HEENT

Question 1

Acute rhinosinusitis (ARS)
Definition

Answer 1

Inflammation of the mucosal lining of nasal passages and paranasal sinuses, lasting up to 4 weeks, caused by allergens, environmental irritants, and/or infection (viruses [majority], bacteria, and fungi [rare])

• Allergies and viral are most common causes
• Avoid antibiotics unless you know micro; you must know the causative bug as to choose the right drug

Question 2

Acute bacterial rhinosinusitis (RBRS)

Answer 2

Secondary bacterial infection of paranasal sinuses, usually following viral URI; relatively uncommon in adult stand children

<2% of viral URIs are complicated by ABRS. In the majority, ABRS will resolve without antimicrobial therapy *may resolve spontaneously; abx rarely needed

Maxillary and frontal sinuses are most affected; fluid is trapped inside the sinuses → 2º bacterial (S. pneumoniae, H. influenzae)” or viral infection
- hx of a “bad cold” or flare-up of allergic rhinitis

Question 3

Principles of Empiric Antimicrobial Therapy
- Definition
- Questions to as prior to choosing an antimicrobial

Answer 3

• Applicable to choice of intervention in all infectious diseases to direct antimicrobial therapy, optimize treatment success and minimize development of resistant pathogens

The decision-making process in which the clinician chooses the agent based on patient characteristics and site of infection

• What is/are the most likely pathogen(s) causing this infection?
• What is the spectrum of a given antimicrobial’s activity?
• What is the likelihood of a resistant pathogen?
• What is the danger if there is treatment failure?
• What is the optimal safe antimicrobial dose?
• What is the duration of the shortest but effective course of therapy?

Question 4

Streptococcus Pneumoniae
1. Diseases caused by S. Pneumoniae
2. Description
3. Resistance

Answer 4

1. COMPS
   +CAPS, ABRS (#1 cause of ABRS)
   Conjunctivitis
   Otitis media
   Meningitis
   Pneumonia
   Sinusitis
2. 100 strains
   Gram+ diplococci
   #1 adult ABRS causative organism
3. > /= 25% drug-resistant (DRSP) via altered protein-binding sites that limit certain antibiotic’s ability to bind to the pathogen

Question 5

Haemophilus Influenzae
1. Diseases caused by H. influenzae
2. Description
3. Resistance

Answer 5

1. COMPS
   +CAPS, ABRS
   Conjunctivitis
   Otitis media
   Meningitis
   Pneumonia
   Sinusitis
2. Gram- bacillus
   #2 adult ABRS causative organism
3. > /= 30% penicillin-resistant via production of beta-lactamase that breaks up beta-lactam ring in most penicillins including amoxicillin, ampicillin. Most cephalosporins are stable in the presence of beta-lactamase

Question 6

Moraxella Catarrhalis
1. Diseases caused by M. Catarrhalis
2. Description
3. Resistance

Answer 6

1. Less common pathogen in ABRS, AOM, uncommon cause of CAP
2. Gram- coccus
   #3 adult ABRS causative organism
3. > /= 90% pencillin-resistant via beta-lactamase production

Question 7

Transillumination

Answer 7

Turn off the light (darkened room)
Place a bright light source directly on the surface of the cheek (on maxillary sinus). Instruct patient to open mouth and look at the roof of the mouth (hard palate) for a round glow of light). Compare both sides.

The “affected” sinus has no glow or duller glow compared with the normal sinus. For frontal sinusitis, place the light under the supraorbital ridge at the medial aspect and compare glow of light

Question 8

ABRS
- Clinical presentation
- When treating, consider resistant presence:

Answer 8

URI-like signs and symptoms, either:
- Persistent and not improving >/= 10 days
- Severe (Fever >/=102º F, >39ºC, purulent nasal discharge, facial pain, >/= 3-4 days)
- Worsening, or “doubling-sickening” (initial improvement URI-like sx, then worsening with fever, headache, nasal discharge, usually p 5-6 days of illness)

• Posterior pharynx: purulent dark-yellow to green postnasal drip
• Sinuses: tender to palpation on the front cheek (maxillar) or on frontal sinus area above 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 than normal sinus)

If no risk for resistance → Initiate first-line antimicrobial therapy
If yes risk for resistance → Initiated second-line antimicrobial therapy

If improved after 3-5 days → Complete 5-7 days of antimicrobial therapy

If worsening or no improvement in 3-5 days → Broaden coverage or switch to different antimicrobial class, if continues to worsening or no improvement in 3-5 days → Refer to specialist; CT/MRI to investigate noninfectious causes or suppurative complications +/- sinus/meatal cultures for pathogen-specific therapy

Question 9

cacosmia

Answer 9

Bad odor in nose

Question 10

ABRS
Treatment Options: mild vs severe case

Answer 10

If mild, uncomplicated in healthy patient → symptomatic treatment without abx
- Oral fluids
- Saline nasal irrigation PRN
- Follow up in 10 days (if better, no abx needed)
- If sx worsens or have not resolved on follow-up → initiate abx

If severe symptoms (toxic, high fever, pain, purulent nasal or post nasal drip for >/=2-3 days, maxillary toothache, unilateral facial pain, sense of bad odor in nose (cacosmia), initial symptom improved, then worsening of symptoms), immunocompromised, or symptoms persist > 10 days (or have worsened) → Initiate abx

Most cases of adult ABRS are viral; only 0.5-2% of cases are bacterial

Question 11

ABRS
Antibiotic Treatment
1. First-line therapy
2. If allergy or alternative antibiotics
3. What if treatment failed with above interventions?

Answer 11

1. Amoxicillin-clavulanate (Augmentin) 1,000/62.5 mg or 2,000 mg/125 mg one table PO BID x 5-7 days
2. If PCN allergy or alternatives:
   - Type 1 allergy (e.g., anaphylaxis, angioedema) → Levofloxacin 750 mg PO daily or doxycycline BID x 5-7 days
   - Type 2 allergy (e.g., skin rash) → Cefdinir (Omnicef), cefpodoxime (Vantin), cefuroxime (Ceftin) PO BID x 5-7 days
3. If symptoms persist despite treatment (purulent nasal discharge, sinus pain, nasal congestion, fever), switch to another abx.
   - If on amoxicillin → amoxicillin-clavulanate (Augmentin PO Q12H x 10-14 days OR levofloxacin (Levaquin) 750 mg daily
   - If current sinusitis → Refer to otolaryngologist
   - Nasal irrigation may help use only sterile water (not tap water) with saline packet

Question 12

ABRS
Risk for antibiotic resistance

Answer 12

Most common:
<2 or >65, daycare attend
Prior systemic antibiotics with the past month

Less common risks:
Hospitalization within p 5 days
Comorbidities (DM, COPD)
Immunocompromised

Question 13

ABRS
Symptomatic or Adjunct Treatment (Rhinosinusistis or Oritis Media)
1. Pain or fever
2. Drainage
3. Cough

Answer 13

1. • Naproxen sodium (Anaprox DS) PO BID or ibuprofen (Advil) PO QID PRN
     - Acetaminophen (Tylenol) Q4-6 hours PRN
2. • Increase 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 max or will cause rebound
     - Saline nasal spray (Ocean spray) 1-2 x Q2-3 hrs PRN
     - Steroid nasal spray (Flonase, Vancenase) if allergic rhinitis
     - Mucolytic (guaifenesin) and ↑ fluid to thin mucus
3. • Dextromethorphan (Robitussin) QID
     - Benzonatate (Tessalon Perles) prescription: Swallow with water; do not crush, suck, or chew; toxic for children <10 years (seizures, cardiac arrest, death)
     - ↑ fluid intake
     - avoid exposure to cigarette smoke and alcohol
     - Systemic steroids are not recommended

Question 14

ABRS
Symptomatic treatment in ABRS (nonpharmaceutical management)

Answer 14

• Saline nasal irrigations
• Intranasal corticosteroids when ABRS is accompanied by allergic rhinitis

Directions:
With sterile saline (do not use tap water, some have bacteria → abscess)
1. Spare opposite nare with opposite hand; if same side, will spray directly on septum → increases risk for epitaxis
2. Keep your nose over your toes → extra drainage out (↓ SE)

Question 15

True or false:
The US FDA advises that the adverse effects associated with fluoroquinolones (cip-, levo-, moxifloxacin[-floxacin suffix] generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections who have other treatment options.

Answer 15

True.

Deviation from guideline. Avoid using fluoroquinolones untill last choice.

Possible adverse effects:
- Spontaneous tendon rupture
- Aortic aneurism/dissection
- Tendonitis

Question 16

Which antibiotic is not effective in ABRS?

Answer 16

Macrolides (-mycins)

Ex:
- azithromycin
- clarithromycin
- erythromycin
- TMP-SMX (bactrim)

These are not recommended in ABRS treatment due to rising resistance rates

Question 17

ABRS
1. Initial/first-line empiric therapy + second-line

Answer 17

1. Amoxicillin-clavulanate 500 mg/125 mg PO TID, or l875 mg/125 mg PO BID for 5-7 days
   - Will miss DRSP
   - High dose (HD, 3-4 g/d) amoxicillin needed against DRSP.
   - Clavulanate, as a beta-lactamase inhibitor, allows amoxicillin to have activity against beta-lactamase-producing organisms, such as H. influenzae, M. catarrhalis
   - Coverage: +/- and beta-lactamase
2. Amoxicillin-clavulanate 2000 mg/125 mg PO BID for 7-10 days
   - Gives coverage to DRSP

OR
Doxycycline 100 mg PO BID or 200 mg PO daily
- If allergic to amoxicillin, miss DRSP
- DO NOT give to pregnant or lactating, photosensitizing (2º burns)
- 0 < 8 - graying of teeth
- Doxycycline: effective against non-resistant S. Pneumoniae. DRSP treatment failure risk, activity against Gram- organisms.
- Stable in presence of beta-lactamase.
- Doxycycline: Pregnancy risk category D

Question 18

ABRS
- If beta-lactam allergy

Answer 18

Allergy to antimicrobials with beta-lactam ring, such as penicillins, cephalosporins
- But does carry a lot of risks, FDA says do not use fluoroquinolones, but can bring DRSP

• Doxycycline 100 mg PO BID or 200 mg PO daily
  OR
• Levofloxacin 500 mg PO daily
  OR
• Moxifloxacin 400 mg PO daily

*Respiratory fluoroquinolones (FQ): activity against DRSP, Gram- organisms, stable in presence of beta-lactamase

Major rationale for use of respiratory FQ is the presence of DRSP risk. See FDA advisory on limiting FQ use.

