Head, Ears, Eyes, Nose, and Throat

Question 1

Soft contact lens user presents with severe eye pain, foreign body sensation, tearing, and photophobia.

Look for a whitish lesion on the cornea by using a penlight and/or performing a slit lamp exam and fluorescein dye test.

Caused by Pseudomonas, Staphylococcus, or Streptococcus

Can permanently impair vision because of scarring or perforation. Considered an ophthalmologic emergency. Refer to ED.

Answer 1

Corneal Ulcers

Question 2

Acute onset of severe eye pain, photophobia, tearing, and blurred vision in one eye. Diagnosed by using fluorescein dye. A black lamp (Wood’s lamp) is used to search for fernlike lines (branching curved lines) in the corneal surface.

Infection permanently damages corneal epithelium, which may result in corneal blindness.

Answer 2

Herpes Keratitis

Caused by herpes simplex or herpes varicella zoster (shingles).

Avoid steroid ophthalmic drops for herpes keratitis.

Refer to ED/Ophthalmologist

Question 3

Elderly patient with acute onset of severe eye pain accompanied by headache, nausea/vomiting, halos around lights, lacrimation, and decreased vision.

Examination reveals a mid-dilated pupil(s) that is oval shaped. The cornea appears cloudy. Funduscopic examination reveals cupping of the optic nerve.

Answer 3

Acute Angle-Closure Glaucoma

Considered an ophthalmologic emergency → refer to ED

Question 4

Common with Multiple Sclerosis (MS). Loss of visual acuity over hours to days. Color vision is affected, and a central scotoma (blind spot central vision) is common.

May be accompanied by other neurologic symptoms (e.g., aphasia, paresthesia, abnormal gait, spasticity). Complains of daily fatigue on awakening that worsens as the day goes on. Higher-than-normal temperature will worsen symptoms (Uhthoff phenomenon). Has recurrent episodes.

Answer 4

Optic Neuritis

Refer to neurologist

Question 5

Sudden onset of floaters (or increase in floaters) associated with “looking through the curtain” sensation with sudden flashes of light (photopsia). Central vision may be intact or lost.

Answer 5

Retinal Detachment

Refer to ED.

Question 6

Patient in their 50s to 60s presents with unilateral hearing loss (sensorineural) and tinnitus, which has been present for about 3 to 4 years. Complains of unsteadiness while walking and episodes of veering or tilting that can fluctuate in severity. More common in Asians. Caused by tumor of the acoustic nerve (CN VIII). If facial nerve (CN VII) involved, may have facial paresis and paresthesias.

Answer 6

Acoustic Neuroma (Vestibular Schwannoma)
Refer to neurologist.

Question 7

Patient complains of hearing loss and intermittent ear discharge (otorrhea) from one ear that is purulent and foul smelling. On examination, there is perforation of the tympanic membrane (TM) on the superior quadrant and a cauliflower-like or pearly-white mass.

Another presentation is an intact TM with missing landmarks with the white mass visible behind the TM. Tympanogram will be abnormal (straight line). History of chronic or recurrent otitis media infection.

Answer 7

Cholesteatoma
Mass is not cancerous, but can erode into the bones of the face and damage the facial nerve (CN VII). Treat with antibiotics and surgical excision and repair. Refer to otolaryngologist

Question 8

Parietal bone is most fractured. Linear fracture most common, followed by depressed and basilar skull fractures. Causes in adults include falls, assaults, car collisions, and penetrating missiles.

“Raccoon eyes” (periorbital ecchymosis) and bruising behind the ear (mastoid area) appear about 1 to 3 days after trauma. Physical exam (after trauma) does not show these two clinical signs immediately.

Search for a clear, golden serous discharge from the ear or nose (cerebrospinal fluid), which is also found in up to 20% of temporal bone fractures. Another common finding is hemotympanum (blue to purple color of the TM), which is caused by blood inside the middle ear.

Answer 8

Battle Sign (Basilar Skull Fracture)
Findings of the Battle sign, raccoon eyes, hemotympanum, and otorrhea/rhinorrhea are highly suggestive of a serious head injury. Additional clinical findings are determined by brain hemorrhage, brain injury, and/or CN injury. Refer to ED.

Question 9

If a young child, determine if it is primary tooth (baby tooth); if yes, do not reimplant. If permanent tooth, avoid touching root, and handle only the crown. Rinse tooth in normal saline; irrigate socket with normal saline and reimplant tooth. Afterward, have patient bite down on gauze. Store tooth in cool milk or saline, or store inside cheek (buccal sulcus) if unable to reimplant.

Answer 9

Avulsed Tooth
Considered a dental emergency – the sooner the avulsed tooth is reimplanted, the better the outcome. Refer to dentist as soon as possible.

Question 10

Serious deep-neck infection, and it is a rare complication of tonsillitis. Severe sore throat and difficulty swallowing, odynophagia (pain on swallowing), trismus (jaw muscle spasm making it difficult to open mouth), and a “hot potato” voice. Unilateral swelling of the peritonsillar area and soft palate. Affected area is markedly swollen and appears as a bulging red mass with the uvula displaced away from the mass. Accompanied by malaise, fever, and chills.

Answer 10

Peritonsillar Abscess (quinsy)
Assess for airway obstruction. About half of cases occur in children and adolescents. Refer to ED or call 911.

Question 11

An enlarged and hard left-sided supraclavicular node(s) that is associated with malignancy, especially in adults age 40 years or older. Highly suggestive of cancers of the stomach, colon, pancreas, gallbladder, kidneys, ovaries, testicles, prostate, or lymphoid tissue. The left supraclavicular lymph node drains via the thoracic duct, abdomen, and thorax.

Answer 11

Virchow’s Node (Troisier’s Sign/Node) or Sentinel

Workup includes a thorough history, physical exam, laboratory testing, and imaging. Refer to surgeon for a biopsy.

Question 12

Inflammation of the edges of the eyelids where the eyelashes grow (hair follicles). The tiny oil glands at the base of the eyelashes become clogged (meibomian glands).

Patient complains of itching or irritation in the eyelids (upper/lower or both), gritty sensation, eye redness, and crusting. Small scales like dandruff may be present.

Lid may be colonized by staphylococcal bacteria. Intermittent exacerbations. May be associated with dandruff, seborrheic dermatitis, or rosacea.

Answer 12

Blepharitis

Johnson’s Baby Shampoo with warm water: Gently scrub eyelid margins until resolves. Consider topical antibiotic solution (erythromycin eye drops) to eyelids two or three times/day (lid hygiene). Commercial eyelid scrub products are available.

Warm compress to eyelids two to four times/day during exacerbations to soften debris and relieve itching.

Question 13

Age-related visual change due to a decreased ability of the eye to accommodate and focus due to stiffening of the lenses; usually starts at the age of 40 years; near vision is affected with decreased ability to read small print at close range.

Answer 13

Presbyopia

Question 14

Fundi: The veins are larger than arteries; veins are darker (in color) than arteries.

Cones: For color perception, sharpest vision (20/20 vision).

Rods: For low-light vision (night vision), peripheral vision.

Macula (and fovea): Responsible for our central vision, sharpest vision (20/20 vision), and color vision. The center of the macula is called the fovea. It contains large numbers of cones. Diseases of the macula cause a loss of central vision.

Answer 14

Eye Examination

Question 15

Bones (ossicles) of the ear: Malleus, incus, and stapes. The stapes is the smallest bone in the body.

TM: Appears as translucent off-white to gray color with the “cone of light” intact. The lateral process of the malleus is located at the upper quadrant of the TM and lies in front of the pars flaccida. The pars tensa is located on the lower aspect and appears to bulge slightly. It is the area of the TM where the cone of light is visible.

