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primary care midterm > HEENT- Adults > Flashcards

HEENT- Adults Flashcards

1
Q

Conjunctivitis: Most common types

A
  • Viral – often caused by adenovirus
  • Allergic – can be seasonal or perennial
  • Vernal and atopic –
    o Vernal – more common in childhood
    o Atopic – adults with hx asthma, allergic rhinitis, eczema
  • Non allergic – reaction to irritant,
    o e.g. contact lenses, artificial smoke
  • Bacterial – extremely rare in adults
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2
Q

viral conjunctivitis

A
  • Typically caused by adenovirus, many types
  • Starts with URI symptoms – adenopathy, fever, sore throat
  • Or, maybe only eye infection
  • Highly contagious
  • Spread by direct contact or contaminated surfaces
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3
Q

viral conjunctivitis: history

A

o Crusting in the morning
o Scratchy, burning, gritty, sandy feeling in the eyes
o Watery or “mucoserous” discharge
o May start in one eye, but usually second eye involved within 24-48 hours
o Often accompanied by other viral symptoms, URI
o Sick contacts (very contagious)
o Self-limiting process, worsening first 3-5 days, can last 1-2 weeks

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4
Q

viral conjunctivitis: exam findings

A

o Minor crusting
o Watery discharge; scant, stringy component which is mucus, not pus
o Pus does not appear spontaneously at the lid margin or in the corners of the eye
o Diffuse redness of the conjunctiva
o Signs/symptoms of viral URI (cough, runny nose, congestion)
o Absence of photophobia; able to keep eyes open
o Visual acuity intact
o May have ipsilateral (same side) preauricular lymphadenopathy
o Tarsal (palpebral) conjunctivae may have follicular or “bumpy” appearance

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5
Q

viral conjunctivitis: management

A

o Self-limiting; 1-2 weeks
o Highly contagious; wash hands frequently, do not share towels
o Cold compresses
o Artificial tears; put bottle in the fridge to soothe the eyes
o Topical antihistamine/decongestant
o Current EBP: no need for antibiotic ointment although patients will ask

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6
Q

Epidemic keratoconjunctivitis or EKC

A
  • Subtype caused by adenovirus types 8, 19, & 37
  • In addition to inflammation of the conjunctiva, keratosis (inflammation of the cornea)
  • Symptoms include foreign body sensation which can be severe; reluctance to open the eye
  • Visual acuity can be decreased by 2 or 3 lines
  • Can be sight threatening, refer emergently
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7
Q

allergic, vernal, atopic conjunctivitis: s/s

A
  • Itching – the cardinal symptom
  • Redness – both eyes
  • Morning crusting is possible
  • Follicular or bumpy appearance to tarsal (palpebral) conjunctiva
  • Other allergic symptoms – allergic rhinitis, asthma, atopic dermatitis in response to triggers
  • Grass and ragweed pollen, dust mites, animal dander or feathers
  • Sometimes profuse watery discharge
  • On exam: diffuse injection
  • Marked chemosis is possible
  • If severe, may lead to corneal ulcers – requires referral
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8
Q

allergic, atopic, vernal conjunctivitis: management

A

o Allergen avoidance!!
o Non-Pharmacological:
* Cool compresses
* Refrigerated artificial tears
* Stop contact lens use while allergies are active

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9
Q

tx allergic, atopic, vernal conjunctivitis

A

o Mast cell stabilizers – cromolyn sodium, nedocromil
o Combination mast cell stabilizer/antihistamines (Olopatidine, azelastine) – these tend to work better
o Systemic therapies – oral antihistamines, e.g. loratidine, fexofenadine, cetirizine
o Topical cetirizine also mentioned in your book
o OTC topical vasoconstrictor/antihistamine combinations should only be used for up to 2 weeks to avoid rebound
o Topical glucocorticoids exist but I do not use these in my practice; would refer if refractory
o ** For someone who is using more than one type of eyedrop, apply 3-5 min apart to avoid the second medication washing out the first one.