Question 19

ABRS
- Treatment for antibiotic resistance or failed initial therapy

Answer 19

• Amoxicillin-clavulanate 2000 mg/125 mg PO BID
  OR
• Levofloxacin 500 mg PO daily
  OR
• Moxifloxacin 400 mg PO daily

All options with activity against DRSP, Gram- organisms, stable in presence of and/or active against beta-lactamase

Question 20

Otitis Media and Rhinosinusitis: Serious Complications

Answer 20

Refer all 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 EOMA (extraorbital muscles) movements of affected orbit (check CNs, EOM). Altered LOC or mental status change
• Meningitis: Acute onset of high fever, stiff neck, severe headache, photophobia, toxicity. Positive Brudzinski or Kernig sign
• Cavernous sinus thrombosis: Patient c/o acute onset of severe headache inferring with sleep, abnormal neurologic exam, confusion, febrility. Life-threatening emergency with high mortality!

Question 21

What is a substrate?

Answer 21

A medication or substance that is metabolized/biotransformed by the isoenzyme, utilizing this enzyme in order to be modified so it can reach drug sit of action and/or be eliminated
- Cannot be broken down if with an inhibitor to be cleared

Clinical example:
CYP450 3A4 substrate examples:
Sildenafil (Viagra)
atorvastatin
Simvastatin
Alprazolam (Xanax)

About 50% of all prescription medications are CYP450 3A4 substrates.
Other commonly utilized CYP450 0isoenyzmes include 1A2, 2D6, 2C9, 2C19, 299.

**3A4 - Most important for interaction

Question 22

What is an inhibitor?

Answer 22

A drug or other substance that blocks the activity of the isoenzyme, limiting substrate excretion, allowing increase in substrate levels, with possible risk of substrate-induced toxicity

CYP450 3A4 = erythro-, clarithromycin

Concomitant use of one of these antibiotics with any of the aforementioned CYP450 3A4 substrates results in an increase in substrate levels.

Clarithromycin + simvastatin = statin-induced rhabdomyolysis risk

Clarithromycin + alprazolam = increased sedation, fall risk

Question 23

Drug-drug Interactions
- Why is this important?
- What areas are high-risk for drug interactions to happen?

Answer 23

• Knowledge of the most common drug-drug interactions is critical to certification and clinical practice success. Drug-drug interactions are the 2nd most common cause of why NPs getting sued (think coumadin with many drug-drug interactions)
• Liver (most serious consequence of interaction; protein binding fighting for site)
• Kidney
• Blood

Question 24

What is an inducer?

Answer 24

Accelerates the activity of the isoenzyme so that the substrate is pushed out the exit pathway, leading to a reduction in substrate level; will spit out substrate faster

Example: St. John’s worth = CYP450 3A4 inducer

Concomitant use of St. John’s wort and 3A4 substrate can lead to reduced target drug levels and diminished therapeutic effect, possible treatment failure

Example: St. John’s wort + COC use = Off-loading of estrogen/progestin, leads to excessive spotting, potential contraceptive failure

Question 25

What is CYP450?

Answer 25

Cytochrome P450 (CYP) is a hemeprotein that plays a key role in the metabolism of drugs and other xenobiotics (Estabrook, 2003). Understanding the CYP system is essential for advanced practitioners (APs), as the consequences of drug-drug interactions can be profound.

Drug metabolism occurs in many sites in the body, including the liver, intestinal wall, lungs, kidneys, and plasma. As the primary site of drug metabolism, the liver functions to detoxify and facilitate excretion of xenobiotics (foreign drugs or chemicals) by enzymatically converting lipid-soluble compounds to more water-soluble compounds. Drug metabolism is achieved through phase I reactions, phase II reactions, or both. The most common phase I reaction is oxidation, which is catalyzed by the CYP system.

Question 26

Conductive Hearing Loss
1. Location
2. Cause
3. Weber Result
4. Rinne Result
5. Treatment

Answer 26

1. Outer ear; temporary middle ear and out.
2. Sound is being BLOCKED (earwax, foreign object, damaged eardrum, serous otitis media [infection], bone abnormality)
3. Sound lateralizes to affected ear (buzzing sound heard louder in the affect ear due to increased tissue density)
4. Negative (Bone > Air); bone conduction better than air conduction
5. Often self-resolves post cerumen impaction removal; post URi or AOM resolution. Rarely, further pharmacologic or surgical intervention is needed. In other words, time and/or remove obstruction

Question 27

Sensorineural Hearing Loss
1. Location
2. Cause
3. Weber Result
4. Rinne Result
5. Treatment

Answer 27

1. Inner ear; Vestibulocochlear nerve (CN VIII)
2. Inner ear or nerve becomes damaged (advanced age, ototoxic medications, immune disorders, trauma)
3. Sound lateralizes to the unaffected ear (go to good ear) (buzzing sound heard lower or not at all in affected ear)
4. Positive or normal (not helpful); air conduction better than bone conduction
5. Hearing aids or cochlear implants possible options with expert consultation

Question 28

COVID-19 vs Seasonal allergies
1. Symptoms more common of COVID 19
2. Symptoms common of both
3. Symptoms more common of seasonal allergies

Answer 28

1. • Fever and chills
     - Muscle and body aches
     - New loss of taste or smell (later symptoms, 5-7 days)
     - Nausea or vomiting
     - Diarrhea
     - Shortness of breath or difficulty breathing
2. • Cough
     - Fatigue
     - Headache
     - Sore throat
     - Congestion or runny nose
3. • Itchy or water eyes
     - Itchy nose and throat
     - Sneezing
     - Similar symptoms in the past

Question 29

Allergic Rhinitis (AR) Treatment: A combination approach
1. Definition
2. First-line therapy/non-pharmacologic

Answer 29

1. Allergic rhinitis (AR) is an inflammatory, IgE-mediated disease due to genetic and environmental interactions and characterized by nasal congestion, rhinorrhea (nasal drainage), sneezing, intraocular and/or nasal itching.
   - Blue-tinged, pale, and/or swollen (boggy) nasal turbinates associated with increased clear nasal discharge
   - May be accompanied by itchy nose, sneezing, and nasal congestion
   - Mucus clear
   - Posterior pharynx → thick mucus, with colors including clear, white, yellow, or green (r/o sinusitis); cobblestoning (hyperplastic lymphoid tissue)
   - Undereye “circles” (venodilation)
   - Children may have transverse nasal crease from frequent rubbing (allergic salute)
2. Allergen avoidance/environmental control
   1st line therapy in any allergic disorder: Patient education to AVOID THE ALLERGEN whenever possible (carpets, Hepa filter, plastic cases on pillows, no pets on bed, close windows at night)

Question 30

AR Treatment: Inhaled Pharmacologic

Answer 30

Controller therapy to prevent symptoms by preventing formation of or inactivating inflammatory mediators

1st line control therapy due to high efficacy: Intranasal corticosteroids (INCS)
Ex: Fluticasone propionate (Flonase) BID, triamcinolone (Nasacort AQ) 1-2 sprays daily
- blocks 6 inflammatory mediators
- takes 6 days to work

Intranasal antihistamine (IAH) - can be used indefinitely
Ex: Azalastine (Astelin, Astepro) -OTC
- Daily or BID
- Rapid symptom relief
- Nose over toes to ↓ SE (sedation ↑ 60%)

Cromolyn sodium nasal spray TID (less effective than steroids)

Question 31

AR Treatment: Oral and ocular pharmacologic

Answer 31

Reliever therapy to relieve acute symptoms by blocking action of histamine, a potent inflammatory mediator

2nd generation oral antihistamines
Ex: - Loratadine (Claritin)
- Cetirizine (Zyrtec)
- Levocetirizine (Xyzal)
NOT 1st generation antihistamine use (diphenhydramine [benadryl] due to sedation risk)

Ocular antihistamine – helpful in managing allergic conjunctivitis signs and symptoms
Ex: - Olopatadine (Patanol, Pataday)
- Azelastine (Optivar)
- Bepotasine (Bepreve)

Use decongestants (e.g., pseudoephedrine, or Sudafed) PRN. Do NOT give to infants/young children

Question 32

AR Treatment: Adjunct/Additional Therapies
- What medication should generally be avoided or advised against?

Answer 32

Leukotriene modifier - blocks controller
Ex: Montelukast (Singulair) PO
- Best as add-on therapy if symptoms not adequately controlled with intranasal corticosteroids
- With use, FDA-mandated neuropsychiatric warning → Behavioral changes, depression, suicidal (FDA warning)

Systemic corticosteroids
- Long-acting (depot) injectable or oral systemic corticosteroid use not advised due to adverse effects including adrenal suppression, ↓ bone density

Refer to allergist!

Question 33

AR Treatment: What treatment can be used if initial therapies are inadequate? Possible complications?

Answer 33

Immunotherapy to restore tolerance to allergen by reducing its tendency to induce IgE production; 2 types - SubQ, Slit (sublingual immunotherapy)

For patients who have inadequate response with standard AR therapies, with specialty consultation, given by injection or sublingual
- Give small quantities to ↓ reaction
- 3-5 years to work

Complications: Acute sinusitis, AOM

Question 34

Bacterial Conjunctivitis

Answer 34

• Onset with one eye
• discharge yellow/green/purulent
• crusty

Question 35

Blepharoconjunctivitis

Answer 35

• Inflammation of lid margin → scaling of lids and margin
  Tx: Johnson’s baby shampoo, hydrocortisone

Question 36

Allergic conjunctivitis description

Answer 36

• Bilateral, intermittent
• Rope-like, thick, sticky discharge

Question 37

Angle-closure glaucoma description

Answer 37

• PAINFUL, pupil, dilated
  Ophthalmologic EMERGENCY!