Tympanogram: This is the most objective measure to test for presence of fluid inside middle ear

Pinna: Has a large amount of cartilage. Blunt trauma can result in a hematoma, which should be drained as soon as possible to avoid damage to the cartilage of the ear. If untreated, it can result in cauliflower ear.

Tragus: A small cartilage flap of tissue on the front of the ear.

Cartilage: Found on the nose and ears. Does not regenerate. Refer injuries to plastic surgeon.

Cerumen: Ear wax; the color can range from yellow to dark brown.

Answer 15

Ears Examination

Question 16

Kiesselbach’s plexus: a vascular network formed by five arteries that supply oxygenated blood to the nasal septum. Located on the anterior inferior aspect of the nose (lower one-third). An anterior nosebleed is the result if the area is traumatized.

Turbinates: Only the inferior nasal turbinates are usually visible. The medial and superior turbinates are not visible without special instruments. Bluish, pale, and/or boggy nasal turbinates are seen in allergic rhinitis.

Cartilage: Lower third of the nose is cartilage. Cartilage tissue does not regenerate.

Septum: Perforation of the nasal septum can result from inhalation of cocaine, which is a potent vasoconstrictor. Refer to plastic surgeon for repa

Answer 16

Nose Examination

Question 17

Sinuses are air-filled cavities in the skull. There are four types:

Ethmoid and maxillary (both present at birth)
Frontal (age 5 years)
Sphenoid (age 12 years).

By age 12 years, a child’s sinuses are nearly at adult proportions.

Answer 17

Sinuses Examination

Question 18

Mucous membranes are pink to dark pink and moist. Look for ulcers, fissures, leukoplakia, and inflammation. If gums are red and swollen, the patient may have gingivitis (gums may bleed when brushing teeth) or be taking phenytoin (Dilantin) for seizures (gingival hyperplasia). The tongue should not be red or swollen (glossitis). Vermilion border is at the edges of the lips. The corners of the lips are called the oral commissures. A normal adult has 32 teeth.

Answer 18

Mouth Examination

Question 19

White-to-light-gray patch that appears on tongue, floor of mouth, or inside cheek. Caused by chronic irritation, such as from chewing tobacco or snuff.

Answer 19

Leukoplakia
Rule out oral cancer. Chewing or smoking tobacco, alcohol abuse, and human papillomavirus (HPV) are risk factors for oral cancer. Refer to oral surgeon for biopsy..

Question 20

There are three salivary glands: parotid, submandibular, and sublingual.

Glands may become infected (sialadenitis, sialadenosis, mumps) or can become blocked with calculi (“stone”; sialolithiasis).

Answer 20

Salivary Glands Examination

Question 21

Also known as the palatine tonsils; tonsils are made up of lymphoid tissue. Butterfly-shaped glands with small pore-like openings that may secrete thick white exudate (mononucleosis) or purulent exudate that is a yellow-to-green color (strep throat).

Answer 21

Tonsils Examination

Question 22

Look for postnasal drip (acute sinusitis, allergic rhinitis). Lying supine worsens a postnasal drip cough. Chronic sinusitis can cause a chronic cough.

Retropharyngeal lymph nodes that are mildly enlarged and distributed evenly on the back of the throat (allergies, allergic rhinitis).

Hard palate: Look for any openings (cleft palate), ulcers, redness.

Uvula: Should be in midline position; is displaced if infected and abscessed (peritonsillar abscess).

Answer 22

Posterior Pharynx Examination

Question 23

Anterior cervical nodes (superficial chain) drain the lymph from the skin and superficial surfaces of the anterior neck – can become enlarged with viral or bacterial infections (strep throat).

Posterior cervical nodes (superficial chain) drain the scalp, neck, and skin of the upper thoracic area. Mononucleosis can cause posterior cervical lymphadenopathy.

Answer 23

Lymph Nodes Examination

Question 24

Mucosal lining inside eyelids

Answer 24

Palpebral conjunctiva

Question 25

Mucosal lining covering the eyes

Answer 25

Bulbar conjunctiva

Question 26

Mucosal lining inside the mouth

Answer 26

Buccal mucosa

Question 27

Area where uvula, tonsils, and anterior of throat are located

Answer 27

Soft palate

Question 28

“Roof” of the mouth

Answer 28

Hard palate

Question 29

“Farsightedness”; distance vision is intact, but near vision is blurry.

Answer 29

Hyperopia

Question 30

“Nearsightedness”; near vision intact, but distance vision is blurry.

Answer 30

Myopia

Question 31

Also called “lazy eye.” Usually starts in infancy. The affected eye has reduced vision.

Answer 31

Amblyopia

Refer to ophthalmologist

Question 32

Drooping of the upper eyelid

Answer 32

Ptosis

Question 33

Tongue surface has a maplike appearance; patches may move from day to day.
Patient may complain of soreness with acidic foods, spicy foods.

Answer 33

Geographic Tongue

Benign Variant

Question 34

Painless bony protuberance midline on the hard palate (roof of the mouth); may be asymmetric; skin should be normal.
Does not interfere with normal function.

Answer 34

Torus Palatinus

Benign Variant

Question 35

On prolonged, extreme lateral gaze, a few beats of nystagmus that resolve when the eye moves back toward midline in healthy patients is normal.

Answer 35

Physiologic Gaze-evoked Nystagmus

Benign Variant: Few horizontal nystagmic beats are within normal limits (WNL).

Question 36

Optic disc swollen with blurred edges due to increased intracranial pressure (ICP) secondary to bleeding, brain tumor, abscess, pseudotumor cerebri

Answer 36

Papilledema

Question 37

Copper and silver wire arterioles (caused by arteriosclerosis)

Arteriovenous (AV) nicking is caused by compression of a vein by an arteriole as it passes over it; it appears as if it is “nicked” or it is missing a small area.
Retinal hemorrhages

Answer 37

Hypertensive Retinopathy

Copper and silver wire arterioles, arteriovenous (AV) nicking

Question 38

Microaneurysms (small bulges in retinal blood vessels that often leak fluid) caused by neovascularization (new fragile arteries in the retina that rupture and bleed)
Cotton-wool spots (fluffy yellow-white patches on the retina

Answer 38

Diabetic retinopathy findings

Neovascularization, microaneurysms, and cotton wool spots,

Question 39

Opacity of the lens of the eye, which can be central (nuclear cataract) or on the sides (cortical cataract).

Symptoms include difficulty with glare (with headlights when driving at night or sunlight), halos around lights, and blurred vision.

Answer 39

Cataracts

Up to 20% of older adults (age 65–74 years) are affected; cataracts can appear at any age from infants (congenital cataracts) through adults to the elderly.

Question 40

Inflammatory changes of nasal mucosa due to allergy. Increases risk of sinusitis. May have intermittent, seasonal, or daily symptoms. Atopic family history (asthma, eczema). May be allergic to dust mites (daily symptoms), mold and grasses (summer), ragweed pollen (fall), cockroach dander (older buildings in urban areas), and others. May affect sleep and quality of life.

Patient complains of chronic or seasonal nasal congestion with clear mucus rhinorrhea or postnasal drip. Coughing due to postnasal drip worsens when supine. Accompanied by nasal itch and, at times, frequent sneezing. Some people produce a clicking sound to clear mucus inside their throat (palatal click).

Blue-tinged or pale and swollen (boggy) nasal turbinates associated with increased clear nasal discharge. Posterior pharynx reveals thick mucus, with colors including clear, white, yellow, or green (rule out sinusitis). Undereye “circles” (venodilation). Children may have transverse nasal crease from frequent rubbing (allergic salute). Posterior pharynx may show cobblestoning (hyperplastic lymphoid tissue).

Answer 40

Allergic Rhinitis

Question 41

Painless, soft round growths inside the nose. Look for fleshy mass inside nasal cavity. May have blockage on one side of the nose.

There is increased risk of aspirin sensitivity or allergy.

