Exam 2 Flashcards
Leukoplakia
adherent white patches/plaques on oral mucosa or tongue
not painful
can present as erythroplakia (red) or leukoerythroplakia (speckled)
*tobacco and alcohol use
Treatment: refer to ENT for biopsy and monitor closely
Squamous Cell Carcinoma (SCC)
ulcers or masses that do not heal
*exophytic (protruding outward) lesions on tongue and lip that are often painful
*tobacco and alcohol use
Treatment: refer to ENT for surgical resection or radiation/chemo –> poor prognosis
Melanoma
*if pigmented oral lesion, MUST consider melanoma in DDx
ABCD’s
often 5th - 7th decade and often missed
Treatment: excision with clear margins, radiation
note - amalgam tattoo DDx look for dental filling nearby
Mucoceles
pinkish/blue soft papules/nodules filled with gelatinous fluid
variable size
may rupture spontaneously
Treatment: generally asymptomatic and resolve on their own via reabsorption or rupture
cryotherapy or excision if necessary
Herpes Simplex Virus (HSV)
etiology: HSV-1 via direct contact
sunlight, trauma, stress
painful grouped vesicles on an erythematous base on buccal mucosa
recurrent infection generally on skin surface, not mucosa
burning/pain/tingling prodrome
Treatment: antiviral at onset of prodrome (acyclovir, valacyclovir, famciclovir) supportive care (fluids, analgesics, miracle mouthwash)
note - herpes zoster is unilateral/dermatomal on palate
Coxsackie Virus (hand, foot, mouth)
painful oral lesions, but tends to spare gingiva and lips (unlike HSV)
palmar/plantar lesions - pale, oval-shaped papules with rim of erythema
Treatment: supportive (hydration and analgesics)
lesions resolve 5-6 days
Oropharyngeal Candidiasis (Thrush)
etiology: Candida albicans (yeast)
opportunistic infection
mouth pain/sore throat
creamy white patches/plaques with underlying erythematous mucosa
“THRUSH WILL BRUSH”
KOH prep
Treatment: topical (nystatin suspension or troche, clotrimazole troche) patient education (clean dentures and rinse mouth after using inhaler)
Erythema Multiforme Major
acute, immune-mediated condition (HLA gene)
etiology: commonly HSV
target-like lesions on skin
mucosal erythema
painful, burning erosions or bullae
70% oral
Treatment: self-limiting (2 weeks)
symptomatic relief (topical corticosteroid or oral antihistamine)
*refer if ocular involvement
Stevens-Johnson Syndrome (SJS)
etiology: med induced (sulfa, NSAIDs, etc.)
prodrome of flu-like sxs 1-3 days tender, erythematous pruritic macules, vesicles edema of lips SKIN SLOUGHING conjunctivitis
Treatment: discontinue medication, corticosteroids (ie. Prednisone)
*Bacteremia is highest risk of death
Pemphigus
vulgaris is most common form
life-threatening blistering disorder
etiology: autoimmune, idiopathic, or drug-induced
FLACCID bullae that will spread when pressed
*Nikolsky sign - gentle application of pressure in uninvolved layer = sloughing –> early acantholysis
Treatment: systemic corticosteroids, immunosuppressive agents, antibiotics for secondary infection
Pemphigoid
chronic autoimmune blistering disorder (less severe than pemphigus)
prodrome of pruritic eczematous, urticaria-like lesions TENSE bullae (deeper in dermis)
Treatment: topical or systemic corticosteroids
Aphthous Ulcers
“canker sores”
recurrent aphthous stomatitis most common cause of mouth ulcers
shallow, round/oval, painful with grayish base on buccal and labial mucosa (single or multiple)
Treatment: typically heals in 10-14 days
symptomatic relief with topical steroid (ie. triamcinolone)
Behcet’s Syndrome
recurrent oral and genital ulcers (3+/yr)
painful, shallow or deep with central yellow necrotic base
often multiple
Treatment: refer to rheumatology
Oral Lichen Planus
etiology: chronic inflammatory disorder
reticular - *Wickham’s striae (lacy, thin white plaques)
erythematous and erosive = painful
Treatment: pain relief, topical corticosteroids, refer to ENT
Black Hairy Tongue (Lingua villosa nigra)