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10
Q

Allergic Conjunctivitis in Contact Lens Wearers

A
  • Giant papillary conjunctivitis (shown in pic)
  • Contact lens deposits act as allergens; less common now with disposable lenses
  • Can also occur in reaction to corneal sutures (overactive immune response in persons with atopy)
  • Can also occur in persons with eye prosthesis
  • Eversion of upper eyelid shows giant papillae
  • I would refer this patient to ophthalmology!
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11
Q

Drug Induced Allergic Conjunctivitis

A
  • Reaction to topical agents applied to the eyes or periorbital region; e.g. cosmetics, or ocular therapy
  • Ocular ointments can cause this
  • Beefy red colored conjunctiva, chemosis
  • Again, would consult or refer
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12
Q

Bacterial Conjunctivitis: Rare in adults!

A
  • Staphylococcus aureus - most common cause of acute bacterial conjunctivitis in adults
  • Hemophilus influenza and Moraxella catarrhalis – more common causes of acute bacterial conjunctivitis in children
  • More rarely - chlamydia, gonorrhea
  • HIGHLY CONTAGIOUS!!
  • Discharge persists throughout the day – thick and globular; can be yellow, white, or green
  • Purulent discharge
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13
Q

Acute bacterial conjunctivitis

A
  • Abrupt presentation with purulent drainage, but usually not painful, no photophobia
  • Usually no visual deficit, unless from copious discharge
  • Purulent discharge; persists throughout the day
  • Injection; possibly chemosis
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14
Q

Chronic Bacterial Conjunctivitis

A
  • Purulent discharge lasting longer than a few weeks, is usually due to chlamydia or dacryocystitis (inflammation of the lacrimal sac, usually secondary to blockage of the nasolacrimal duct)
  • For this presentation the NP would refer the patient to a specialist
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15
Q

Hyperacute Bacterial Conjunctivitis

A
  • Caused by gonorrhea; spread from genitalia, to hands, to eyes. Concurrent urethritis.
  • Rapid onset of symptoms, within 12 hours of exposure
  • Injection, eyelid edema, severe, continuous, copious purulent discharge, chemosis, pain or discomfort, tenderness to palpation, tender preauricular lymphadenopathy
  • Frequent corneal involvement, can perforate
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16
Q

Bacterial Conjunctivitis: Topical treatments usually not necessary

A
  • Self-limiting and topical treatment is not necessary.
  • But Indicated for high risk patients: immunocompromised, health care workers, uncontrolled DM, hx glaucoma surgery
  • Erythromycin Ophthalmic Ointment 1.25 cm (1/2 inch) applied to inner lower eyelid 4 times daily. May cause blurring
  • Polymixin/trimethoprim drops, 1-2 drops 4 times daily – drops better for driving
  • Duration of treatment: 5-7 days
  • Alternative treatments: bacitracin ointment, sulfacetamide ointment, polymixin-bacitracin ointment, fluoroquinolone drops, azithromycin drops. If no improvement in 1-2 days would refer.
  • Contact lens wearers: use glasses until sclera is white and at least 24 hours after antibiotic therapy is completed.
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17
Q

Bacterial Conjunctivitis: Systemic (oral or by injection) treatment is indicated for:

A
  • H. Flu – amoxicillin-clavulanate
  • Gonococcal – ceftriaxone 250 mg IM and 1 gram po of azithromycin
  • Chlamydia – azithromycin, 1 gram po, or doxycycline, 100 mg po BID x 7 days
  • Be sure to treat sexual partners of patients with chlamydial or gonococcal conjunctivitis
  • Take home message here: When in doubt, consult
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18
Q

Blepharitis

A
  • Chronic condition (eyelid and near eyelashes)
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19
Q

Blepharitis: presentation

A

o Burning and itchy eyes.
o Feeling of dryness.
o Eyelids are swollen in the morning, sometimes with crusting.
o Eyes feel gritty, sometimes with excessive tearing or blurring of vision.