Question 38

Chlorpheniramine

Answer 38

1st generation antihistamine; crosses blood-brain barrier

Question 39

Oral Cancer
1. Most common type of cancer causing oral cancer:
2. Risk factors (potent vs less potent)
3. Risk factor reduction
4. Clinical Presentation
5. Diagnostic studies
6. Treatment

Answer 39

1. Squamous cell carcinoma (SCC) = 95% of cases
2. Most potent risk factors: Longstanding HPV infection, especially HPV-16 (high risk HPV); tobacco use, alcohol misuse
   Less potent but significant risk factors: Male gender, advancing age (2/3 of individuals age >55 years at time of diagnosis)
3. • HPV-9 immunization
     - Reducing HPV-15 acquisition
     - Avoidance/cessation of tobacco use
4. • Painless, ulcerating oral lesions, usually present for many months prior to presenting clinically
     - Adjacent lymphadenopathy = immobile, nontender nodes usually >1 cm in diameter
5. Referral for lesion biopsy
   Additional imaging based on results
6. Refer to ENT or oral maxillary surgeon

Question 40

Syphilitic chancre

Answer 40

• Painless, self-resolving 2-3 weeks
• anal-genital region

Question 41

Aphthous stomatitis

Answer 41

• Painful (canker sore)
• Node would be tender

Question 42

Oral candidiasis

Answer 42

• non-ulcerating, but expect white coating of tongue & uncomfortable

Question 43

When to measure visual acuity:
1. What does the guideline say? What test/item is used to measure visual acuity?
2. At what age should 20/20 vision occur?
3. When should you refer to eye care specialist?

Answer 43

1. Guideline says to do it on every child and adult, with comprehensive physical examination in adult or child. Typically done in office with SNELLEN CHART. Refer to eye care specialist for additional eval if patient fails test. Have patient use appropriate vision aid (contact lens, eyeglasses) if normally used.
2. 20/20 vision by age 6 years; 20/30 at 5 years. Refer out if abnormal.
   - If they miss 2 items on a line, they flunk that line.
   - 20/100 - stand 20 feet from Snellen to see 100 feet with perfect vision
3. With any eye complaint.
   If significant change from baseline → eye care specialist for additional evaluation, particularly if findings are of new onset.

Ex: A patient presenting with the triad of red eye, painful eye, and new-onset vision change → PROMPT referral to ophthalmology (EMERGENCY).
Possible causes:
- herpes zoster
- angle-closure
- anterior uvitis

Question 44

When to measure visual acuity:
1. What does the guideline say? What test/item is used to measure visual acuity?
2. At what age should 20/20 vision occur?
3. When should you refer to eye care specialist?

Answer 44

1. Guideline says to do it on every child and adult, with comprehensive physical examination in adult or child. Typically done in office with SNELLEN CHART. Refer to eye care specialist for additional eval if patient fails test. Have patient use appropriate vision aid (contact lens, eyeglasses) if normally used.
2. 20/20 vision by age 6 years; 20/30 at 5 years. Refer out if abnormal.
   - If they miss 2 items on a line, they flunk that line.
   - 20/100 - stand 20 feet from Snellen to see 100 feet with perfect visionPap
3. With any eye complaint.
   If significant change from baseline → eye care specialist for additional evaluation, particularly if findings are of new onset.

Ex: A patient presenting with the triad of red eye, painful eye, and new-onset vision change → PROMPT referral to ophthalmology (EMERGENCY).
Possible causes:
- herpes zoster
- angle-closure
- anterior uvitis

Question 45

Papilledema

Answer 45

Caused by increased intracranial pressure, regardless of etiology, with patient report of a new-onset “blind spot” in the visual field.
-Optic disc swollen with blurred edges due to ↑ intracranial pressure 2º bleeding, brain tumor, abscess, pseudotumor cerebri

d/t ↑ ICP, brain hem., or brain tumor

Tx: CT scan

Question 46

Arteriovenous (AV) nicking

Answer 46

Stiffened, thickened arterioles, seen with chronic, poorly-controlled HTN, usually without visual change (narrowing of the arteriovenous vessel)

Grade 2 HTN retinopathy

Question 47

Hemorrhagic lesion

Answer 47

Caused by high great HTN or proliferative DM retinopathy, trauma, with patient complaint of new onset “floaters” in visual field
- bleeding, can be lasered
- will have normal vision again
* Get HTN under control

Question 48

A deeply cupped optic disc or disc cupping

Answer 48

As a result of acute angle-closure glaucoma, typically with new-onset unilateral eye discomfort, redness, blurred vision; physiological cup

If >50% of optic disc → EMERGENCY!
- Measured 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 ration becomes abnormal

If ax → @ risk for glaucoma “suspects”

Question 49

Lid ectropion

Answer 49

Lid everts out, not normal

Question 50

What does it mean when an eye has a white reflex? Possible causes?

Answer 50

• Retinal blastoma
• malignancy of eye
• cataracts
  → Refer to Opthalmology

Question 51

Macular degeneration

Answer 51

Central vision loss
- leading cause of blindness
In blue eyes (most common), smokers, DM, Fam Hx
Tx: Develop Amsler Grid

Question 52

Presbyopia

Answer 52

Gradual onset blurring of near vision
- abnormal Snellen test
- Will need reading glasses

Question 53

Glaucoma

Answer 53

Open-angle glaucoma (more common)
- <20 pressure, normal tonometry
- loses peripheral vision
- Needs to be followed by eye care 2x/year
- Needs field of dept testing at 40-50 years

Question 54

Presbycusis

Answer 54

Age-related hearing changing
- Bilateral, sensineural (background noise)

Question 55

Pharyngitis
- Bacterial vs viral
- Treatment

Answer 55

Bacterial (GABHS)
- Significant anterior cervical lymphadenopathy
- Frontal headache without body aches
- Patchy exudates in posterior pharynx
- “The sore throat started all of a sudden”

Viral
- Clear nasal discharge
- Hoarseness
- Scattered small vesicles on soft palate and tonsils
- Generalized body aches
- “The sore throat started after my nose started to run”

Treatment: * Oral penicillin or amoxicillin is preferred over parenteral therapy
- Azithromycin is not considered a first-line therapy d/t antimicrobial resistance

** Still need to swab and culture in child, but swab in adults!

Question 56

Presbyopia
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy

Answer 56

1. Hardening of lens; age-related visual change due to decreased ability of the eye to accommodate and focus due to stiffening of the lenses; near vision is affected with decreased ability to read small print at close range; usually starts at age 40 years
2. Close vision problems
3. Nearly all >/= 45 year olds need reading glasses or other similar correction

Question 57

Senile Cataracts
1. Etiology/Definition
2. Clinical presentation + Risk Factors
3. Possible Treatment/Therapy

Answer 57

1. Lens clouding
2. • Progressive vision dimming
     - Distance vision problems
     - Close vision usually retained and often initially improves

Risk Factors: Tobacco use, poor nutrition, sun exposure, systemic corticosteroid therapy

3. Potentially correctable with surgery, lens implant

Question 58

Open-angle glaucoma
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy

Answer 58

1. Painless, gradual onset of increased intraocular pressure → optic atrophy
2. • Loss of peripheral vision if untreated
     - Avoidable with appropriate and ongoing intervention
3. • > /= 80% of all glaucoma
     - Periodic screening with tonometry, assessment of visual fields
     - Treatment with topical miotics, beta-blockers, others, or surgery effective in vision perservation

Question 59

Angle-closure glaucoma
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy

Answer 59

1. Sudden increase in intraocular pressure
2. • Usually unilateral
     - Acutely RED
     - PAINFUL eye with vision change
     - Halos around lights
     - Eyeball firm when compared to other
3. Immediate referral to ophthalmology care for rapid pressure reduction via medication, possible surgery

Question 60

Age-related maculopathy (macular degeneration)
1. Etiology/Definition
2. Clinical presentation + Risk factors
3. Possible Treatment/Therapy

Answer 60

1. Thickening, sclerotic changes in retinal basement membrane complex; caused by gradual damage to the pigment of the macula (area of central vision) → severe visual loss or blindness
2. • Usually asymptomatic during early stages
     Painless vision changes including DISTORTION OF CENTRAL VISION (central vision loss).
     - Reports that straight lines (doors, windows) appear distorted or curved
     - Peripheral vision is usually preserved
     On fundoscopic exam, drusen (soft yellow deposits in the macular region) often visible.

Risk Factors: Aging, tobacco use, sun exposure, family hx
* Leading cause of blindness in elderly; more common in smokers

3. Dry form (atrophic): Given few treatment options, prevention should be the goal. Develops over decades, no treatment available.
   - More common (85-90%)
   - “less severe” than wet form

Wet form (exudative): Laser treatment for photocoagulation to obliterate neovascular membrane; intravitreal injection of anti-vascular growth factor. Develops relatively quickly, usually over months
- 80% of vision loss (choroidal neovascularization)

4. Refer to ophthalmologist
   - Patient is given 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 sport or scotoma, or wavy lines)
   - “Ocular” vitamins:” lutein and zeaxanthin with zinc; consult with ophthamologist before taking ocular vitamins

Question 61

Anosmia, hyposmia
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy

Answer 61

1. Neural degeneration
   Anosmia - partial of full loss of smell
   Hyposmia - reduced ability to detect odor
2. Diminished sense of smell, with resulting decline in fine taste discrimination
3. Accelerated by tobacco use

Question 62

Presbycusis
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy

Answer 62

1. Loss of CN VIII sensitivity
2. Difficulty with conversation in noisy environment
   Person can hear but cannot understand what is said
3. Accelerated by excessive noise exposure; hearing aids helpful

Question 63

Cerumen Impaction
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy

Answer 63

1. Conductive hearing loss
2. General diminution of hearing
3. Cerumen removal helpful in improving hearing

Question 64

Suppurative conjunctivitis (non-gonococcal, non-chlamydial)
1. Common pathogens
2. Recommended antimicrobial
3. Treatment considerations

Answer 64

1. • S. aureus
     - S. pneumoniae
     - H. influenzae
     - Outbreaks d/t S. pneumoniae
     * Contagious for 24 hours
2. Primary: Ophthalmic treatment with FQ ocular solution (cipro-, levo-, moxifloxacin)
   Alternative: Ophthalmic treatment with polymyxin B with trimethoprim solution
3. Most S. pneumoniae are resistant to tobramycin, gentamicin
   - Relieve irritative symptoms with use of cold artificial tear solution

Question 65

What is pink eye? How do you treat it?