BENIGN associated with antibiotics, candida infection or poor oral hygiene
elongated filiform papillae
yellow-white to brown dorsal tongue surface
Treatment: BRUSH
etiology: unknown
erythematous patches on dorsal tongue with circumferential white borders
Treatment: reassurance
Geographic Tongue ( Benign migratory glossitis)
etiology: nutritional deficiency, dry mouth, oral candida
*atrophy of filiform pupillae
tongue appears smooth, glossy, erythematous
Treatment: address underlying condition
Atrophic Glossitis
heat/moisture, trauma, associated skin disease
bacterial (pseudomonas or staph) or fungal
ear pain (movement of tragus) pruritic, erythematous, edematous pseudomonas discharge = green staph = yellow fungal = fluffy white or black decreased hearing
Treatment: fungal - Clotrimazole 1% soln
bacterial - cortisporin or ofloxacin otic soln if TM perf
pain control
Otitis Externa (“swimmer’s ear”)
DM and immunocompromised pts
*Pseudomonas infection
intense otalgia and otorrhea
red, granulated tissue of EAC
trismus, edema, LAD
Treatment: IV Ciprofloxacin
Malignant Otitis Externa
etiology: strep pneumoniae, H. influenzae, M. catarrhalis
peak incidence 6-18 months
usually precipitated by URI
+/- fever
otalgia - “tugging” on the ear
N/V and otorrhea
conjunctivitis (H. influenza)
opaque/reddened BULGING TM, decreased mobility
*check for conductive hearing loss
Treatment: antibiotics for all under 6mo
6-23mo if bilateral or severe sxs
older than 24mo if dx certain and illness severe
*otherwise, observation and follow-up
Amoxicillin (high dose) 80-90mg/kg/day divided Q12 x7-10d
*Augmentin if antibiotics in past 30d or conjunctivitis
*Cef drugs if PCN allergy - IV daily x3d
tympanostomy tubes for recurrent AOM
Acute Otitis Media (AOM)
etiology: recurrent OM, trauma or cholesteatoma (accumulation of epithelial cells in middle ear)
pseudomonas, MRSA
otorrhea >2wks and associated TM perf
conductive hearing loss
Treatment: refer to ENT
Chronic Otitis Media
postauricular pain
edema, fever
erythema
protrusion of pinna
Treatment: IV antibiotics, mastoidectomy if needed
Mastoiditis
etiology: viral URI, AOM, AR
ear fullness and decreased hearing
pt afebrile (not acutely ill) - no infection associated with fluid in the ear
neutral or retracted TM - TYPE B tympanogram
conductive hearing loss
Treatment: “watchful waiting”, intranasal steroids if underlying AR
Otitis Media with Effusion
inflammation or blockage resulting in negative middle ear pressure
ear fullness and hearing loss
retracted TM - TYPE C tympanogram
Treatment: steroid nasal spray
topical nasal decongestant (ie. Afrin) but limit to 3 days or rebound congestion
Eustachian Tube Dysfunction
discomfort or damage to ear due to pressure difference
ear fullness
pain
tinnitus
hemotympanum (bloody otorrhea) if TM perf
Treatment: supportive
Ear Barotrauma
benign acute inflammation/infection of vestibular system
may follow AOM and/or precede URI
N/V
acute onset severe vertigo
horizontal nystagmus
+ head thrust (cannot maintain visual fixation)
Treatment: symptomatic (bed rest, hydration)
meclizine (Antivert) 25mg TID
benzodiazepines
Labyrinthitis
etiology: inherited hyper-responsiveness to allergen exposure (IgE antibodies)
rhinorrhea
sneezing
itchy eyes and nose (allergic salute)
nasal congestion
pale, “blue” mucosa and clear discharge
Allergic Shiners - bluish, purple ring around eyes
Denie Morgans lines - skin folds under eyes
ImmunoCAP - IgE or scratch skin testing (wheal&flare)
Treatment: avoid allergens
topical intranasal corticosteroids (Flonase, Nasocort)
antihistamines (Benadryl 25-50mg BID or Claritin/Allegra)
decongestants (Sudafed)
immunotherapy (last resort)
Allergic Rhinitis (AR)
Stress, sex, perfume, etc. induced
normal IgE and nasal mucosa
nasal congestion
rhinorrhea
Treatment: avoid triggers
topical steroids, antihistamines and anticholinergics
Vasomotor (non-allergic) Rhinitis
nasal congestion/obstruction
non-tender soft grey tissue growths