Answer 41

Nasal Polyps

Intranasal glucocorticoids (fluticasone or budesonide twice a day) are used as first-line treatment. If poor response or recurrent sinus infection, refer to an ear, nose, and throat (ENT) specialist for surgical treatment.

Question 42

Clusters of small red papules with white centers inside the cheeks (buccal mucosa) by the lower molars.

Pathognomonic for measles (rubeola)

Answer 42

Koplik’s Spots

Prodromic viral enanthem of measles manifesting 2 to 3 days before the measles rash itself.

Question 43

Painful skin fissures and maceration at the corners of the mouth due to excessive moisture. More common in the elderly with dentures. Can be acute or chronic. Secondary infection with Candida albicans (yeast) or bacteria (Staphylococcus aureus).

Multiple etiologies such as oversalivation, poorly fitting dentures, nutritional deficiencies (vitamins B2 [riboflavin], B3 [niacin], B6 [pyridoxine], or B9 [folic acid]), lupus, autoimmune disease (Sjögren’s syndrome), irritant dermatitis, and squamous cell carcinoma, and pacifier use, lip licking, and thumb sucking in children.

Answer 43

Cheilosis (Angular Cheilitis, Perleche)

Remove underlying cause. Check vitamin B12 level; consider checking other B vitamins (B3, B6, B9). Check if dentures fit correctly; if loose, refer to dentist.

If yeast infection is suspected, microscopy with potassium hydroxide (KOH). If positive (pseudohyphae and spores), treat with topical azole ointment (e.g., clotrimazole, miconazole) twice a day.

If suspect staphylococcal infection, order culture and sensitivity. If positive, treat with topical mupirocin ointment twice a day.

When infection has cleared, apply barrier cream with zinc or petroleum jelly at night. High rate of recurrence.

Question 44

Snellen chart, If person is illiterate, use Tumbling E chart. Patient must stand 20 feet away from the chart.

If the patient wears glasses, test the vision with the glasses in both eyes (OU), the right eye (OD), and the left eye (OS).

Answer 44

Central distance vision.

Question 45

Definition of a Snellen test result:

Top number (or numerator): The distance in feet at which the patient stands from the Snellen or picture eye chart (always 20 feet and never changes).

Bottom number (or denominator): The number of feet at which the patient can see compared with a person with normal vision (20/20 or less). Number changes, dependent on patient’s vision. For example, the patient can see at 20 feet what a person with normal vision can see at 60 feet.

Answer 45

Vision of 20/60

Question 46

Ask patient to read small print.

Answer 46

Assessing Near Vision

Question 47

Use the “visual fields of confrontation” exam.

Look for blind spots (scotoma) and peripheral visual field defects.

Answer 47

Assessing Peripheral Vision

Question 48

Defined as a best corrected vision of 20/200 or less or a visual field less than 20 degrees (tunnel vision).

Answer 48

Legal blindness

Question 49

Pediatric visual acuity using Snellen chart:

Normal s vs Abnormal Findings

Answer 49

By the age of 6 years, visual acuity (retina or CN II) is 20/20 in both eyes.
If the child’s vision is not at least 20/30 in either eye by age 6 years, refer to ophthalmologist.

Question 50

Hearing test: Place tuning fork first on mastoid process, then at front of the ear. Time each area.

Answer 50

Rinne Test

Normal finding: Air conduction (AC) lasts longer than bone conduction (BC)

Question 51

Normal Hearing: Clinical Findings

Tests of the acoustic nerve (CN VIII)

Answer 51

Weber Test: no lateralization

Rinne Test: AC > BC

Question 52

Sensorineural loss: Clinical Findings

• Presbycusis
• Ménière’s disease
• Labyrinthitis
• Acoustic neuroma

Answer 52

Weber Test: Lateralization to “good” ear (sound is heard louder in the ear that is normal)

Rinne Test: AC > BC

Question 53

Conductive hearing loss: Clinical Findings

• Otitis media
• Serous otitis media
• Ceruminosis
• Perforation of tympanic membrane

Answer 53

Weber Test: Lateralization to “bad” ear (sound is heard louder in the “bad” or affected ear)

Rinne Test: BC > AC

Question 54

Damage (or aging) of the cochlea/vestibule (presbycusis, Ménière’s disease) and/or to the nerve pathways (CN VIII or acoustic nerve).

Other causes are ototoxic drugs (e.g., oral aminoglycosides, erythromycin, tetracyclines, high-dose aspirin, sildenafil) and stroke. Usually results in permanent hearing loss.

Answer 54

Sensorineural Hearing Loss (Inner Ear)

Question 55

Patient complains of acute onset of severe eye pain with tearing. Reports feeling of a foreign body sensation on the surface of the eye. Always ask any patient with eye complaints whether they wear contact lenses.

Answer 55

Corneal Abrasion

Corneal abrasions appear more linear or round on fluorescein dye

Question 56

Patient complains of acute onset of red eye, blurred vision, watery eyes, photophobia, and sometimes a foreign-body sensation in affected eye. History of using contacts past prescribed time schedule, sleeping with contact lens, bathes/showers or swims with contacts, extended lens use, and use of tap/well water or poor disinfection practices.

Use fluorescein dye strips with Wood’s lamp (black lamp) in darkened room. Contact lens–associated abrasions are usually in the center and are round.

Answer 56

Contact Lens–Related Keratitis

Always check visual acuity and check pupils with penlight. Rule out penetrating trauma, retained foreign body, and contact lens–associated eye infections. If suspect bacterial infection, obtain C&S of eye discharge.

Flush eye with sterile normal saline to remove foreign body. Evert eyelid to look for foreign body. If unable to remove, refer.

Use topical ophthalmic antibiotic with pseudomonal coverage (especially if contact lens user), such as ciprofloxacin (Ciloxan), ofloxacin (Ocuflox), or trimethoprim–polymyxin B (Polytrim), applied to affected eye × 3 to 5 days.

Do not patch eye. Follow up in 24 hours. If not improved, refer to ED or ophthalmologist stat (Zovirax or Valtrex twice a day). Avoid steroid ophthalmic drops for herpes keratitis.

Consider eye pain prescription (hydrocodone with acetaminophen; prescribe enough for 48 hours of use).

Topical pain medication Acular 1 gtt four times a day (contraindication: allergy to nonsteroidal anti-inflammatory drugs [NSAIDs]).

Question 57

Abscess of a hair follicle and sebaceous gland in the upper or lower eyelid. Involves inflammation of the meibomian gland if internal. May have history of blepharitis.

Patient complains of acute onset of a swollen, red, and warm abscess on the upper or lower eyelid involving one hair follicle that gradually enlarges. May spontaneously rupture and drain purulent exudate. Infection may spread to adjoining tissue (preseptal cellulitis).

Answer 57

Hordeolum (Stye)

Hot compresses for 5 - 10 minutes x two to three times a day until it drains.

If infection spreads (preseptal cellulitis), systemic antibiotics such as dicloxacillin or erythromycin orally four times a day. Refer to ophthalmologist for incision and drainage (I&D).

Question 58

Chronic inflammation of the meibomian gland (specialized sweat gland) of the eyelids. It may resolve spontaneously in 2 to 8 weeks.

Patient complains of a gradual onset of a small superficial nodule on the upper eyelid that feels like a bead and is discrete and movable. Painless. Can slowly enlarge over time. If it gets too large, it can press on the cornea and cause blurred vision.

Answer 58

Chalazion

Hot compresses

Treatment is incision and drainage, surgical removal, or intrachalazion corticosteroid injections by ophthalmologist.

Question 59

A raised, yellow-to-white, small round growth in the bulbar conjunctiva (skin covering eyeball) next to the cornea. Located on the nasal and temporal side of the eye. Caused by chronic sun exposure.

Answer 59

Pinguecula

If inflamed, refer to ophthalmologist for prescription of weak steroid eye drops only during exacerbations. Use artificial tears as needed for irritation.