Answer 65

Viral conjunctivitis
- “pink eye,” usually caused by adenovirus, often self-limiting
- Relieve irritative symptoms with use of cold artificial tear solution

Question 66

Otitis externa (Swimmer’s ear)
1. Common pathogens
2. Recommended antimicrobial
3. Treatment considerations
* Which medication should be avoided if TM puncture is suspected?

Answer 66

1. Pseudomonas spp., anaerobes, S. epidermidis
   - Acute infection often with S. aureus
   - Fungi rare etiology
2. • For milder disease: Acetic acid with propylene glycol and hydrocortisone (VoSoL) drops
     - For mod-severe disease: Otic drops with ciprofloxacin with hydrocortisone
3. • Systemic (oral or injectable) antimicrobial seldom needed
     - Ear canal cleansing important. ↓ risk of reinfection by use of eardrops of 1:2 mixture of white vinegar and rubbing alcohol after swimming
     - Do not use neomycin-containing product if puncture TM is suspected

Question 67

Malignant Otitis externa in person w/ DM, HIV/AIDS, or on chemotherapy
1. Common pathogens
2. Recommended antimicrobial
3. Treatment considerations
*What is this patient at an increase risk of?

Answer 67

1. Pseudomonas spp., in >95%
2. • Oral ciprofloxacin for early disease suitable for outpatient therapy
     - Other options are available if inpatient therapy warranted in severe disease
3. • Risk for osteomyelitis of the skull of TMJ
     - MRI/CT imaging to rule out osteomyelitis often indicated.
     - ENT consultation with surgical debridement should be considered.
     - Obtain cultures of ear drainage or results of surgical debridement
     - Parenteral antimicrobial therapy often warranted for severe disease

Question 68

Exudative Pharyngitis
1. Common pathogens
2. Recommended antimicrobial
3. Treatment considerations

Answer 68

1. • Group A, C, G Streptococcus
     - Viral
     - HHV-6
     - N. gonorrhoeae
     - F. necrophorum
2. • Group A beta hemolytic strep (GABHS) with documented positive strep screen or throat culture (associated with rheumatic fever) → proceed to antimicrobial therapy
     - 1st line: Penicillin V PO x 10 days or benzathine penicillin IM x 1 dose if adherence an issue
     - Alternative: 1st or 2nd generation cephalosporin x 4-6 days
     - Alternative in severe IgE-mediated beta-lactam allergy: Azithromycin x 5 days, clarithromycin x 10 days, clindamyucin x 10 days (all PO)
     - Up to 35% of S. pyogenes isolates resistant to macrolides
3. • Vesicular, ulcerative pharyngitis, usually viral
     - Only 10% of adult pharyngitis d/t Group A Streptococcus (GAS). More common in children, teens, younger adults. Major rationale to treat GAS is prevention of rheumatic fever and eradication of organism to ↓ transmission
     - No treatment recommended for asymptomatic group A Streptococcus carrier (neg for strep)
     - For recurrent culture-proven S. pyogenes infection, consider coinfection w/ beta-lactamase-producing organism; treat with amoxicillin-clavulanate or clindaymycin

Question 69

Corneal Ulcers
1. Definition/Population
2. Clinical presentation + diagnostics
3. Most common pathogens
4. Complications
5. Treatment

Answer 69

1. Soft contact lens users
2. • Severe eye pain
     - Foreign body sensation
     - tearing
     - photophobia
     *Look for a whitish lesion on the cornea by using a penlight and/or performing a slit lamp exam and fluorescein dye test
3. • Pseudomonas
     - Staphylococcus
     - Streptococcus
4. Can cause permanent impaired vision because of scarring or perforation
5. Ophthalmologic emergency! → Refer to ED!

Question 70

Herpes Keratitis
1. Definition/Population
2. Clinical presentation + diagnostics
3. Most common pathogens
4. Complications
5. Treatment

Answer 70

1 & 2. Acute onset of severe eye pain, photophobia, tearing, and blurred vision in ONE eye.

3. • Fluorescein dye (black lamp in a darkened room to search for fernlike lines in the corneal surface); corneal abrasions appear round or irregularly shaped
     - Herpes zoster ophthalmicus: eye findings accompanied by acute eruption of crusty rashes following the ophthalmic branch (CN V) of the trigeminal nerve (one side of forehead, eyelids, and tip of nose)
4. 2 types of herpesvirus that can affect the eyes:
   - Herpes simples → due to self-inoculation “cold sore,” herpes whitlow → called herpes simplex keratitis
   - Herpes varicella zoster (shingles) → usually due to singles of the trigeminal nerve (CN V) → herpes zoster ophthalmicus
5. Infection permanently damages corneal epithelium → corneal blindness
6. Refer to ED.

Question 71

Acute Angle-Closure Glaucoma
1. Definition/Population
2. Clinical presentation + diagnostics
3. Most common pathogens
4. Complications
5. Treatment

Answer 71

OPHTHALMOLOGIC EMERGENCY!
1 & 2. - Elderly patient with acute onset of severe eye pain accompanied by:
- headache
- nausea/vomiting
- halos around lights
- lacrimation
- decreased vision
PE:
- mid-dilated pupil(s) that is oval shape
- Cornea appears cloudy
* If rise in intraocular pressure (IOP) is slower, patient may be asymptomatic
- With chronic angle-closure glaucoma, the patient may be asymptomatic or report a dull ache and blurred vision

3. Fundoscopic exam → cupping of the optic nerve
4. Permanent blindness
5. Refer to ED!

Question 72

Multiple Sclerosis (Optic Neuritis)
1. Definition/Population
2. Treatment

Answer 72

1. • Young, Caucasian woman in heer 20-30s reports:
     - Loss of vision acuity over hours to days
     - Color vision is affected
     - A central scotoma (blind spot central vision) is common
     - Other neuro symptoms: aphasia, paresthesia, abnormal gait, spasticity
     - Daily fatigue on awakening and worsens as the day goes on
     - Higher than normal temp will worsen symptoms (Uhthoff phenomenon)
     - Has recurrent episodes
2. Refer to neurologist

Question 73

Uhthoff phenomenon

Answer 73

A transient worsening of neurological symptoms related to a demyelinating disorder such as multiple sclerosis when the body becomes overheated in hot weather, exercise, fever, saunas, or hot tubs.

Question 74

Orbital Cellulitis
1. Definition/Population
2. Clinical presentation + diagnostics
3. Most common pathogens
4. Complications
5. Treatment

Answer 74

*Caused by acute bacterial infection of the orbital contents (fat and ocular muscles)
1. - Acute onset of erythematous swollen eyelid with proptosis (bulding of the eyeball)
- Pain in affected eye
- Unable to perform full ROM of eyes (abnormal EOM exam) with pain on eye movement
- More common in young children than adults

2. Look for history of recent rhinosinusitis or URI.
3. See URI.
4. Serious complications.
5. Refer to ED!

Question 75

Retinal Detachment
1. Definition/Population
2. Treatment

Answer 75

1. • Sudden onset of floaters (or increase in floaters)
     - Associated with “looking through the curtain” sensation
     - Sudden flashes of light (photopsia)
     - Central vision may be intact or lost if macula is detached.
2. Refer to ED!

Question 76

Photopsia

Answer 76

Sudden flashes of light

Question 77

Auricular Hematoma
1. Definition
2. Complications
3. Treatment

Answer 77

Direct blunt trauma to the ear that can cause bleeding in the auricular cartilage.

Hematoma should be drained asap. If not drained, it can result in cauliflower ear.
More common in wrestlers, boxers, and mixed martial arts fighters.

Question 78

Acoustic Neuroma (Vestibular Schwannoma)
1. Definition
2. Clinical presentation
3. Treatment/Referral

Answer 78

Patient in 50s-60s with unilateral hearing loss (sensorineural) and tinnitus, which has been present for about 3-4 years.
- More common in Asians
- Tumor of acoustic nerve (CN VIII)

S/S
- Unsteadiness with walking
- Episodes of veering or tilting, fluctuating in severity
- May have facial paresis and paresthesia

Refer to neurologist!

Question 79

Cholesteatoma
1. Definition
2. Clinical presentation
3. Lab/Diagnostics
4. Treatment/Referral

Answer 79

1 & 2. History of chronic or recurrent otitis media infection
Complains of:
- hearing loss and intermittent ear discharge (otorrhea) from one ear that is purulent and foul smelling
PE:
- perforation of TM on the superior quadrant + cauliflower-like or pearly-white mass
AND/OR
- Intact TM with missing landmarks with the white mass visible behind the TM
* Mass is not cancerous, but can erode into bones of the face and damage the facial nerve (CN VII).

3. Tympanogram will be abnormal (straight line)
4. Antibiotics and surgical excision and repair
   Refer to otolaryngologist

Question 80

Battle sign (Basilar Skull Fracture)
1. Definition/Etiology
2. Clinical presentation
3. Lab/Diagnostics
4. Treatment/Referral

Answer 80

1. • Parietal bone is most fractured
     - Linear fracture most common, followed by depressed basilar skull fractures.
     - Causes in adults: falls, assaults, care collisions, and penetrating missiles.
2. • “Raccoon eyes” (periorbital ecchymosis) + bruising behind the ear (mastoid area), appears 1-3 days after trauma
     - PE (after trauma) does not show these two clinical signs immediately.
     - Search for clear, golden serous discharge from ear or nose (up to 20% of temporal bone fractures)
     - Hemotympanum (blue to purple color of the TM), caused by blood inside the middle ear
     ** The findings of Battle sign, raccoon eyes, hemotympanum, and otorrhea/rhinorrhea → highly suggestive of serious head injury

Other possible findings:
- brain hemorrhage
- brain injury
- CN injury

3. Imaging
4. Refer to ED!

Question 81

Clear, Golden Fluid Discharge from the Nose/Ear
(Otorrhea/Rhinorrhea of Cerebrospinal Fluid)
What does this indicate?

Answer 81

Indicative of a basilar and/or temporal skull bone fracture. If accompanied by the Battle sign, raccoon eyes, and hemotympanum → serious head injury → Refer to ED!

