Management of thrush
Nystatin 4-6 ml (100,000 u/ml) swish and swallow. Diflucan 100-200 mg daily for moderate to severe disease in immunocompromised persons
Strep pharyngitis
Inflammation of the pharynx and surrounding lymph tissue. Caused by Group A Steptococcus bacteria
History and clinical presentation of strep pharyngitis
Sore throat, fever, headache, N/V, swollen lymph nodes
Centor score - strep pharyngitis
Patients are judged on 4 criteria. Each is worth 1 point: fever, tonisillar exudate, tender anterior cervical adenopathy, absence of cough. Add pts age to criteria: age 15 subtract 1 point. 0-1 point - no antibiotic or culture. 2-3 points - throad culture and antibiotic if positive. 4-5 points - treat empirically with antibiotic
Management of strep pharyngitis
Based on RST, culture, empirical treatment based on Centor Score. Penicillin-amoxil: zithromax if PCN allergic. Teaching - dispose of toothbruth in 3 days. Tylenol or NSAIDS for pain or fever
Infectious mononeucleosis
Viral infection caused by Epstein Barr or cytomegalovirus
History and clinical presentation of infectious mononeucleosis
Fever, sore throat, swollen lymph nodes, severe fatigue, splenomegaly
Management of infectious mononeucleosis
Fluids, rest, analgesics or NSAIDs for pain and fever, salt water gargles, corticosteroids for extreme swelling of throat/tonsils. Teaching - no contact sports for 4-6 weeks. Extremely infectious.
The best prevention for swimmer’s ear (external otitis) is to use
Ear drops made from alcohol and vinegar in each ear after swimming
Mononucleosis differs from strept throat in that:
Symptoms such as fatigue and anorexia occur prior to sore throat onset
Maury, age 52, has throbbing pain in this left eye, pupiliary constriction, marked photophobia, and redness around the iris. What is your initial diagnosis?
Iritis
Acute otitis media is diagnosed when there is
An arythematous, opaque tempanic membrane
The first-line antibiotic therapy for an adult with no know drug allergies and suspected group A beta hemolytic streptococcal pharyngitis:
Penicillin
Considerations of an adult compaining of a respiratory infection
Where is the infection? Is there an underlying condition that creates an additional risk? Is this consistent with a viral or bacterial picture? What is the presentation of a lower respiratory infection?
Lower respiratory tract infections involve…
Trachea, bronchial tubes, bronchioles, and alveoli
Bronchitis
Limited to trachea and mainstem bronchi
Pneumonia
Involves lobes of lungs
Elderly patient with chronic cardiac or lung disease and presentation of respiratory infection
They may de-compensate from the same organism that the immume system of a healthy young person would manage without problems. May wish to consult with a physician.
Underlying conditions and respiratory infections
Alcoholism, smoking, and impaired immunity such as HIV increases changes you are dealing with a more pathogenic or resistent organism that requires an broad spectrum antibiotic
Antibiotic response of viral bronchitis or pneumonia
Except for CMV, it will not respond to an antibiotic
Manifestations of pathogenic bacterial which colonize the oropharynx
Takes over and causes a frank infection in the denuded epithelium remaining after a viral infection.
If a history that sounds viral becomes worse instead of better…
It is most likely a bacterial process
Presentation of lower respiratory infection
Fever, malaise, cough, sputum production, and chest wall pain related to coughing
Presentation of bronchitis
Clear lungs of diffuse wheezes and rhonchi due to large airway secretions and bronchospasms. May have low-grade fever.
Medications and bronchitis
Usually viral and does not require antibiotics. Inhalers are used for wheezing and will help decrease bronchospams, thereby decreasing cough
Presentation of lobar pneumonia
Caused by pneumococcus. Typically has crackles, wheezes, bronchial breath sounds, and dullness to percussion over involved areas of lungs. Areas of lung with infiltrate will also have increased fremitus and egophony.
Presentations of atypical pneumonia caused by nycoplasma or chlamydia pneumoniae
Less dramatic symptoms but will usually have wheezing and or crackles. Headache and myalgia are common with low-grade fever, scanty sputum production, minimal respiratory distress and minimal physical findings. Dramatic patchy infiltrates that are out of proportion with physical exam.
Current research, antibiotics, and uncomplicated bronchitis in low risk individuals
Should not be prescribed. Prepare to meet disbelief andn resistance from patients.
Preferred outpatient treatment for atypical pneumonia proven by clinical exam and x-ray
Azithromycin
Sympathomimetic agent is drug of choice for asthma
Beta 2 agonists
Patient works with a person recently diagnosed with active TB, what is first step in care of patient?