Recommend use of good-quality sunglasses (100% against UVA and UVB).

Remove surgically if the growth encroaches on cornea and affects vision.

Question 60

A yellow triangular (wedge-shaped) thickening of the conjunctiva that extends across the cornea on the nasal side. Results from chronic sun exposure. Sometimes called surfer’s eye. Can be red or inflamed at times. Patient may complain of foreign body sensation on the eye.

Answer 60

Pterygium

If inflamed, refer to ophthalmologist for prescription of weak steroid eye drops only during exacerbations. Use artificial tears as needed for irritation.
Recommend use of good-quality sunglasses (100% against UVA and UVB).
Remove surgically if the growth encroaches on cornea and affects vision.

Question 61

Blood that is trapped underneath the conjunctiva and sclera secondary to broken arterioles. Can be caused by coughing, sneezing, heavy lifting, vomiting, or local trauma or can occur spontaneously. Resolves within 1 to 3 weeks (blood reabsorbed) like a bruise, with color changes from red, to green, to yellow. Increased risk if patient is on aspirin or anticoagulants or has hypertension. No visual loss or pain.

Answer 61

Subconjunctival Hemorrhage

Watchful waiting and reassurance of patient. Follow up until resolution.

Question 62

Primary Open-Angle Glaucoma Medications

Side effects & Contraindications

Answer 62

Betimol 0.5% (timolol): Beta-blocker eye drops (decrease aqueous production)
Latanoprost (Xalatan): Topical prostaglandin eye drops (increase aqueous outflow)

Side effects: Same as oral form; includes bronchospasm, fatigue, depression, heart failure, bradycardia

Contraindications: Asthma, emphysema, chronic obstructive pulmonary disease (COPD), second- or third-degree heart block, heart failure

Question 63

Sudden blockage of aqueous humor causes marked increase of the IOP, resulting in ischemia and permanent damage to the optic nerve (CN II).

Older patient complains of acute onset of decreased/blurred vision with severe eye pain and frontal headache that is accompanied by nausea and vomiting.

Eyes: Fixed and mid-dilated, cloudy pupil (4–6 mm) that looks more oval than round. Pupil reacts slowly to light. Conjunctival injection with increased lacrimation.

Answer 63

Primary Angle-Closure Glaucoma

Refer to ED.

Question 64

Gradual onset of eye pain with conjunctival injection (redness; note that injection of the eye means the superficial blood vessels of the conjunctiva are prominent [red eyes]) located mainly on the limbus (junction between cornea and sclera) that is a complication of autoimmune disorders (rheumatoid arthritis, lupus, ankylosing spondylitis), sarcoidosis, syphilis, others.

No purulent discharge (as in bacterial conjunctivitis).

Answer 64

Anterior Uveitis (Iritis)
Refer to ophthalmologist for management as soon as possible within 24 hours. Anterior uveitis can result in blindness.

Question 65

Usually asymptomatic during early stages. Caused by gradual damage to the pigment of the macula (area of central vision) that results in severe visual loss or blindness. Leading cause of blindness in the elderly. More common in smokers.

Elderly smoker complains of gradual or sudden and painless loss of central vision in one or both eyes. Reports that straight lines (doors, windows) appear distorted or curved. Peripheral vision is usually preserved.

Answer 65

Age-Related Macular Degeneration (AMD)

Can either be atrophic (dry form) or exudative (wet form). The dry form of AMD is more common (85%–90%) and is “less severe” compared with the wet form. The wet form of AMD is responsible for 80% of vision loss (choroidal neovascularization).

Question 66

Chronic autoimmune disorder characterized by decreased function of the lacrimal and salivary glands. It can occur alone or with another autoimmune disorder (e.g., with RA).

Classic symptoms are persistent daily symptoms of dry eyes and dry mouth (xerostomia) for >3 months. Patient complains of chronic “dry eyes” and a sandy or gritty sensation (keratoconjunctivitis sicca). Has used over-the-counter (OTC) artificial tears more than three times per day. Marked increase in dental caries; oral examination shows swollen and inflamed salivary glands.

Answer 66

Sjögren’s Syndrome

Use OTC tear-substitute eye drops three times daily. Refer to ophthalmologist (keratoconjunctivitis sicca) and dentist (dental caries).

Refer to rheumatologist for management.

Question 67

The eyelid is turned outward or sags away from the eye. It causes irritation and eye dryness. More common in the elderly.

Answer 67

Ectropion

Question 68

The eyelid (usually the lower eyelid) is turned inward. The eyelashes continuously rub against the cornea, causing irritation, watery eyes, redness, pain, and/or foreign body sensation. More common in the elderly.

Answer 68

Entropion

Question 69

Allergic Rhinitis Treatment Plan

Answer 69

First-line treatment: Topical nasal sprays
Nasal steroid sprays (OTC): Fluticasone (Flonase) twice a day, triamcinolone (Nasacort Allergy 24HR), one or two sprays once a day.
If only partial relief → topical antihistamine nasal spray with azelastine (Astelin) daily or twice a day.
If no relief → combination product (azelastine and fluticasone nasal spray).
Use cromolyn sodium nasal spray three times a day (less effective than steroids).

Use decongestants (pseudoephedrine or Sudafed) as needed. Do not give to infants/young children.

Consider oral antihistamines as needed. Second-generation antihistamines (OTC) are less sedating. Cetirizine (Zyrtec), loratadine (Claritin) orally once daily or as needed. Be careful with diphenhydramine (Benadryl); it causes sedation.

Ideally, eliminate environmental allergens.

Dust mite allergies: Avoid using ceiling fans; no stuffed animals or pets in bed; use a HEPA (high-efficiency particulate air) filter for air conditioners, room filters, and the like. Refer to allergist.

Question 70

Prolonged use of topical nasal decongestants (>3 days) causes rebound effects that result in severe and chronic nasal congestion.

Patients present with daily severe nasal congestion and nasal discharge (clear, watery mucus).

Answer 70

Rhinitis Medicamentosa

Stop the use of nasal decongestants.
Encourage use of nasal saline spray to control symptoms.

Question 71

A hole on the nasal septum (cartilage) can range in size from small to large. Shining a light on one nostril will transilluminate both sides. One of the most common causes is snorting or inhalation of cocaine, a potent vasoconstrictor, which can cause ischemia. Other causes are trauma, prior septal surgery, untreated septal hematomas, and self-induced lesions.

Answer 71

Septal Perforation

Question 72

An acute infection of the pharynx and/or palatine tonsils caused by group A streptococcal bacteria (Streptococcus pyogenes). Keep in mind that the most common pathogen is viral (e.g., rhinovirus, adenovirus, respiratory syncytial virus [RSV]). Suspect viral etiology (or coinfection) if cough and symptoms such as stuffy nose, rhinitis with clear mucus, and watery eyes (coryza).

All ages are affected, but most common in children. Abrupt onset of fever, sore throat, pain on swallowing, and mildly enlarged submandibular nodes. Pharynx is dark pink to bright red. May have purulent exudate on tonsils that is yellow-to-green color. May have petechiae on the hard palate (roof of the mouth). Anterior cervical nodes mildly enlarged and tender (anterior cervical adenitis).

Answer 72

Streptococcal Pharyngitis/Tonsillopharyngitis (“Strep” Throat)

Centor criteria are a clinical decision tool used to help diagnose “strep” throat. Criteria for strep throat include tonsillar exudate, tender anterior cervical adenopathy, history of fever, and absence of cough.

Rapid antigen detection testing (RADT) is a rapid “strep” test or throat C&S

Question 73

Streptococcal Pharyngitis/Tonsillopharyngitis (“Strep” Throat) Complications

Answer 73

Scarlet fever (scarlatina): Sandpaper-textured pink rash with sore throat and strawberry tongue (red sore tongue). Rash starts on the head and neck and spreads to the trunk and then the extremities. Next, the skin desquamates (peels off). Increased risk of acute rheumatic fever.