Question 82

Avulsed Tooth
Is this an emergency? Treatment?

Answer 82

Considered a dental emergency. The sooner reimplanted, the better the outcome!

If young child and primary tooth, do not implant.

If permanent, avoid touching root, handle only the crown.
Rinse in normal saline, irrigate socket with normal saline and reimplant tooth
Afterward, have patient bite down on gauze and refer to dentist ASAP!

Store tooth in cool milk or saline, or store inside cheek (buccal sulcus) if unable to reimplant

Question 83

Peritonsillar Abscess
1. Definition & S/S
2. Treatment

Answer 83

1. • Severe sore throat
     - Difficulty swallowing
     - Odynophagia (pain on swallowing)
     - Trismus (jaw muscle spasm making it difficult to open mouth)
     - “hot potato” vopice
     - Unilateral swelling of the peritonsillar area and soft palate
     - Affected area is markedly swollen and appears as a bulging red mass with uvula displaced away from the mass (uvula displacement)
     - malaise
     - fever
     - chills
2. Refer to ED!

Question 84

Odynophagia

Answer 84

Pain on swallowing

Question 85

Trimus

Answer 85

jaw muscle spasm making it difficult to open mouth

Question 86

Diphtheria
1. Definition & S/S
2. Treatment

Answer 86

1. • Sore throat
     - Fever
     - Markedly swollen neck (“bull neck”)
     - Low-grade fever
     - Hoarseness
     - Dysphagia
     - The posterior pharynx, tonsils, uvula, and soft palate are coated with a gray to yellow pseudomembrane that is hard to displace
     ** Very contagious
     **Contact prophylaxis required
2. Refer to ED!

Question 87

Virchow’s Node
1. Definition & S/S
2. Treatment

Answer 87

AKA Troisier’s Sign/Node
1. - an enlarged and hard left-sided supraventricular node(s)
* Associated with malignancy, especially in adults >/= 40 years; highly suggestive of cancers of the stomach, colon, pancreas, gallbladder, kidneys, ovaries, testicles, prostate, or lymphoid tissue

The left supraventricular lymph node drains vai the thoracic duct, abdomen, and thorax.

Workup:
- thorough history
- physical exam
- lab testing
- imaging

2. Refer to surgeon for biopsy!

Question 88

Normal Findings for the EYES:
1. Fundi
2. Cones
3. Rods
4. Macular (and fovea)

Answer 88

1. Veins are larger than arteries; veins are darker (in color) than arteries
2. For color perception, sharpest (20/20 vision)
3. For low-light vision (night vision), peripheral vision
4. Responsible for our central vision, sharpest vision (20/20 vision), and color vision. The center of the macula is called the fovea; contains large numbers of cones. Diseases of macular → loss of central vision

Question 89

Blepharitis
1. Definition & S/S
2. Treatment

Answer 89

1. Chronic condition caused by inflammation of the eyelids (hair follicles, meibomian glands); associated with seborrheic dermatitis and rosacea. Lid may be colonized by staphylococcal bacteria.
   - Intermittent exacerbations

• Itching or irritation on the eyelids (upper/lower or both)
• gritty sensation, eye redness, and crusting
• Inflammation of the edges of the eyelids where the eyelashes grown
• tiny oil glands at the base of the eyelashes become clogged
• eyelids (upper and/or lower) are red, irritated, and itchy
• small scales like dandruff may be present
• tends to recur
• may be associated with dandruff, seborrheic dermatitis, or rosacea

2. • Johnson’s Baby Shampoo with warm water: gently scrub eyelid margins until resolves. Consider topical antibiotic solution (erythromycin eye drops_ to eyelids BID/TID (lid hygiene); commercial eyelid scrub products are available.
     - Warm compress to eyelids BID - QID during exacerbations to soften debris and relieve itching

Question 90

Normal Findings: Ears
1. Bones
2. TM
3. Pinna
4. Tragus
5. Cartilage
6. Cerumen

Answer 90

1. AKA Ossicles of the ear: Malleus, incus, and stapes
   - Stapes → smallest bone in the body
2. Appears translucent off-white to gray color with the “cone of light” intact.
   - Lateral process of the malleus is located at the upper quadrant of 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
3. Has a large amount of cartilage; blunt trauma can result in a hematoma; drain asap to avoid damage to cartilage. If untreated → cauliflower ear
4. A small cartilage flap of tissue on the front of the ear
5. Found on the nose and ears; does not regenerate; refer injuries to plastic surgeon
6. Ear wax; the color range from yellow to dark brown

Question 91

What is Tympanogram?

Answer 91

Most objective measure test for presence of fluid inside middle ear (results in a straight line vs. a peaked shape; graph). Acute otitis media (AOM) and serous otitis media will show a straight line on testing.

Question 92

Normal Findings: NOSE
1. Kiesselbach’s plexus
2. Turbinates
3. Cartilage
4. Septum

Answer 92

1. Located on anterior inferior aspect of nose (lower 1/3); an anterior nosebleed if result if the area is traumatized
2. Only the inferior nasal turbinates are usually visible; medial and superior turbinates are not visible without special instruments. Bluish, pale, and/or boggy nasal turbinates are seen in allergic rhinitis
3. Lower third of the nose is cartilage; if damaged, does not regenerate
4. Nasal divider. Perforation can result of cocaine inhalation, which is a potent vasoconstrictor → Refer to plastic surgeon for repair.

Question 93

Sinuses

Answer 93

Air-filled cavities in the skull.

Four types:
- Ethmoid
- Maxillary
* Both above are present at birth
-Front (at age 5)
- Sphenoid (age 12)

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

Question 94

Normal Findings: Mouth (mucous membranes, gums, tongue, teeth)

Answer 94

Mucous membranes are pink to dark pink and moist.

Look for ulcers, fissures, leukoplakia, and inflammation. If gums are red and swollen, patient may have gingivitis (gums may bleed when brushing teeth) or be taking phenytoin (Dilantin) for seizures (gingival hyperplasia).

Tongue should not be red of swollen (glossitis)

Normal adult has 32 teeth

Question 95

Leukoplakia

Answer 95

White-to-light gray patch that appears on tongue, floor of mouth, or inside cheek. R/o oral cancer. Chewing or smoking tobacco, alcohol abuse, and HPV are risk factors for oral cancer

Question 96

Aphthous stomatitis

Answer 96

Canker sores
Painful shallow ulcers on soft tissue of the mouth that usually heal within 7-10 days.
Unknown cause.
Treatment: Magic mouthwash (combination of liquid diphenhydramine, viscous lidocaine, and glucocorticosteroid); swish, hold, and spit Q4H PRN.
Other options: Orabase cream/ointment (OTC)

Question 97

Vermilion Border

Answer 97

Vermilion border is the edges of lips

Question 98

oral commisures

Answer 98

Corners of the lips; the corner of the mouth, at the point where the upper and lower lips meet

Question 99

Cheilosis
- Definition
- Etiologies
- Treatment

Answer 99

an inflammatory condition that causes cracking, crusting, and scaling of the corners of the mouth

aka perleche

• Painful skin fissures and maceration at the corners of the mouth d/t excessive moisture
• More common in elderly with dentures
• Can be acute or chronic

Multiple Etiologies:
- 2º infection with Candida albicans (yeast) or bacteria (Staphylococcus aureus).
- Overesalivation
- Poorly fitting dentures
- Nutritional deficiencies (B2-riboflavin, B3-niacin, B6-pyridoxine, or B9-folic acid)
- Lupus
- Autoimmune disease (Sjogren’s syndrome)
- Irritant dermatitis
- Squamous cell carcinoma

In children:
- Pacifier use
- Lip licking
- Thumb sucking

Treatment:
- Check Vit B12; consider checking other B vitamins (B3, B6, B9)
- Remove underlying cause. Check if dentures fit correctly; if loose → dentist
- If yeast infection suspected → microscopy with potassium hydroxide (KOH) → If + (pseudohyphae and spores) → topical azole ointment (e.g., clotrimazole, miconazole) BID
- If staphylococcal infection → culture and sensitivity (C&S) → If +, treat with topical mupirocin ointment BID
- When infection has cleared → barrier cream with zine or petroleum jelly at night
* High rate of recurrence

Question 100

Perleche

Answer 100

an irritation at the corners of the lips. When someone suffers from perlèche, the corners of the lips become very red and dry, and can sometimes turn whitish in colour. There are often fissures or crusts that can occasionally bleed

aka cheilosis

Question 101

Salivary Glands

Answer 101

3 salivary glands:
- parotid
- submandibular
- sublingual

May become infected (sialadenitis, sialadenosis, mumps) or become blocked with calculi (“stone”, sialolithiasis)

Question 102

Sailadenitis

Answer 102

a swollen salivary gland. It’s caused by infections, autoimmune diseases and salivary gland stones. When a salivary gland becomes inflamed, it can stop functioning. Sialadenitis usually goes away in about a week

Question 103

Sialadenosis

Answer 103

nonneoplastic,non-inflammatory swelling of the salivary gland in association with acinar hypertrophy and ductal atrophy. Sialdenosis presents as non-tender swelling that is often bilateral and symmetric. Sialadenosis is often associated with systemic metabolic conditions

Question 104

Sialolithiasis

Answer 104

a condition in which stones (calculi) form in your salivary gland or ducts, blocking the flow of saliva. These stones, usually made of calcium phosphate and hydroxyapatite, can cause facial pain and swelling. Symptoms may occur on one side (unilateral) or both sides (bilateral)

Question 105

Mumps (Parotitis)
1. Definition/Population
2. Clinical Presentation
3. Complications
4. Treatment

Answer 105

1. School-aged children to adult
   - Acute onset of fever
   - headache
   - fatigue
   - myalgia
   - anorexia
   Within 48 hours, the salivary/parotid gland(s) become swollen and tender
   - can be unilateral (25%) or bilateral
   - Cheek appears puffy
   - Angle of jaw on the involved side appears swollen
   - Swelling and tenderness usually subsides in ~1 week
2. Rare complications but can include orchitis (of one testicle)
   - Meningitis
   - Encephalitis
   - Deafness
3. Nationally notifiable disease; report ALL cases to local or state health department

Question 106

Tonsils
1. Normal findings
2. Possible diseases
3. Most severe complication
4. Treatment

Answer 106

1. AKA palatine tonsils; made up of lymphoid tissues
   - Butterfly-shaped glands with small pore-like openings that may secrete thick white exudate (mononucleosis) or purulent exudate (yellow-to-green color; strep throat)
2. • Mono
     - Strep throat
     - Peritonsillar abscess (quinsy) → serious deep-neck infection; rare complication of tonsillitis
3. Airway obstruction!
4. Refer to ED!