Mantoux testing
Patient with persistent asthma in Step 2 should have this medication added to their short acting beta agonist
Low-dose inhaled corticosteroid
Patient suspected of having pneumonia. A chest x-ray is negetive. This finding…
Does not exclude the diagnosis of pneumonia
Tuberculosis
Infectious disease caused by mycobacterium tuberculosis and affects the apex of the lung primarily
Secondary tuberculosis
Usually pulmonary
Clinical manifestations of pulmonary tuberculosis
Fatigue, anorexia, weight loss, night sweats, low-grade diurnal fever, cough, chest pain related to cough, hemoptysis, irregular menses
Exam of pulmonary tuberculosis
Maybe rales in upper posterior area, maybe evidence of pleural effusion, lymphadenopathy
TB diagnostic testing
Mantoux test (read in 48-72 hrs, two-step, anergy), QFT-G blood test (resulted in 24 hrs), chest x-ray
TB diagnostic chest x-ray
If positive to exclude pulmonary disease; if negative then prophylaxis with isoniazid
Candida antigen
Used to determine if the individual’s immune system is functioning well; a normal immune system demonstrates a positive reaction
Criteria for TB prophylaxis with INH
Positive TB skin test, other tests negative, no liver contraindications, regardless of history of BCG vaccination
Side effects of TB prophylaxis with INH
Hepatitis - need baseline and monthly LFTs; drugs that increase risk; peripheral neuropathy
Treatment of peripheral neuropathy with TB prophylaxis
Use B6 (pyridoxine) to decrease risk if patient has diabetes, uremia, alcoholism, malnutrition, during pregnancy, or if patient has a seizure disorder requiring Dilantin
If x-ray shows active TB
Refer
Reporting of TB
Mandatory in all 50 states and must be reported to local health department
Influenza
Active infection of respiratory tract - virus Type A or B, highly contagious, self-limiting, spread by droplet, virus shed 24 hrs before symptoms occur
Signs and symptoms of influenza
Fever, chills, headache, malaise, loss of appetite, dry cough, nasal congestion with clear drainage, sore throat, cough is most prominent
Diagnostic test of influenza
Rapid test or cell culture for virus - takes 2-7 days
Treatment of influenza
Rest, fluids, antipyretic/analgesic. Antiviral meds - zanamivir (relenza) and osteltamivir (tamiflu) should be started within first 48 hrs; reduces severity and durations of symptoms and may be used prophylactically for high-risk persons.
Prevention of infuenza
Vaccine
Asthma
Chronic inflammatory disorder of the airways. 6th most common reason for visit - most common respiratory disorder of all age groups. Can be acute severe asthma or chronic stable asthma
Triggers of asthma
Many factors, including allergens, infections, exercise, changes in weather, irritants, allergy to aspirin
Signs and symptoms of asthma
Episodic wheezing associated with dyspnea, cough, breathlessness, anxiety, sputum production. Most common - cough. Between attacks - none. Exercise induced - begins 5-10 minutes after exercise
Allergens of asthma
Cat dancer, dust mites, cochroach allergen, tree and grass pollen
Other causes of asthma
Viral illness, occupational exposure, socioeconomic deprivation, anxiety, depression, stress
Initial assessment of asthma
Diagnosis by signs, symptoms, and spirometry
Physical exam of asthma
Forced expiration, both inspiratory and expiratory as it worsens, use of accessory muscles increases, hyperinflation
Severe asthma attacks
Labored breathing = ED
Diagnostic tests of asthma
Spirometry - most useful = peak expriatory flow rate (PERF), FEVI, MMEFR, and FVC; diagnostic hallmark - decreased obstruction after bronchodilator
Diagnosis of mild asthma
Decreased PEFR, FEVI, MMEFT
Diagnosis of bronchospasm
Decreased FEVI, MMEFT, and FEVI/FVC ratio
Control of asthma
Environmental controls, anti-inflammatory medications, patient education
Classification of severity of asthma
Steps 1-4 or 5
Acute bronchitis
Transcient inflammation of the trachea and major bronchi. Begins with URI, cough that causes burning pain in chest, nose, and throat symptoms that subside but cough persists, along with wheezes, rhonchi, course rales
Clinical diagnosis of acute bronchitis
Signs, symptoms. No diagnostic testing
Other causes of acute bronchitis
Viral illness, occupational exposure, socioeconomic deprivation, anxiety, depression, stress
Treatment of acute bronchitis
Refer is not responding to treatment or if symptoms linger for longer than 2 weeks. Education - side effects of medication; cough may persist 10-14 days
Pneumonia
Bacteial and atypical or “walking pneumonia”. Bacterial - most common organism for CAP - streptococcus pneumoniae
Mortality of pneumonia
Leading cause of death from infectious disease and 7th most common cause of death in US from all causes
Organisms of gram positive pnemonia
Streptococcus pneumoniae
Organism of gram negative bacteria
Haemophilus influenza
Organism of atypical pneumonia
Mycoplasm pneumoniae
History and physical exam of pneumonia
Will determine pneumonia but will not reveal the causative organism.
Outpatient management of Group I pneumonia
Macrolides are first line or doxycycline. Dynamed outpatient CAP - macrolides (level I evidence). If comorbidities or high risk for resistance - moxifloxacin, genifloxacin, or lefofloxacin or macrolide + augmentin
Patient education and pneumonia
Rest, increased fluids, antipyretic/analgesic, avoid cough suppressant, directions for antibiotic use and side effects, follow-up
Smoking
Most preventable cause of premature death in US; 1 in 5 death is related to smoking. 35 million try to stop smoking each year and about 7% succeed. A few minutes of counseling is an effective way to help people stop smoking
Six phases of change
Precontemplation, contemplation, determination, action, maintenance, and relapse
Four “A’s” for health care providers
Ask, advise, assist, arrange
General concerns about quitting smoking
Women - weight gain; men - professional athlete image; adolescents - point out effect on appearance; adults - more concern about health
Pharmacologic interventions for smoking cessation
Nicotine replacement, buproprion (wellbutrin, zyban), varenicline (chantix), nic vax - facilitates nicotine antibody development that prevents nicotine getting to the brain