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20
Q

Blepharitis: non pharm management

A

o Warm compresses
o Lid massage
o Lid washing
o Artifical tears

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21
Q

Blepharitis: pharm management

A

o For blepharitis caused by demodex mites, tea tree oil scrubs to the eyelashes
o Hypochlorous spray aka Avenova reduces bacterial load on the skin

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22
Q

Blepharitis: tx

A

If refractory, may use:
* Topical antibiotics – azithromycin or tobrex ophthalmic solution; erythromycin or bacitracin ointments (though they can cause contact dermatitis)
* Oral antibiotics – doxycycline, tetracycline, azithromycin, erythromycin in pregnancy or children
o Ophthalmologists may prescribe:
* Topical glucocorticoids – for oph’thy only
* Topical cyclosporine – again, for oph’thy only

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23
Q

Hordeolum: s/s

A
  • Acute infection and inflammation of gland in the eyelid
  • Tender
  • Warm
  • Erythematous
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24
Q

Hordeolum: tx

A

o Hot compresses
o OTC analgesics

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25
Q

Chalazion: s/s

A
  • Painless lump on the eyelid
  • Chronic, sterile, nontender
  • May result from hordeolum which has not drained
  • Bothers patients due to appearance; may obstruct vision
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26
Q

Chalazion: management

A

o Frequent hot compresses
o Practice good eyelid hygiene
o Referral to ophthalmologist
o Incision and curettage
o Glucocorticoid injection
o Scrub eyelids with washcloth moistened with warm water and baby shampoo; or expensive wipes

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27
Q

dry eye: etiology

A

o Multifactorial
o Defect in tear film due to meibomian gland dysfunction
o Poor eyelid closure
o Infrequent blinking
o Contact lens wear
o Caution: If the patient reports dry mouth or other systemic symptoms, consider further workup for Sjogren’s disease

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28
Q

dry eye: risk factors

A

o Assigned female at birth
o Age over 50
o Hormone changes (such as menopause)
o Contact lenses
o Hormone replacement therapy (HRT)

29
Q

dry eye: presentation

A

o Itchy, burning eyes with frequent tearing.
o Eyes feel scratchy and gritty though symptoms are relieved with blinking.
o Often worse with reading.
o Sometimes eyes tear up so patient can’t read easily.

30
Q

dry eye: management

A

o Artificial tears
o Frequent blinking
o Avoid windy, smoky, low humidity environments
o Take frequent breaks during close visual attention tasks such as computer work or reading
o Lid hygiene as for blepharitis
o Symptom Questionnaires—Salisbury Eye Evalution (SEE)
* 1. Do your eyes ever feel dry?
* 2. Do you ever feel a gritty or sandy sensation in your eye?
* 3. Do your eyes ever have a burning sensation?
* 4. Are your eyes ever red?
* 5. Do you notice much crusting on your lashes?
* 6. Do your eyes ever get stuck shut in the morning?
* * Allowable responses: never, rarely, sometimes, often or all the

31
Q

otitis media

A
  • Patients come in reporting significant ear pain
  • They may report upper respiratory symptoms as well
32
Q

otitis media: history

A

o History of previous ear infection? How often?
o Ear pain?
o Fullness/popping?
o Rhinorrhea?
o Fever?
o Nausea/vomiting?
o Vertigo?
o Hearing loss?
o Stuffiness?

33
Q

otitis media: physical findings

A

o Right eardrums.
o Left side, healthy ear, pearly gray cone of light is visible on right with cone of light at 4 o’clock.
o On right, TM is bulging and opaque; there is some erythema and landmarks are obscured; anvil not visible.

34
Q

Why are children more prone to otitis media?

A

o More trouble fighting off infections due to immature immune system
o Eustachian tube is shorter and straighter, thus making it easier for infection to travel up from the throat. The eustachian tubes are usually closed but open regularly to ventilate the middle ear
o Larger adenoids (lymphatic tissue) at the back of the throat may make it harder for eustachian tubes to ventilate
o Also, adenoids may become infected and thus spread infection up the eustachian tubes

35
Q

otitis media: demographics

A

o More common in children
o Higher risk groups:
* low socioeconomic status
* smokers
* persons exposed to second-hand smoke
* children in large day care settings

36
Q

otitis media: vaccinations

A

o Incidence going down, due to high pneumococcal vaccination rates
o Although children are the target population