Question 107

Possible diseases in Posterior Pharynx

Answer 107

• Postnasal drip (from acute sinusitis, allergic rhinitis) → Lying supine worsens a postnasal drip cough
• Chronic sinusitis → chronic cough
• Retropharyngeal lymph nodes → mildly enlarged and distributed evenly on back of throat (allergies, allergic rhinitis)

Hard palate: look for any openings (cleft palate), ulcers, redness
Uvula: Should be in midline position; displaced if infected and abscessed (peritonsillar abscess)

Question 108

Lymph Nodes
- Locations in head and neck

Answer 108

• Anterior cervical nodes (superficial chain) drain lymph from the skin and superficial surfaces of the anterior neck → 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

Question 109

Benign variants: What is geographic tongue?

Answer 109

Tongue surface has a maplike appearance; patches may move from day to day.

Patient may complain of soreness with acidic foods, spicy foods

Question 110

Bening variants: What is torus palatinus?

Answer 110

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

Question 111

Bening variants: Fishtail or split uvula

Answer 111

Uvula is split into two sections and resembles a fishtail
- may be a sign of an occult cleft palate (rare)

Question 112

Bening variants: Physiologic Gaze-evoked Nystagmus

Answer 112

• On prolonged, extreme lateral gaze, a few beats of nystagmus that resolve when the eye moves back toward midline in health patients is normal
• can also be caused by brain lesions

Question 113

What is Hypertensive Retinopathy?

Answer 113

• Copper and silver wire arterioles (caused by arteriosclerosis)
• Arteriovenous nicking → compression of vein by an arteriole as it passes over it; appears as if “nicked” or missing a small area
• Retinal hemorrhages

Question 114

What is Diabetic Retinopathy?

Answer 114

• 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)

Question 115

What are cataracts? Symptoms? Age population?

Answer 115

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

Up to 20% of older adults (ages 65-74) are affected; however, cataracts can appear at any age from infants (congenital cataracts) through adults to the elderly

Symptoms:
- difficulty with glare (with headlights when driving at night or sunlight)
- halos around lights
- blurred vision

Question 116

What are Koplik’s Spots?

Answer 116

• Clusters of small red papules with white centers inside the cheek (buccal mucosa) by the lower molars
• pathognomonic for measles (rubeola)

Question 117

What are nasal polyps?

Answer 117

• Painless, soft round growths inside the nose (look for fleshy mass inside nasal cavity; may have blockage on one side of the nose)
• Intranasal glucocorticoids (fluticasone or budesonide twice a day) are used as first-line treatment. If poor response or recurrent sinus infection → Refer to ENT specialist for surgical treatment
• ↑ risk of aspirin sensitivity or allergy

Question 118

What is Hairy Leukoplakia?

Answer 118

• Elongated papilla on the lateral aspects of the tongue that is pathognomic for HIV infection
• Caused by Epstein-Barr virus (EBV) infection of tongue

Question 119

What is leukoplakia of the oral mucosa/tongue?

Answer 119

• Bright-white plaque on the inner cheeks (buccal mucosa) caused by chronic irritation, such as from chewing tobacco or snuff
• Rule out ORAL CANCER!
• Refer to oral surgeon for biopsy

Question 120

EENT Terminology: Palpebral conjunctiva

Answer 120

Mucosal lining side eyelids

Question 121

EENT Terminology: Bulbar conjunctiva

Answer 121

Mucosal lining covering the eyes

Question 122

EENT Terminology: Buccal muscosa

Answer 122

Mucosal lining inside the mouth

Question 123

EENT Terminology: Soft palate

Answer 123

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

Question 124

EENT Terminology: Hard palate

Answer 124

“Roof” of the mouth

Question 125

EENT Terminology: Hyperopia

Answer 125

“Farsightedness”
- Distance vision is intact, but near vision is blurry

Question 126

EENT Terminology: Myopia

Answer 126

“Nearsightedness”
- Near vision intact, but distance vision is blurry

Question 127

EENT Terminology: Amblyopia

Answer 127

“Lazy eye”
- Usually starts in infancy. The affected eye has reduced vision. → Refer to ophthalmologist

Question 128

EENT Terminology: Miosis

Answer 128

Excessive constriction of the pupil of the eye

Question 129

EENT Terminology: Ptosis

Answer 129

Dropping of the upper eyelid

Question 130

Vision Testing:
1. Distance Vision
- What if person is illiterate?
2. Near Vision
3. Peripheral Vision
4. Color Blindness

Answer 130

1. The Snellen Chart
   - measures central distance vision
   - If person is illiterate, use the Tumbling E chart
   - Must stand 20 feet away from the chart
   - Patient wears glasses, test the vision with glasses on both eyes (OU), right eye (OD), and left eye (OS)
2. Read small print
3. • Use “visual fields of confrontation” exam
     - Look for blind spots (scotoma) and peripheral visual field defects
4. Use Ishihara chart

Question 131

Vision Testing: Visual Test Results
1. Snellen Test
2. Legal Blindness

Answer 131

1. If 20/60:
   - Top number (numerator): Distance in feet at which the patient stands from the Snellen or picture eye chart (always 20 feet and never changes)
   - Bottom number (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
   - In this example, the patient can see at 20 feet what a person with normal vision can see at 60 feet
2. Legal blindness: best corrected version of 20/200 or less or a visual field <20 degrees (tunnel vision)

Question 132

Children’s Vision normals

Answer 132

By 6 years → visual acuity (retina or CN II) is 20/20 in both eyes

Use Snellen chart with child, standing at 20 feet.
If child’s vision is not at least 20/30 in either eye by age 6 → Refer to ophthalmologist

Question 133

Hearing Tests:
1. Weber Test
2. Rinne Test

Answer 133

1. Place tuning fork midline on forehead
   Normal: No lateralization.
   - Lateralization (hears the sound in only one ear or sound is louder in one ear) is abnormal finding.
2. Place tuning fork first on mastoid process, then at front of ear. Time each area.
   Normal: Air conduction (AC) lasts longer than bone conduction (BC); can hear longer in front of ear than on mastoid bone; AC > BC

Question 134

Hearing Tests: Sensorineural Hearing Loss

Answer 134

Inner Ear
- Damage (or aging) of the cochlea/vestibule and/or to the nerve pathways (CN VIII or acoustic nerve)

Presbycusis
Meniere’s disease
Ototoxic drugs (oral aminoglycosides, erythromycin, tetracyclines, high-dose aspirin, sildenafil)
Stroke
- Usually results in permanent hearing loss

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

Question 135

Hearing Tests: Conductive Hearing Loss

Answer 135

Outer ear and middle ear
- Any type of obstruction (or conduction) of the sound waves

• Blockage of outer ear and/or fluid inside middle ear
  EX: Otitis media
  Serous otitis media
  Ceruminosis
  Perforation of tympanic membrane
  Otitis externa

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

Question 136

Corneal Abrasion

Answer 136

• Acute onset of severe eye pain with tearing
• Reports feeling of foreign body sensation on surface of the eye
  *Always ask any patient with eye complaints if they wear contact lenses

Question 137

Contact Lens-Related Keratitis
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment

Answer 137

1 & 2. - Acute onset of red eye
- Blurred vision
- Watery eyes
- Photophobia
- Sometimes a foreign-body sensation in affected eye

• Hx of using contacts past prescribed time schedule, sleeping with contacts, bathes/showers or swims with contacts, extended lens use, and use of tap/well water or poor disinfection practices

3. Fluorescein dye strips with Wood’s lamp (black lamp) in darkened room
   - Contact lens-associated abrasions are usually in center and round
   - Herpes keratitis: fernlike or branching curved lines (in contrast, corneal abrasions usually appear round or linear)
4. • Always check visual acuity and 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; ever eyelid to lok for foreign body. If unable to remove → refer
     - Use topical ophthalmic antibiotic with pseudomonal coverage (especially if contact lens user); ciprofloxacin (Ciloxan), ofloxacin (Ocuflox), or trimethoprim-polymyxin B (Polytrim); apply to affect eye x 3-5 days
     - Do not patch eye.
     - Follow up in 24 hours. If not improve → Refer to ED or ophthalmologist STAT!
     - Zovriax or Valtrex BID
     - 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 QID
     *Contraindication: allergy to NSAIDs

Question 138

Hordeolum
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment

Answer 138

1. Stye – An external hordeolum is an abscess of a hair follicle and sebaceous gland in the upper or lower eyelid. An internal hordeolum involves inflammation of the meibomian gland. May have history of blephritis
2. • Acute onset of a swollen, red, and warm abscess on 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)
3. Clinical diagnosis
4. • Hot compresses x 5-10 mins BID-TID until it drains
     - If infection spread (preseptal cellulitis), systemic antibiotics such as dicloxacillin or erythromycin PO QID → Refer to ophthalmologist for I&D

Question 139

Chalazion
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment

Answer 139

1. A chronic inflammation fo the meibomian gland (specialized sweat gland ) of the ey lids. May resolve spontaneously in 2-8 weeks
2. • Gradual onset of a small superficial module on upper eyelid
     - Feels like a bead, discrete and mobile/moveable
     - Painless
     - Can slowly enlarge over time
     - If large, can press on cornea and cause blurred vision
3. Clinical diagnosis
4. I&D, surgical removal, or intrachalazion corticosteroid injections by ophthalmologist

Question 140

Pinguecula

Answer 140

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.