Treatment: intranasal glucocorticoids
refer to ENT if obstructive
Nasal Polyps
tachyphylaxis with overuse of topical decongestants (decreased response to successive doses of drug)
REBOUND CONGESTION
nasal mucosa is erythematous
Treatment: discontinue med and intranasal glucocorticoid
Rhinitis Medicamentosa
etiology: adults- rhinovirus, coronavirus
peds- parainfluenza virus
rhinitis/congestions sore throat hacking cough mild headache and fatigue \+/- fever nasal mucosa edema and pharyngeal erythema clear lungs
Treatment: supportive (analgesics, antihistamines)
1-2 wk duration, pt education
Common Cold
etiology: influenza virus type A (most severe) and B
abrupt onset fever prominent headache general aches/pains and fatigue coughing PND (post nasal drainage) hot, dry skin and flushing
Diagnostics: RAT (rapid antigen tests), viral culture
Treatment: antiviral (Tamiflu PO, Relenza inhalation)
Influenza
etiology: group A strep or virus
cervical LAD sore throat fever headache *palatal petechiae purulent exudate tonsillar hypertrophy
Dx Group A Strep (3 of 4): pharyngeal exudates cervical LAD fever lack of cough/rhinorrhea
Non-group A treatment: supportive
HSV - acyclovir, famcyclovir
Gonnorhea - ceftriazone
Group A treatment: PCN-V 500mg po BID-TID x10d
*clindamycin if PCN allergy
Pharyngitis/Tonsillitis
severity of sore throat out of proportion
stridor/resp. distress
peritonsillar abscess
trismus
Tonsillectomy if:
7+ episodes in 1 year
5+ episodes in each of past 2 years
3+ episodes in each of past 3 years
Emergent Acute Pharyngitis
etiology: polymicrobial (group A step & staph)
severe sore throat - usually unilateral muffled voice drooling trismus - spasm of internal pterygoid muscle) fever ipsilateral ear pain neck swelling/pain with cervical LAD deviation of uvula to opposite side
Treatment: drainage
antimicrobial - oral = amoxicillin or clindamycin x14d
parenteral (IV/IM/SubQ) - ampicillin or vancomycin
Peritonsillar Abscess
etiology: viral, bacterial, or non-infectious (ie trauma)
hoarseness rhinorrhea nasal congestion cough and sore throat direct laryngoscopy = laryngeal erythema and edema
Treatment: underlying cause (resp. virus)
humidify
voice rest and hydration
Acute Laryngitis
etiology: viral (rhinovirus, influenza)
bacterial (H. influenza)
fever >102 severe headache periorbital edema abnormal vision facial pain maxillary teeth discomfort
Treatment: viral - supportive days 1-9 (analgesics, decongestants, saline irrigation)
bacterial - Augmentin 500/125mg TID, doxycycline if PCN allergy
Acute Rhinosinusitis
4 cardinal symptoms: mucopurulent white/yellow nasal drainage nasal obstruction/congestions facial pain, pressure or fullness reduction or loss of smell (adults) cough (children)
Treatment: nasal saline lavage intranasal corticosteroids oral antimicrobials antihistamines topical/systemic antifungals
Chronic Rhinosinusitis
etiology: Epstein Barr Virus (EBV)
cervical/general LAD fever/malaise pharyngeal exudative petechiae on soft palate splenomegaly drug-induced ampicillin rash
Diagnostics: CBC, LFTs, Monospot
+IgM/-IgG = acute infection
Treatment: supportive (NSAIDs, fluids and rest)
4wk sport restriction
Infectious Mononucleosis
age-related or traumatic opacity of the lens
gradual, chronic, painless loss of vision
decreased visual acuity
yellowing of lens
Treatment: referral, intraocular lens implant (phacoemulsification)
Cataracts
etiology: decreased aqueous outflow resulting in increased intraocular pressure
chronic, painless visual loss
*peripheral first, central late
increased cup/disc ratio
Treatment: refer
topical anti-ocular hypertensives
Primary Open Angle Glaucoma
separation of retina from underlying choroid layer
*associated with myopia and DM
floaters
photopsias (light flashes)
acute loss of vision - “CURTAIN-LIKE”
raised, whitish retina
Treatment: refer, cryotherapy, vitrectomy
Retinal Detachment (RD)