Acute rheumatic fever: Inflammatory reaction to strep infection that may affect the heart and the valves, joints, and brain.

Peritonsillar abscess: Displaced uvula, red bulging mass on one side of anterior pharyngeal space, dysphagia, fever. Refer to ED stat.

Poststreptococcal glomerulonephritis: Abrupt onset of proteinuria, hematuria, dark-colored urine, and red blood cell (RBC) casts (urine) accompanied by hypertension and edema.

Question 74

Most cases occur in childhood. An acute infection of the middle ear cavity with bacterial pathogens due to mucus that becomes trapped in the middle ear; secondary to temporary eustachian tube dysfunction. The infection is usually unilateral but may at times involve both ears. Most have middle ear effusion (MEE).

Patient complains of ear pain (otalgia), popping noises, muffled hearing. Recent history of a cold or flare-up of allergic rhinitis. Adult infections usually develop much more slowly than in children. Afebrile (low-grade fever). May be accompanied by rupture of the TM (reports blood and pus seen on pillowcase on awakening with relief of ear pain).

*Decreased mobility of the tympanic membrane as measured by tympanogram.

Answer 74

Acute Otitis Media (Purulent or Suppurative Otitis Media)

Question 75

Acute Otitis Media (Purulent or Suppurative Otitis Media) Pathogens

Answer 75

Adult infections usually due to Streptococcus pneumoniae. High rates of beta-lactamase resistance.

S. pneumoniae (gram positive; up to 40% of cases)

Haemophilus influenzae (gram negative; up to 50% of cases)

Moraxella catarrhalis (gram negative; up to 20% of cases)

Question 76

Type of AOM infection that is more painful due to the presence of blisters (bullae) on a reddened and bulging TM. Conductive hearing loss. Caused by different types of pathogens (mycoplasma, viruffirs, bacteria).

Weber exam shows lateralization to the “bad”/affected ear (conductive hearing loss).
Rinne test result is BC > AC (conductive hearing loss).

TM: Bulging or retraction with displaced light reflex (displaced landmarks); may look opaque
Erythematous TM
Decreased mobility with flat-line tracing on tympanogram (most objective finding)
If TM is ruptured, purulent discharge from affected ear (and relief of ear pain)

Answer 76

Bullous Myringitis
Treat the same as bacterial AOM

Amoxicillin is the first-line treatment: for any age group (if no antibiotics in the prior month). Give amoxicillin 500 mg PO TID × 5 to 7 days.
Mild-to-moderate disease: Treat 5 to 7 days.
Severe disease: Treat 10 days.
Most patients will respond in 48 to 72 hours.

If no response to treatment, switch to second-line drug such as amoxicillin–clavulanate (Augmentin) TID, cefdinir (Omnicef) or cefprozil (Ceftin) BID, or levofloxacin (Levaquin) or moxifloxacin (Avelox) daily × 5 days.

In addition to antibiotic, treat symptoms of ear pain (otalgia) and eustachian tube dysfunction (becomes swollen due to inflammation and cannot drain). Patient will complain of a “plugged-up” ear (MEE) and decreased hearing in affected ear (temporary). When fluid in the middle ear drains, hearing will become normal.

Question 77

Acute Otitis Media (Purulent or Suppurative Otitis Media)

Treatment Plan

Answer 77

Amoxicillin is the first-line treatment: for any age group (if no antibiotics in the prior month). Give amoxicillin 500 mg PO TID × 5 to 7 days.
Mild-to-moderate disease: Treat 5 to 7 days.
Severe disease: Treat 10 days.
Most patients will respond in 48 to 72 hours.

If no response to treatment, switch to second-line drug such as amoxicillin–clavulanate (Augmentin) TID, cefdinir (Omnicef) or cefprozil (Ceftin) BID, or levofloxacin (Levaquin) or moxifloxacin (Avelox) daily × 5 days.

In addition to antibiotic, treat symptoms of ear pain (otalgia) and eustachian tube dysfunction (becomes swollen due to inflammation and cannot drain). Patient will complain of a “plugged-up” ear (MEE) and decreased hearing in affected ear (temporary). When fluid in the middle ear drains, hearing will become normal.

Question 78

Maxillary and frontal sinuses are most affected. Reports a history of a “bad cold” or flare-up of allergic rhinitis. Fluid is trapped inside the sinuses, causing secondary bacterial (S. pneumoniae, H. influenzae) or viral infection. Antibiotics rarely needed.

Patient complains of unilateral facial pain or upper molar pain (maxillary sinus) with nasal congestion for 10 days or longer with purulent nasal and/or postnasal drip. If frontal sinusitis, pain is located over the frontal sinus. May report hyposmia (reduced ability to smell). Postnasal drip cough worsens when supine and may interfere with sleep. Self-treatment with OTC cold and sinus remedies provides no relief of symptoms.

Posterior pharynx: Purulent dark-yellow to green postnasal drip
Sinuses: Tender to palpation on the front cheek (maxillary) or on frontal sinus area above the inner canthus of the eye
If seen with allergy flare-up, possible swollen (boggy) nasal turbinates
Fever seen more often in children than adults
Transillumination (frontal and maxillary sinuses): Positive (“glow” of light on infected sinus is duller compared with normal sinus).

Answer 78

Acute Bacterial Rhinosinusitis

Symptomatic treatment without antibiotics if mild, uncomplicated acute bacterial rhinosinusitis (ABRS) in healthy patient. Treatment is oral fluids and, if needed, saline nasal irrigations.

Follow up in 10 days (if better, no antibiotics needed). If symptoms are worse (or have not resolved) on follow-up visit, initiate antibiotic treatment.

Treat with antibiotics if there are severe symptoms (toxic, high fever, pain, purulent nasal or postnasal drip for ≥2 to 3 days, maxillary toothache, unilateral facial pain, sense of bad odor in nose [cacosmia], initial symptom improved, then worsening of symptoms), patient is immunocompromised, symptoms present for >10 days (or have worsened).

Most cases of adult acute rhinosinusitis are due to viral infection. Acute bacterial infection accounts for only 0.5% to 2% of cases.

Question 79

Acute Bacterial Rhinosinusitis Antibiotic Treatment Plan

Answer 79

First-Line (Adults):
Amoxicillin–clavulanate (Augmentin) 1,000/62.5 mg or 2,000 mg/125 mg one tablet orally twice a day × 5 to 7 days.

Penicillin Allergy or Alternative Antibiotics:
Type 1 allergy (e.g., anaphylaxis, angioedema): Levofloxacin 750 mg PO daily or doxycycline BID × 5 to 7 days
Type 2 allergy (e.g., skin rash): Cefdinir (Omnicef), cefpodoxime (Vantin), cefuroxime (Ceftin) PO BID × 5 to 7 days

Question 80

Symptomatic or Adjunct Treatment (Rhinosinusitis or Otitis Media)

Answer 80

Pain or fever:
Naproxen sodium (Anaprox DS) PO BID or ibuprofen (Advil) PO QID PRN
Acetaminophen (Tylenol) every 4 to 6 hours PRN

Drainage:
Increased oral fluids will thin mucus
Oral decongestants such as pseudoephedrine (Sudafed) or pseudoephedrine combined with guaifenesin (Mucinex D)
Topical decongestants (i.e., Afrin): Use only for 3 days maximum or will cause rebound
Saline nasal spray (Ocean spray) one or two times every 2 to 3 hours PRN
Steroid nasal spray (Flonase, Beclomethasone) if allergic rhinitis
Mucolytic (guaifenesin) and increase fluid to thin mucus

Cough:
Dextromethorphan (Robitussin) QID
Benzonatate (Tessalon Perles) prescription: Swallow pills with water; do not crush, suck, or chew; toxic for children younger than age 10 years (seizures, cardiac arrest, death)
Increase intake of fluids, avoid exposure to cigarette smoke and alcohol
The use of systemic steroids is not recommended

Question 81

Acute Bacterial Rhinosinusitis Antibiotic Treatment Failure and Referral

Answer 81

If symptoms persist despite treatment (purulent nasal discharge, sinus pain, nasal congestion, fever), switch to another antibiotic.