Question 141

Pterygium
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment

Answer 141

1 & 2. 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
- May complain of foreign body sensation on the eye

3. Clinical diagnosis
4. • In inflamed → Refer to ophthalmologist for prescription of weak steroid eye drops only during exacerbations; use artificial tears PRN for irritation
     - Use good-quality sunglasses (100% against UVA and UVB)
     - Remove surgically if growth encroaches on cornea and affects vision

Question 142

Subconjunctival Hemorrhage
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment

Answer 142

1. Blood trapped underneath conjunctiva and sclera 2º to broken arterioles. Can be caused by coughing, sneezing, heavy lifting, vomiting, or local trauma, or occur spontaneously.
   - Resolves within 1-3 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 HTN
2. • Sudden onset of bright-red blood in one eye after an incident of severe coughing, sneezing, or straining
     - May also be d/t trauma such as a fall
     - Denies visual loss and pain
3. Clinical diagnosis
4. Watchful waiting and reassurance of patient. Follow up until resolution

Question 143

Primary Open-Angle Glaucoma
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment

Answer 143

1. Graduate onset of ↑ IOP >22 mmHg d/t blockage of drainage of aqueous humor inside eye. Retina (CN II) undergoes ischemic changes and, if untreated, become permanently damaged.
   - Most common type of glaucoma (60-70%). → Refer to ophthalmology
   - Most seen in elderly patients esp African or Caucasian ancestry, or diabetics
2. • Usually asymptomatic in early stages
     - Gradual changes in peripheral vision (lost first)
     - Then central vision
     - May complain of missing portions of words when reading
3. Funduscopic exam → cupping, IOP is too high → Refer to Ophthalmology
   - Check IOP (use tonometer) - Normal range: 8-21 mmHg
   * IOP >30 mmHg is considered very high. Urgent referral within </= 24 hours to ophthalmologist or refer to ED
4. • Betimol 0.5% (timolol): Beta-blocker eye drops (↓ aqueous production)
     - Latanoprost (Xalatan): Topical prostaglandin eye drops (↑ aqueous outflow)
     - SE: Same as oral form; includes bronchospasm, fatigue, depression, heart failure, bradycardia
     - Contraindications: Asthma, emphysema, COPD, second- or third-degree heart block, HF

Complication: Blindness d/t ischemic damage to retina (CN II)

Question 144

Primary Angle-Closure Glaucoma
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment

Answer 144

1. Sudden blockage of aqueous humor causes marked ↑ of the IOP → ischemia and permanent damage to optic nerve (CN II)
2. • Older patient c/o acute onset of ↓/blurred
     - Severe eye pain
     - Front headache
     - Accompanied by nausea and vomiting

Objective findings:
- Fixed and mid-dilated, cloudy pupil (4-6 mm)
- Looks more oval than round
- Reacts slowly to light
- Conjunctival infection with ↑ lacrimation

3. Clinical diagnosis
   - Tonometry for IOP
4. Refer to ED!

Question 145

Anterior Uveitis

Answer 145

Iritis
Insidious onset of eye pain with conjunctival injection
Refer to ophthalmologist for management ASAP wi th 24 hours!
- can result in blindness!

Question 146

Conjunctival injection

Answer 146

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 (RA, Lupus, ankylosing spondylitis, sarcoidosis, syphilis, etc); no purulent discharge (as in bacterial conjunctivitis)

Question 147

Sjogren’s Syndrome
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment

Answer 147

1. Chronic autoimmune disorder characterized by ↓ function of lacrimal and salivary glands; can occur alone or with another autoimmune disorder (e.g., with RA)
2. • Persistent daily symptoms of dry eyes and dry mouth (xerostomia) for >3 months
     - “dry eyes” or sandy/gritty sensation
     - has used OTC artificial tears > TID
     - Marked increase in dental caries
     - oral exam → swollen and inflamed salivary glands
3. Clinical diagnosis
4. • OTC tear-substitute eye drops TID
     - keratoconjunctivitis sicca → Refer to ophthalmology
     - dental caries → dentist
     - Refer to rheumatologist for management

Question 148

Xerostomia

Answer 148

Dry mouth

Question 149

keratoconjunctivitis sicca

Answer 149

Dry eyes or sandy/gritty sensation

chronic, bilateral desiccation of the conjunctiva and cornea caused by too little tear production or accelerated tear evaporation. Typical symptoms include intermittent itching; burning; blurring, a gritty, pulling, or foreign body sensation; and photosensitivity

Question 150

Entropion

Answer 150

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

Question 151

Ectropion

Answer 151

Eyelid is turned outward of sags away from eye → irritation and eye dryness
- More common in elderly

Question 152

Rhinitis Medicamentosa
1. Definition
2. Clinical presentation
3. Treatment

Answer 152

1. Prolonged use of topical nasal decongestants (>3 days) causes rebound effects → severe and chronic nasal congestion
2. Presents with daily severe nasal congestion and nasal discharge (clear, watery mucus)
3. • Stop the use of nasal decongestants
     - Encourage use of nasal saline spray to control symptoms

Question 153

Epistaxis
1. Anterior vs posterior
2. Clinical presentations
3. Treatment

Answer 153

1. Nosebleeds - most are self-limiting
   Anterior - located anteriorly on lower 1/3 of nose
   - milder and more common
   - result of bleeding from Kiesselbach’s plexus (vascular area)

Posterior
- can lead to severe hemorrhage
- Aspirin use, NSAIDs, cocaine abuse, severe HTN, anticoagulants (warfarin; place patients at higher risk); intranasal cocaine use can cause nosebleeds and nasal septum perforation

2. • acute onset of nasal bleeding 2º trauma (e.g., nose picking)
     - bright-red blood may drop externally through nasal passage and/or posterior pharynx
     - profuse bleeding can result in vomiting of blood
3. • Apply direct pressure on front of nose for several minutes
     - use nasal decongestants (Afrin) to shrink tissue helps to stop bleeding
     - Apply triple antibiotic ointment or petroleum jelly in front of nose using cotton swab for a few days
     - If recurrent anterior nasal bleeds → Refer ENT for cauterization

Posterior nasal bleeds may hemorrage → Refer to ED!

Question 154

Septal Perforation

Answer 154

A hole on the nasal septum (cartilage_ can range in size from small to large
- Shine a light on one nostril will transilluminate both sides
- One of most common cause: snorting or inhaling cocaine (potent vasoconstrictor; causes ischemia)

Other causes:
- trauma
- prior septal surgery
- untreated septal hematomas
- self-induced lesions

Question 155

Streptococcal Pharyngitis/Tonsillopharyngitis
1. Definition/Population
2. Clinical Presentation
3. Labs/Diagnostics
4. Treatment

Answer 155

“Strep” throat
1. An acute infection of the pharynx and/or palatine tonsils caused by group A streptococcal bacteria (streptococcus pyogenes)
- Most common: 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 water eyes (coryza)
- All ages are affected, but most common in children

2. • Abrupt onset of fever
     - Sore throat
     - pain on swallowing
     - mildly enlarged submandibular nodes
     - may have purulent exudate on tonsils
     - anterior cervical nodes mildly enlarged and tender (anterior cervical adenitis)
     - Adult may report that child goes to preschool
3. Centor Criteria – clinical decision tool used to help diagnose “strep” throat, including:
   - tonsillar exudate
   - tender anterior cervical adenopathy
   - history of fever
   - absence of cough
4. • Rapid antigen detection testing (RADT) is a rapid “strep” test or throat C&S
     - First line: PO penicillin V 500 mg BID-TID x 10 days
     - Alternative: amoxicillin 500 mg BID x 10 days
     - PCN or beta-lactam allergy: azithromycin (Z-Pak) x 5 days
     - Throat pain and fever: ibuprofen (advil) or acetaminophen (Tylenol)
     - Symptomatic treatment: Saltwater gargles, throat lozenges, drink more fluids
     - Repeat C&S after antibiotic treatment (test of cure): Hx of mitral valve prolapse or heart valve surgery

Question 156

coryza

Answer 156

an acute inflammatory contagious disease involving the upper respiratory tract: : common cold

Question 157

Acute Otitis Media
1. Definition
2. Common pathogens
3. Clinical Presentation
4. Labs/Diagnostics
5. Treatment

Answer 157

1. An acute infection of the middle ear cavity with bacterial pathogens d/t mucus that becomes trapped in the middle ear; 2º to temporary eustachian tube dysfunction; usually unilateral but may involve both ears. Most have middle ear effusion (MEE).
   - Most cases occur in childhood
2. Adult infections usually d/t Streptococcus pneumoniae; high rates of beta-lactamase resistance.
   - S. pneumoniae (Gram+; up to 40% of cases)
   - Haemophilus influenzae (Gram-; up to 50% of cases)
   - Moraxella catarrhalise (Gram-; up to 20% of cases)
3. • ear pain (otalgia)
     - popping noises
     - muffled hearing
     - Recent hx of cold or flare-up of allergic rhinitis

Adults
- develop more slowly than children
- afebrile to low-grade fever
- May be accompanied by TM rupture (reports blood and pus seen on pillowcase with relief of ear pain)
- Bullous Myringitis

PE:
- Weber exam shows lateralization to the “bad”/affected ear (conductive hearing loss)
- Rinne test: BC > AC (conductive hearing loss)
- TM: buldging or retraction with displaced light reflex (displaced landmarks); may look opaque
- Erythematous TM
- ↓ mobility with flat-line tracing on tympanogram (most objective finding)
- If TM is ruptured, purulent discharge from affected ear (and relief of ear pain)

4. Clinical diagnosis
5. First line: Amoxicillin (any age group if no abx in prior month) 500 mg PO TID x 5-7 days
   - Mild-to-mod disease: treat 5-7 days
   - Severe disease: treat 10 days
   - Most patients will respond in 48 - 72 hours. If no response → second-line drug such as amoxicillin-clavulanate (Augmentin) TID OR cefdinir (Omnicef) OR cefprozil (Ceftin BID), or levofloxacin (Levaquin) or moxifloxacin (Avelox) daily x 5 days
   - Treat symptoms of otalgia and eustachian tube dysfunction (becomes swollen d/t inflammation and cannot drain); pt will c/o “plugged-up” ear (MEE) and ↑ hearing in affected ear (temporary). When fluid in middle ear drains, hearing will return to normal

Question 158

Otalgia

Answer 158

ear pain

Question 159

Bullous Myringitis

Answer 159

Type of AOM infection that is more painful d/t presence of blisters (bullae) on a reddened and bulging TM.
- Conductive hearing loss
- Caused by different types of pathogens (e.g., mycoplasma, virus, bacteria)

Treat the same as bacterial AOM

Question 160

Middle Ear effusions (MEE)
1. How long can MEEs persist for after treatment of AOM?
2. What are some nonpharmacological considerations for treating MEE?