37
Q

otitis media: tx

A
  • First line: Amoxicillin/clavulanate to cover S. pneumoniae – 875/125 BID for mild to moderate cases. Safe in pregnancy! (UpToDate). For mild to moderate cases treat for 5-7 days.
  • For severe disease, pain, or fever, or if pt is >65, recently hospitalized, has used antibiotics in the past month, or is immunocompromised, consider high dose amoxicillin clavulanate; e.g. 1000/62.5 BID; in higher weight patients may use 2000/125 BID; 10 days.
  • If penicillin allergic without history of urticaria (hives) or anaphylaxis may use cephalosporin such as cefdinir, cefpodoxime, cefuroxime, ceftriaxone
  • If penicillin allergic with history of urticarial or anaphylaxis, may use doxycycline, or macrolide such as azithromycin or clarithromycin
  • If severe pain, no improvement with treatment, or recurrence within 6 months, refer to ENT
38
Q

otitis media: health promotion/education

A

o Stop smoking/limit smoke exposure
o No evidence for alternate therapies
o In children:
* Educate family about higher risk in large day care settings
* Educate family about risk with smoke exposure
* Educate family about protective effect of breast feeding
* Discuss antibiotic prophylaxis for frequent episodes
* May benefit from myringotomy with tubes (ENT referral)

39
Q

Red flags/complications: otitis media

A

o Ruptured tympanic membrane
o Lack of response to antibiotic therapy
o Complications include:
* Hearing loss
* Perforation
* Cholesteatoma
* Mastoiditis
* Meningitis
o Epidermal abscess
* Warning: if you suspect otitis media, do not irrigate the ear due to danger of perforation

40
Q

Otitis media with effusion (OME)

A
  • Fluid presence in middle ear without signs of illness or inflammation
  • Usually follows acute otitis media but can also be caused by barotrauma or allergy
  • Presence of fluid without infection
  • Often caused by URI, allergies, or airplane travel
  • Hearing loss and a sense of fullness can persist for up to 12 weeks, but should resolve on its own.
    o Follow patient closely
    o If hearing loss is severe, or persists, refer to ENT
41
Q

Otitis externa “swimmer’s ear”

A
  • Inflammation or infection of the external ear
  • May be caused by infectious, allergic, and dermatological disease
  • More frequent in summer
42
Q

Otitis externa “swimmer’s ear”: risk factors

A

o Swimming
o Excessive cleaning or scratching of the canal
o Devices in ear – hearing aid, ear buds, bathing caps
o Chronic dermatological conditions – psoriasis, atopic dermatitis
o Prior radiation therapy

43
Q

otitis externa: presentation

A

o Pain in canal
o Fullness or itchy feeling
o Possible discharge
o Possible mild lymphadenopathy
o Possible low grade fever
o Possible mild hearing loss
o Other pertinent history:
* Known infection of TM
* Previous ear infections
* Prior ear surgery
* Recent ear instrumentation
* Water exposure

44
Q

otitis externa: physical findings

A

o Well appearing
o Vital signs wnl
o HEENT:
* Tender tragus
* Discharge, erythema, debris in canal
* Poorly visualized TM
* Mild hearing deficit R ear

45
Q

otitis externa tx

A

o For mild cases:
* Cleaning of the ear canal (aural toilet). In pcp office, gentle irrigation with room temp hydrogen peroxide, saline, or water if TM is intact.
* Instillation of acetic acid/ hydrocortisone solution if TM is intact TID or QID
* Another option for mild to moderate cases:
* Acidifying/antiseptic plus hydrocortisone such as Acetasol HC; VolSol HC Otic – TID or QID
o For moderate cases:
* Topical abx with glucocorticoid: Cortisporin, or Cipro HC; twice daily for 7 days; Cipro HC more expensive but fewer reactions
* Cortisporin, combination of neomycin and polymixin B is less expensive but more likely to cause ototoxicity. Caution if you cannot verify intact TM
* Caution of potential ototoxicity: neomycin, tobramycin, and gentamicin

46
Q

**Red flags **: otitis externa

A

o Whole canal swollen shut, or cellulitic appearance of helix- malignant otitis externa
o Refer urgently
o Most commonly found in elderly diabetic patients, caused by pseudomonas aeruginosa. Refer to specialist for management, may need IV antibiotics and wick placed

47
Q

pt education: otitis externa

A

o Use earplugs while swimming
o Do not use cotton tipped swabs or other pointed objects to clean canal
o Follow prescribed regime and finish antibiotics