common in the elderly more commonly gradual blurred vision metamorphopsia (wavy/distorted) *central scotoma (blind spot) Amsler Grid distortion Dry = Drusens Wet = neovacularization
Treatment: refer (vitamins, quit smoking, photocoagulation)
Macular Degeneration
embolic - different location
acute TOTAL painless loss of vision
afferent pupillary defect
“cherry red spot”
Treatment: refer, non effective
poor prognosis
Central Retinal Artery Occlusion (CRAO)
thrombotic
acute VARIABLE painless loss of vision
“blood and thunder” retinal appearance
Treatment: aspirin and observation
Central Retinal Vein Occlusion (CRVO)
retinal vascular changes due to systemic HTN
asymptomatic systemic HTN characteristic fundus findings AV nicking cotton-wool spots
Treatment: systemic BP control
refer if severe
Hypertensive Retinopathy
#1 cause of blindness non-proliferative = cotton-wool spots, microaneurysms proliferative = non + neovascularization macular edema = hard exudates
Treatment: blood sugar control
Diabetic Retinopathy
eyelid inflammation
CHRONIC itching, burning, scratching (worse in AM)
no vision decrease
erythema, scales, meibomian gland disease
Treatment: warm compress
antibiotics/steroids for severe cases
Blepharitis
infection of periorbital tissue
ACUTE onset of pain, swelling
+/- vision decrease
warm, edema, erythema, tender
Treatment: systemic antibiotics
Cellulitis
deficient aqueous tear production
CHRONIC itching, burning, scratching
“tired” eyes esp. in PM
vision fluctuation
punctate epithelial erosions
Treatment: artificial tears
topical cyclosporin
Dry Eye
Viral ACUTE bilateral burning soreness watery discharge URI sxs and preauricular LAD Treatment: vasoconstrictors and artificial tears
Bacterial ACUTE unilateral irritation mucopurulent discharge adherent lids Treatment: topical and/or systemic antibiotics
Allergic CHRONIC (seasonal) bilateral stringy/mucoid discharge chemosis - fluid within conjunctiva causing swelling Treatment: topical antihistamines
Conjunctivitis
blood in conjunctiva
ACUTE asymptomatic
vision unaffected
diffuse red patch
Treatment: reassurance
Subconjunctival Hemorrhage
inflammation of episcleral or scleral tissue
SUBACUTE onset of foreign body sensation/pain
vision usually unaffected
focal injection (deep, bluish hue around sclera)
Treatment: topical/systemic steroids
refer
Episcleritis/Scleritis
corneal epithelial defect
ACUTE onset of pain, foreign body sensation and epiphora
+/- vision affected
irrigate
numb with topical anesthetic
fluorescein
use blue light to see if stain lights up
Treatment: topical lubricants and antibiotics, oral pain medicines
NO TOPICAL ANESTHETICS
Corneal Abrasion
caustic chemical exposure
ACUTE pain/burning
decreased vision
red/pink.white
Treatment: IRRIGATE!!
topical lubricants or antibiotics
refer
Chemical Injury
“speck in my eye”
ACUTE onset of foreign body sensation
vision usually unaffected
Treatment: irrigation, cotton-tipped applicator
lubricant/antibiotic drops
refer
Corneal Foreign Body
infection of the cornea ACUTE onset of pain mucous discharge *contact lens abuse vision usually decreased white infiltrate *hypopyon - WBC and mucous in anterior chamber
Treatment: intensive topical antibiotics
refer
Keratitis/Corneal Ulcer
dendritic pattern on fluorescein stain
Treatment: topical antivirals
NO STEROIDS
Keratitis: HSV
inflammation of uveal tissue ACUTE onset *photophobia \+/- vision decrease ciliary flush around iris hypopyon
Treatment: topical steroids, dilation drops, refer
Iritis/Uveitis
blood in anterior chamber due to trauma of iris/uvea ACUTE onset pain photophobia \+/- vision decrease layered heme
Treatment: eyeshield/bedrest
refer
Hyphema
PAINFUL ACUTE rise of intraocular pressure due to outflow obstruction (rare)
decreased vision *halos around lights nausea \+/-pain *ciliary flush *steamy cornea mid-dilated pupil crescent shadow
Treatment: refer
topical anti-ocular hypertensives
oral/intravenous osmotic agents
Acute Angle Closure Glaucoma