Answer 160

1. MEEs can persist for 8 weeks or longer after treatment of AOM
2. Recommended for allergic rhinitis:
   *Many are allergic to dust mites (an indoor allergen)
   - Allergy pillow covers
   - Allergy mattresses
   - HEPA allergy filters for air conditioners

Question 161

Transillumination

Answer 161

Turn off the light (darkened room)
Place a bright light source directly on the surface of the cheek (on maxillary sinus). Instruct patient to open mouth and look at the roof of the mouth (hard palate) for a round glow of light). Compare both sides.

The “affected” sinus has no glow or duller glow compared with the normal sinus. For frontal sinusitis, place the light under the supraorbital ridge at the medial aspect and compare glow of light

Question 162

cacosmia

Answer 162

Bad odor in nose

Question 163

Otitis Media with Effusion
1. Definition
2. Clinical Presentation
3. Treatment

Answer 163

Serous Otitis Media
1. May follow AOM; can also be caused by chronic allergic rhinitis. sterile serous fluid is trapped inside middle ear.

2. • C/o ear pressure
     - popping noises
     - muffled hearing in affected ear

PE/Objective findings:
- 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

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

Question 164

Otitis Externa (Swimmer’s Ear)
1. Definition
2. Common pathogens
3. Clinical Presentation
4. Treatment

Answer 164

1. Bacterial infection of the skin of the external ear canal (rarely fungal). More common during warm and humid weather (e.g, summer)
2. Pseudomonas aeruginosa (gram-)
   S. aureus (gram+)
3. • External ear pain
     - Swelling
     - discharge
     - pruritis
     - hearing loss (if ear canal is blocked with pus)
     - hx of recent activities that involve swimming or getting ears wet

PE/Objective findings:
- 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

4. • Polymyxin B-neomycin-hydrocortisone (Cortisporin Otic) suspension 4 gtt QID x 7 days; Ofloxacin otic or ciprofloxacin (Cipro HC) otic ear drops BID x 7days
     - Immunocompromised (e.g., poorly controlled diabetes, chemotherapy, immunosuppressive drugs, AIDs) → topical antibiotics + systemic/oral abx such as ciprofloxacin or ofloxacin BID x 7-10 days
     - Keep ears out of water during treatment. If patient has recurrent episodes, prophylaxis is Otic Deomoboro (boric) or alcohol and vinegar (VoSol)

Question 165

Infectious Mononucleosis
1. Definition
2. Clinical Presentation + Classic triad
3. Objective Findings
4. Treatment
5. Complications

Answer 165

1. Infection by the EBC (herpesvirus family). Peak ages of acute infection is US are 15-24 years. After acute infection, EBC lies latent in oropharyngeal; can become reactivated and cause symptoms; virus is hed mainly through saliva
2. • Classic triad: fever, pharyngitis, lymphadenopathy (>50% cases)
     - hx sore throat (usually teen)
     - enlarged posterior cervical nodes
     - symmetric lymphadenopahty
     - fatigue (several weeks; can last weeks to months)
     - Tonsillar exudate with color of exudate ranging from white to gray-green
     - May have abdominal pain d/t hepatomegaly and/or splenomegaly
     - Hx of intimate kissing
3. • CBC: atypical lymphocytes and lymphocytosis (>50%); repeat CBC until resolves
     - 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
4. Acute states: - Limit physical activity (exercise, contact sports, weightlifting) for 4 weeks to ↓ risk of splenic rupture
   - Order abdominal US if splenomegaly/hepatomegaly is present, esp if pt is athlete or physically active, or athletic coach
   - Repeat abdominal US in 4-6 weeks if abnormal to document resolution
   - Treat symptoms
   - Avoid using amoxicillin if patient has “strep” throat (drug rash from 70-90%).
   - Avoid close contact; kissing, sharing toothbrush, fork, spoon, or knife; and using the same glass
5. • Splenomegaly/splenic rupture: rare but serious
     - If airway obstruction, hospitalize and give high-dose steroid to ↓ swelling
     - Neuro complications: GBS, aseptic meningitis, optic neuritis, etc
     - Blood dyscrasias (atypical lymphocytes): Repeat CBC until lymphocytes are normalized

Question 166

Vertigo
1. Types
2. Clinical Presentation
3. Important assessment components
4. Treatment

Answer 166

1. Two types:
   - Peripheral vertigo: caused by disorders of the vestibular apparatus of inner ear or inflammation of vestibular nerve (CN VIII)

• Central vertigo: associated with serious to life-threatening conditions such as stroke (Cerebellar or brainstem bleeding), MS, infections, or tumor

2. • room spinning sensation
     - rotational movement
     - may be associated with nystagmus
     - Person has vertigo or other types of dizziness such as near syncope, hypoglycemia, orthostatic hypotension, cerebrovascular disease, and arrhythmias
3. • Antivertigo medications (meclizine)
     * Be careful with geriatric patients as some of these meds are antihistamines and may cause dizziness and sedation (↑ risk of falls)

Question 167

Vertigo: Dix-Hallpile Maneuver

Answer 167

GOLD STANDARD clinical test for benign paroxysmal positional vertigo disease (BPPV)

• Positive finding: rotary nystagmus with latency of limited duration

Direction: Assuming affected ear is on the right, with the patient sitting on the exam table (facing forward, with eyes open), turn the patient’s head 45º to the right. While standing behind the pt and supporting the pt’s head with one hand, rapidly move head from an upright to “head hanging” position, where the patient’s head is at least 10º below horizontal.

To achieve complete dependency of pt’s head during maneuver, pt should be positioned in such a way that their shoulders will meet the head of the table when they are reclined.

Question 168

Vertigo: Epley Maneuver

Answer 168

This maneuver can be done in the clinic or at home by the pt.

Direction: Assuming affected ear is on the right, with the patient sitting on the exam table (facing forward, with eyes open), turn the patient’s head 45º to the right. While standing behind the pt and supporting the pt’s head with one hand, rapidly move head from an upright to “head hanging” position, where the patient’s head is at least 10º below horizontal.

Then, maintain for 30 seconds or until any nystagmus and vertiginous symptoms subsite. Reposition hands on either side of pt’s head and turn pt’s head 90 º away from the affected ear, placing it at 45º toward opposite shoulder. Ask pt to roll onto their shoulder on unaffected side (left). While pt rolls onto their shoulder, maintain pt’s head at its 45º oriented on shoulder. As pt rolls, their face will be directed to floor. Pt should keep this position until nystagmus/vertigo subside or 30 seconds have passed then sit up.

Question 169

Differential diagnoses for vertigo

Answer 169

• Meniere’s disease
• BPPV
• Acoustic neuroma (vestibular schwannoma)
• Labyrinthitis
• Cerebellar infarction or hemorrhage (cerebellar stroke)

Question 170

Vertigo Ddx: Meniere’s disease
1. Characteristics
2. Assessment
3. Treatment

Answer 170

1. Tirad of recurrent vertigo, tinnitus, and unilateral hearing loss that is chronic
   - may be nausea/vomiting with episodes
   - usually affects only one ear, but in 15% will involve both
   - no associated neuro symptoms

2 & 3. - Initial tx: lifestyle changes
- Salt restriction (203 g/day)
- avoid MSG and nicotine
- minimize intake of caffeine, alcohol (one serving/day)
- Vestibular suppressant PRN
- nausea/vomit mediations PRN
- Persistant attacks → Refer to ENT; consider vestibular rehabilitation

Question 171

Vertigo Ddx: BPPV
1. Characteristics
2. Assessment
3. Treatment

Answer 171

1. • Abrupt onset with brief episodes of vertigo that last <1 min induced by sudden head movements and positions
     - Due to calcium carbonate crystal s)otoconia) trapped in semicircular canals
     - RF: head trauma, high intensity aerobics, bike riding in rough trails; most common cause of vertigo in US; ages 50-70
2. GOLD STANDARD: Dix-Hallpile maneuver
   - Epley maneuver/modified Epley done in clinic or at home
3. Meclizine PO Q4-8 H (vertigo)
   - Prochlorperazine IM, rectal suppository, or PO (nausea/vomiting)
   - Avoid sleeping on side of affected ear for several days

Question 172

Vertigo Ddx: Acoustic neuroma (vestibular schwannoma)
1. Characteristics
2. Assessment
3. Treatment

Answer 172

1. • CN VIII (vestibular portion) tumor; Schwann cell-derived tumors; Symptoms are slow and insidious.
     - Two major symptoms:
     - chronic hearing loss (avg duration 4 years)_
     - Chronic tinnitus
     - If trigeminal nerve is compressed, symptoms are facial numbness and pain
     → leads to asymmetric sensorineural hearing loss
2. Weber and Rinne tests; hearing testing CN testing
3. Refer to ENT; surgical removal, radiation

Question 173

Vertigo Ddx: Labyrinthitis
1. Characteristics
2. Assessment
3. Treatment

Answer 173

1. Sudden onset of severe vertigo
   - Accompanied by sensorineural hearing loss and tinnitus
   - Last from hours to days
   - Due to inflammation of vestibular nerve caused by viral or bacterial infection

2 & 3. - Vestibular suppressants PRN for severe attacks of vertigo only. If mild symptoms, do not use, since delay recovery
- If suspect bacterial infection → broad-spectrum antibiotic and refer to ENT

Question 174

Vertigo Ddx: Cerebellar infarction or hemorrhage (cerebellar stroke)
1. Characteristics
2. Assessment
3. Treatment

Answer 174

1. • Sudden onset of severe headache
     - vertigo
     - nausea/vomiting
     - motor deficits
     - impaired gait
     - imbalance
     - impaired control arm/leg movements
     - slurred speech (dysarthria)
     - <10% of strokes, higher mortality
2. GOLD STANDARD: MRI for diagnosing infarction on brain
3. Call 911!

Question 175

dysarthria

Answer 175

slurred speech