If on amoxicillin Δ amoxicillin–clavulanate (Augmentin) PO q12h × 10 to 14 days OR levofloxacin (Levaquin) 750 mg daily.

If recurrent sinusitis, refer to otolaryngologist. Nasal irrigation may help use only sterile water (not tap water) with saline packet.

Question 82

Serious Complications of Otitis Media and Rhinosinusitis

Answer 82

Refer to ED stat.
Mastoiditis: Red and swollen mastoid that is tender to palpation.

Preorbital or orbital cellulitis (more common in children): Swelling and redness at periorbital area, double vision or impaired vision, and fever. Abnormal EOM (extraorbital muscles) movement of affected orbit (check CNs, EOM). Altered level of consciousness (LOC) or mental status changes.

Meningitis: Acute onset of high fever, stiff neck, severe headache, photophobia, toxicity. Positive Brudzinski or Kernig sign.

Cavernous sinus thrombosis: Patient complains of acute onset of severe headache that interferes with sleep, abnormal neurologic exam, confusion, febrility. Life-threatening emergency with high mortality.

Question 83

Otitis Media with Effusion (Serous Otitis Media) Treatment Plan

Answer 83

Oral decongestants (pseudoephedrine or phenylalanine)
Steroid nasal spray BID to TID × few weeks or saline nasal spray (Ocean spray) PRN
Allergic rhinitis: Steroid nasal sprays with long-acting oral antihistamine (Zyrtec)

Question 84

Bacterial infection of the skin of the external ear canal (rarely fungal). More common during warm and humid weather (e.g., summer).

Patient complains of external ear pain, swelling, discharge, pruritus, and hearing loss (if ear canal is blocked with pus). History of recent activities that involve swimming or getting ears wet.

Ear pain with manipulation of the external ear or tragus. Purulent green discharge. Erythematous and swollen ear canal that is very tender to the touch.

Answer 84

Otitis Externa (Swimmer’s Ear)

• Otitis externa does not involve the middle ear or the tympanic membrane (translucent tympanic membrane with intact landmarks, no redness, no bulging).
• Tenderness of the mastoid area is not a complication of otitis externa.

Question 85

Otitis Externa (Swimmer’s Ear) Pathogens

Answer 85

Pseudomonas aeruginosa (gram-negative) *most common = bright-green pus

S. aureus (gram-positive)

Question 86

Otitis Externa (Swimmer’s Ear) Treatment Plan

Answer 86

Polymyxin B-neomycin-hydrocortisone (Cortisporin Otic) suspension 4 gtt QID × 7 days PLUS
Ofloxacin otic or ciprofloxacin (Cipro HC) otic ear drops BID × 7 days.

Aluminum acetate solution PRN: provides soothing, effective relief of minor skin irritations and inflammation.

Immunocompromised (e.g., poorly controlled diabetes, chemotherapy, immunosuppressive drugs, AIDS) treatment consists of topical antibiotics plus systemic/oral antibiotics such as ciprofloxacin or ofloxacin BID × 7 to 10 days.

Keep water out of ear during treatment. If patient has recurrent episodes, prophylaxis is Otic Domeboro (boric) or alcohol and vinegar (VoSol).

Question 87

Infection by the EBV (herpesvirus family). Peak ages of acute infection in the United States are between 15 and 24 years. After acute infection, EBV lies latent in oropharyngeal tissue. Can become reactivated and cause symptoms. Virus is shed mainly through saliva.
Classic triad: Fever, pharyngitis, lymphadenopathy (>50% cases).

Teenage patient presents with history of sore throat, enlarged posterior cervical nodes, symmetric lymphadenopathy, and fatigue (several weeks). Tonsillar exudate with color of exudate ranging from white to gray-green. Fatigue may last weeks to months. May have abdominal pain due to hepatomegaly and/or splenomegaly. History of intimate kissing.

Answer 87

Infectious Mononucleosis

Question 88

Infectious Mononucleosis Treatment Plan

Answer 88

Acute stages: Risk for ruptured spleen. Limit physical activity (exercise, contact sports, weightlifting) for 4 weeks to reduce risk of splenic rupture. Order abdominal ultrasound if splenomegaly/hepatomegaly is present, especially if patient is an athlete, a physically active adult, or an athletic coach. Repeat abdominal ultrasound in 4 to 6 weeks if abnormal to document resolution.

Treat symptoms.

Avoid using amoxicillin → drug rash from 70% to 90%

Avoid close contact; kissing; sharing toothbrush, fork, spoon, or knife; and using the same glass.

Question 89

Infectious Mononucleosis Complications

Answer 89

Splenomegaly/splenic rupture is a rare but serious complication of mononucleosis.

If airway obstruction, hospitalize and give high-dose steroids to decrease swelling.

Neurologic complications: Guillain–Barré syndrome, aseptic meningitis, optic neuritis, others.

Blood dyscrasias (atypical lymphocytes): Repeat CBC until lymphocytes are normalized.

Question 90

Two types: Peripheral vs Central

A person with vertigo will describe the sensation of the room spinning or of rotational movement. May be associated with nystagmus.

Assess if the person has vertigo or other types of dizziness such as near syncope, hypoglycemia, orthostatic hypotension, cerebrovascular disease, and arrhythmias.

Answer 90

Peripheral vertigo is caused by disorders of the vestibular apparatus of the inner ear or by the inflammation of vestibular nerve (CN VIII).

Central vertigo is associated with serious to life-threatening conditions such as stroke (cerebellar or brainstem bleeding), multiple sclerosis, infections, or tumor.

Question 91

A positive finding is rotary nystagmus with latency of limited duration. Assuming affected ear is on the right, with the patient sitting on the examination table (facing forward, with eyes open), turn the patient’s head 45 degrees to the right. While standing behind the patient and supporting the patient’s head with one hand, rapidly move the head from an upright to “head hanging” position, where the patient’s head is at least 10 degrees below horizontal. To achieve complete dependency of the patient’s head during the maneuver, the patient should be positioned in such a way that their shoulders will meet the head of the table when they are reclined

Answer 91

Dix–Hallpike maneuver

Gold-standard clinical test for benign paroxysmal positional vertigo disease (BPPV)

Question 92

With the patient sitting on the examination table (facing forward, eyes open), turn the patient’s head 45 degrees toward the affected ear. While standing behind the patient and supporting the patient’s head with one hand, rapidly move the head from an upright to “head hanging” position, where the patient’s head is at least 10 degrees below horizontal. Maintain for 30 seconds or until any nystagmus and vertiginous symptoms subside. Reposition hands on either side of the patient’s head and turn the patient’s head 90° away from the affected ear, placing it at 45 degrees toward the opposite shoulder. Ask the patient to roll onto their shoulder on the unaffected (left) side. While the patient rolls onto their shoulder, maintain the patient’s head at its 45-degrees orientation to the shoulder. As the patient rolls, their face will be directed to the floor. Patient should keep this position until the nystagmus and vertigo subside, or 30 seconds have passed, and then sit up.

Answer 92

Epley maneuver

Question 93

Triad of recurrent vertigo, tinnitus, and unilateral hearing loss that is chronic; may have nausea/vomiting with episodes.

Usually affects only one ear, but in 15% it will involve both ears.

No associated neurologic symptoms

Answer 93

Ménière’s disease

*Diagnosis of exclusion → Rule out all other possible causes

Question 94

Ménière’s disease Treatment Plan

Answer 94

Initial treatment involves lifestyle changes.

Salt restriction (2–3 g/day); avoid MSG and nicotine; minimize intake of caffeine, alcohol (one serving/day).

Vestibular suppressant PRN (anticholinergics, antihistamines and benzodiazepines)

Nausea/vomit medication PRN.

Persistent attacks, refer to ENT specialist; consider vestibular rehabilitation.

Question 95

Abrupt onset with brief episodes of vertigo that last <1 minute induced by sudden head movements and positions.

Due to calcium carbonate crystals (otoconia) trapped in the semicircular canals.

Risk factors are head trauma, high-intensity aerobics, bike riding in rough trails. The most common cause of vertigo in the United States. More common in ages 50–70 years.

Answer 95

Benign paroxysmal positional vertigo (BPPV)

Question 96

Benign paroxysmal positional vertigo (BPPV) Treatment Plan

Answer 96

Meclizine PO q4–8h (vertigo); prochlorperazine IM, rectal suppository, or PO (nausea/vomiting).

Advise to avoid sleeping on the side of the affected ear for several days.

Question 97

Cranial nerve VIII (vestibular portion) tumors. Schwann cell–derived tumors. Symptoms are slow and insidious. Two major symptoms are chronic hearing loss (average duration 4 years) and chronic tinnitus. If trigeminal nerve is compressed, symptoms are facial numbness and pain. Causes asymmetric sensorineural hearing loss.

Answer 97

Acoustic neuroma (vestibular schwannoma)

Question 98

Acoustic neuroma (vestibular schwannoma) Assessment/Treatment Plan

Answer 98

Weber and Rinne tests, hearing testing, cranial nerve testing.

Refer to ENT specialist; surgical removal, radiation.

Question 99

Sudden onset of severe vertigo accompanied by sensorineural hearing loss and tinnitus. Episodes can last from hours to days. Due to inflammation of the vestibular nerve caused by viral or bacterial infection.

Answer 99

Labyrinthitis

Question 100

Labyrinthitis Treatment Plan

Answer 100

Vestibular suppressants (anticholinergics, antihistamines and benzodiazepines) PRN for severe attacks of vertigo only. If mild symptoms, do not use; they can delay recovery.

If suspect bacterial infection, treat with broad-spectrum antibiotic and refer to ENT specialist.

Question 101

Sudden onset of severe headache, vertigo, nausea/vomiting, motor deficits, impaired gait, imbalance, impaired control arm/leg movements, slurred speech (dysarthria).

Answer 101

Cerebellar infarction or hemorrhage (cerebellar stroke)
Call 911.
MRI is gold standard for diagnosing infarction on the brain.

Question 102

Macular degeneration (changes in central vision), which can be attributed to (medication) use

Answer 102

Atenolol

Question 103

Usually affects only one eye (rarely both eyes are involved). During infancy, the tumor is a small size, and it continues to grow with the child. This rare cancer is diagnosed by noting a pupil that appears white or has white spots on it. One or both eyes may be affected. It is often first noted in photographs, because a white glow is present in the eye instead of the usual “red eye” that results from the flash.

Answer 103

Retinoblastoma – congenital tumor of the retina

Question 104

Leukocoria: finding and indication

Answer 104

White color is noted on one eye while checking for the red reflex. Rule out retinoblastoma of the eye, which is a malignant tumor of the retina.

Question 105

First-line drug for treating strep throat

Answer 105

Penicillin V PO × 10 days. If penicillin allergy → macrolides and clindamycin can be used instead.

*Levofloxacin contraindicated in children

Question 106

Pseudoephedrine (Sudafed) contraindications

Answer 106

Do not use for infants, young children, or patients with hypertension.

Question 107

White, gray, or blue opaque ring in the corneal margin (peripheral corneal opacity) or white ring in front of the periphery of the iris. Does not affect vision.

Present at birth but then fades; commonly present in older adults. It can also appear earlier in life as a result of hypercholesterolemia.

Unilateral arcus is a sign of decreased blood flow to the unaffected eye due to carotid artery disease or ocular hypotony.

Answer 107

Arcus senilis

Question 108

Streptococcal Pharyngitis/Tonsillopharyngitis (“Strep” Throat) Treatment Plan

Answer 108

First line: Oral penicillin V 500 mg two to three times a day × 10 days *Safe for pregnancy
Alternative: Amoxicillin 500 mg twice a day × 10 days
Penicillin or beta-lactam allergy: Azithromycin (Z-Pak) × 5 days

Throat pain and fever: Ibuprofen (Advil) or acetaminophen (Tylenol)

Symptomatic treatment: Saltwater gargles, throat lozenges; drink more fluids

Repeat culture and sensitivity after antibiotic treatment (test of cure): History of mitral valve prolapse or heart valve surgery. *If a patient returns post strep-pharyngitis and has completed a course of treatment, a throat C&S should be repeated.

Question 109

Dacryostenosis

Answer 109

Obstruction of the lacrimal duct(s)

Question 110

Aminoglycoside otic drops contraindications

Answer 110

Gentamycin, tobramycin are ototoxic and should not be used to treat otitis media or perforation of the TM.

Question 111

Treatment with TM perforations.

Answer 111

Ofloxacin ear drops are not considered to be ototoxic and can be used.

Aminoglycoside otic drops (gentamycin, tobramycin) are ototoxic and should not be used to treat otitis media or perforation of the TM.

Question 112

Allergic conjunctivitis Treatment

Answer 112

Initial treatment: Topical antihistamines/mast cell stabilizers

Although oral antihistamines can be used for mild allergic conjunctivitis, they may induce dry eye syndrome, which impairs the protective barrier of tears and worsens allergic conjunctivitis. Artificial tears may be needed if oral antihistamines are prescribed.

Question 113

Elongated papilla of the lateral aspects on the tongue. Epstein–Barr virus is the causative agent.

Answer 113

Oral hairy leukoplakia

Question 114

Lacrimal ducts are immature at birth

Answer 114

Typically a newborn can shed tears by 2 weeks

Question 115

Strep throat treatment for pregnancy

Answer 115

Pen VK is safe to use for strep throat during pregnancy

Question 116

Mnemonic for high-risk factors for hearing loss is HEARS

Answer 116

HYPERbilirubinemia; EAR infection frequency; low APGAR scores; exposure to RUBELLA, cytomegalovirus (CMV), or toxoplasmosis; and SEIZURES.

Question 117

Eyes look misaligned (crossed-eyed), but really they are not – due to epicanthal folds

Answer 117

Pseudostrabismus

Question 118

Type of strabismus (eye misalignment) that causes the eye to turn inward.

Answer 118

Intermittent esotropia

Common in infants younger than 20 weeks and usually resolves spontaneously.

Question 119

Corneal light reflex test to check ocular alignment

If there is normal alignment, the reflection will appear in the same position in each pupil. If there is misalignment of the eyes, the location of the corneal reflex will appear asymmetric and “off center” of the pupil in the deviating eye.

Answer 119

Hirschberg test

Question 120

Classically presents with high fever; enlarged lymph nodes in the neck; conjunctivitis; dry, cracked lips; and a “strawberry” (bright-red) tongue. Most cases occur in children under 5 years of age.

Answer 120

Kawasaki disease

Question 121

Most common sign or symptom of allergic rhinitis

Answer 121

Transverse nasal crease (allergic salute) from frequent rubbing and wiping away of nasal discharge.

Question 122

Acute onset of erythematous swollen eyelid with proptosis (bulging of the eyeball) and pain in affected eye. Unable to perform full range of motion (ROM) of the eyes (abnormal extraocular movement [EOM] exam) with pain on eye movement. History of recent rhinosinusitis or upper respiratory infection (URI).

Answer 122

Orbital Cellulitis
Caused by acute bacterial infection of the orbital contents (fat and ocular muscles). More common in young children than adults. Serious complication. Refer to ED.

Question 123

Direct blunt trauma to the ear that can cause bleeding in the auricular cartilage. The hematoma should be drained as soon as possible. If hematoma is not drained, it can result in cauliflower ear. More common in wrestlers, boxers, and mixed martial arts fighters.

Answer 123

Auricular Hematoma

Question 124

Sore throat, fever, and markedly swollen neck (“bull neck”). Low-grade fever, hoarseness, and dysphagia. The posterior pharynx, tonsils, uvula, and soft palate are coated with a gray to yellow pseudomembrane that is hard to displace.

Answer 124

Diphtheria

Very contagious. Contact prophylaxis required. Refer to ED.

Question 125

Painful shallow ulcers on soft tissue of the mouth that usually heal within 7 to 10 days. Cause is unknown.

Treat symptoms with “magic mouthwash” (combination of liquid diphenhydramine, viscous lidocaine, and glucocorticosteroid). Swish, hold, and spit every 4 hours as needed. Other options includes Orabase cream/ointment (OTC).

Answer 125

Aphthous stomatitis (canker sores)

Question 126

School-aged child to adult with acute onset of fever, headache, fatigue, myalgia, and anorexia. Within 48 hours, the salivary/parotid gland(s) becomes swollen and tender. It can be unilateral (25%) or bilateral. The cheek appears puffy, and the angle of the jaw on the involved side appears swollen. The swelling and tenderness usually subside in about 1 week. Complications are rare and include orchitis (of one testicle), meningitis, encephalitis, deafness, and others.

Answer 126

Parotitis (Mumps)

Mumps is a nationally notifiable disease; report all cases to local or state health department.

Question 127

Excessive constriction of the pupil of the eye

Answer 127

Miosis

Question 128

Uvula is split into two sections and resembles a fishtail.

May be a sign of an occult cleft palate (rare).

Answer 128

Fishtall or Split Uvula

Question 129

Optic nerve cupping is associated with glaucoma. It is caused by increased IOP, and it is measured by using the “cup-to-disc” ratio. The “cup” of the optic disc is the center, and the surrounding area is the “disc.” As glaucoma progresses, the cup-to-disc ratio becomes abnormal.

Answer 129

Disc Cupping

Question 130

Ishihara chart

Answer 130

Assessing Color Blindness

Question 131

Hearing Test: Place the tuning fork midline on the forehead.

Answer 131

Weber Test
Normal finding: No lateralization. Lateralization (hears the sound in only one ear or sound is louder in one ear) is an abnormal finding

Question 132

Any type of obstruction (or conduction) of the sound waves. Other causes include blockage of the outer ear (ceruminosis, otitis externa) or fluid inside the middle ear (otitis media, serous otitis media).

Answer 132

Conductive Hearing Loss (Outer Ear and Middle Ear)

Question 133

Gradual onset of increased IOP >22 mmHg due to blockage of the drainage of aqueous humor inside the eye. The retina (CN II) undergoes ischemic changes and, if untreated, becomes permanently damaged.

Mostly seen in elderly patients, especially those of African or Caucasian ancestry, or diabetics. Usually asymptomatic during early stages. Gradual changes in peripheral vision (lost first) and then central vision. May complain of missing portions of words when reading. If funduscopic exam shows cupping, IOP is too high.

Answer 133

Primary Open-Angle Glaucoma
Most common type of glaucoma (60%–70%).

Check IOP (use tonometer). Normal range is 8 to 21 mmHg. IOP ≥30 mmHg is considered very high. Urgent referral within 24 hours or less to ophthalmologist or refer to ED.

Question 134

Age-Related Macular Degeneration Treatment Plan and Referral

Answer 134

Refer to ophthalmologist. Patient is given a copy of the Amsler grid (focus eye on center dot and view grid 12 inches from eyes). Patient checks visual field loss daily to weekly (center of grid is distorted, blind spot or scotoma, or wavy lines).

“Ocular” vitamins are lutein and zeaxanthin with zinc. Patients should consult their ophthalmologist before taking ocular vitamins.

Question 135

Anterior nasal bleeds are milder and more common than posterior nasal bleeds. Most episodes are self-limiting. Anterior nasal bleeds are the result of bleeding from Kiesselbach’s plexus (vascular area), which is located anteriorly on the lower one-third of the nose. Posterior nasal bleeds can lead to severe hemorrhage. Aspirin use, NSAIDs, cocaine abuse, severe hypertension, and anticoagulants place patients at higher risk. Intranasal cocaine use can cause nosebleeds and nasal septum perforation.

Patient complains of acute onset of nasal bleeding secondary to trauma (e.g., nose picking). Bright-red blood may drip externally through the nasal passages and/or the posterior pharynx. Profuse bleeding can result in vomiting of blood.

Answer 135

Epistaxis (Nosebleeds)

Question 136

Epistaxis Treatment Plan

Answer 136

Apply direct pressure on the front of the nose for several minutes. Use of nasal decongestants (i.e., Afrin) to shrink tissue helps to stop bleeding.
Apply triple antibiotic ointment or petroleum jelly in front of the nose using cotton swab for a few days.
If recurrent anterior nasal bleeds, refer to an ENT specialist for cauterization.

Posterior nasal bleeds may hemorrhage. Refer to ED.

Question 137

May follow AOM. Can also be caused by chronic allergic rhinitis. Patient complains of ear pressure, popping noises, and muffled hearing in affected ear. Sterile serous fluid is trapped inside middle ear.

TM may bulge or retract. Tympanogram abnormal (flat line or no peak).
TM should not be red.
A fluid level and/or bubbles may be visible inside the TM.

Answer 137

Otitis Media with Effusion

Question 138

Objective Findings:
Complete blood count (CBC): Atypical lymphocytes and lymphocytosis (>50%); repeat CBC until resolves
Liver function tests (LFTs): Abnormal for 80% for several weeks
Heterophile antibody test (Monospot): Positive (80%–90% of adults)
Nodes: Large cervical nodes that may be tender to palpation
Pharynx: Erythematous
Tonsils: Inflamed, sometimes with cryptic exudate (off-white color)
Hepatomegaly (20%) and splenomegaly (50%): Avoid vigorous palpation of abdomen until resolves
Skin: Occasionally a generalized red maculopapular rash is present.

Answer 138

Infectious Mononucleosis

Question 139

First-line antibiotic for both AOM and acute sinusitis in children (with no risk factors for resistant organisms).

Second line treatment/Treatment Failure

Answer 139

Amoxicillin. If penicillin allergic, an alternative is azithromycin (Z-Pack) and clarithromycin (Biaxin) BID.

If the patient is a treatment failure or was on an antibiotic in the previous 3 months, then a second-line antibiotic, such as amoxicillin-clavulanate (Augmentin) BID or cefdinir (Omnicef) BID, should be given.

Question 140

First molars are the first permanent teeth to develop

Answer 140

Appear at approximately 6 years of age

Question 141

Viral keratoconjunctivitis (pink eye) Treatment Plan

Answer 141

Symptomatic tx.

Cold compresses and slightly chilled artificial tears may help with the itching.

Topical ophthalmic vasoconstrictor to be used two times per day as needed for up to 3 days to reduce redness.

Avoid touching eyes with hands, avoid sharing towels, perform frequent handwashing, and use tissues if touching the eyes.

Usually caused by an adenovirus. Contagious for 10 - 12 days after onset of symptoms and is a self-limiting condition. It can be transmitted through swimming pools, fomites, and hands. Children should not attend school until symptoms resolve.

Question 142

Caused by the coxsackievirus. The virus is found in the saliva, sputum, nasal mucus, feces, and blister fluid. It is transmitted through direct contact of the secretion or in fomites (e.g., preschool toys). Treatment is symptomatic.

Answer 142

Hand, foot, and mouth disease (HFMD)