48
Q

Temporomandibular Disorders: s/s

A

o facial pain
o ear discomfort
o headache
o jaw discomfort or dysfunction

49
Q

Temporomandibular Disorders: history: symptoms & behavior

A

o Constant dull ache”
o Jaw feels “heavy and tired,” esp. after eating
o Waxes and wanes
o Worse with jaw motion
o Can also present as ear pain, or sinus pain around the orbit
o Neck pain, shoulder pain, dizziness
o Can be associated with teeth grinding (bruxism), teeth clenching, chewing gum, pencils, nailbiting, other repetitive jaw motions (violinists, woodwind players)

50
Q

Temporomandibular Disorders: exam

A

o Observe patient opening and closing their mouth
o Measure jaw opening – normal is 35-55 mm
o Palpate TMJ & muscles of mastication for tenderness
o Grasp mandible and press down & back for tenderness
o Examine oral cavity for unusual wear on teeth
o Observe upper body posture for asymmetry
o Palpate neck and shoulders for tenderness

51
Q

red flags: Temporomandibular Disorders

A

o Previous hx malignancy (metastasis)
o Persistent or unexplained cervical mass or lymphadenopathy (neoplasm, infection, autoimmune cause)
o Neuro sx e.g. headache or cranial nerve abnormalities (intracranial cause or malignancy)
o Facial asymmetry, swelling, or inability to completely open the mouth (trismus) – neoplasm, infection, inflammation
o Recurrent nosebleed, purulent nasal discharge, persistent anosmia, reduced hearing on ipsilateral side (nasopharyngeal carcinoma)
o Unexplained fever or weight loss (malignancy)
o New onset unilateral headache or scalp tenderness (giant cell arteritis)
o Occlusal changes (neoplasia, RA, trauma, bone growth around the TMJ e.g. acromegaly)

52
Q

Temporomandibular Disorders: management

A

o Initial pharmacotherapy: NSAIDs. Add muscle relaxant is recommended if there is clinical evidence of muscle spasm.
o Cognitive behavior therapy and biofeedback improve short- and long-term pain management for patients with TMD.
o Occlusal adjustments of the teeth (i.e., grinding the enamel) should not be recommended for the management or prevention of TMD.
o Referral to an oral and maxillofacial surgeon recommended when conservative therapy is ineffective and in those with functional jaw limitations or unexplained persistent pain

53
Q

Temporomandibular Disorders: tx

A

o Non-pharmacological: Change head posture, sleeping positions, behaviors.
o First line treatment: Naproxen, 250-500 mg BID
o For muscle spasm, consider cyclobenzaprine (flexeril, amrix, fexmid) 5-10 mg at bedtime or metaxolone 800 mg TID (aka metaxall, skelaxin)
o Tricyclic antidepressant (TCA) such as nortriptyline or doxepin for chronic disease
o Complementary therapy - acupuncture
o Referral: Patient’s own dentist; oral and maxillofacial surgeon

54
Q

Common Viral Causes of Pharyngitis

A
  • Adenovirus
  • Rhinovirus
  • Covid
  • Cytomegalovirus (CMV)
  • Epstein-Barr virus (EBV)
  • Influenza viruses A & B
  • Parainfluenza virus
  • Herpes Simplex Virus (HSV)
  • Also: enteroviruses and respiratory syncytial virus (RSV)
55
Q

Pharyngitis: URI is a common cause, can be caused by group A strep

A
  • Patients often report sore throat; may be painful
  • The patient may also report other URI symptoms such as:
    o Nasal congestion
    o Cough
    o Fatigue
56
Q

Pharyngitis: exam

A

o Boggy turbinates with clear nasal discharge; soft palate with mild erythema; tonsils without exudate
o Well appearing with normal vital signs
o Neck may have mild tenderness; however unlikely to have adenopathy (swollen glands)

57
Q

Centor Criteria (used to rule out Group A Strep):

A

o For each of the following, 1 point is awarded:
* Tonsillar exudate
* Tender swollen anterior cervical nodes
* Absence of cough
* History of fever
o With Centor score 2 or less  pt unlikely to have GAS; in general, do not test or treat these patients
o If Centor score is 3 or 4 rapid strep test or RADT (Rapid antigen detection test).
o If negative, clinician may elect not to culture or treat. However, some positives may be missed with this approach

58
Q

Pharyngitis: red flags

A

o Secretions
o Drooling
o Dysphonia (difficulty speaking)
o “Hot potato” or muffled voice
o Neck swelling
o Difficulty breathing

59
Q
  • When to culture if rapid test is negative
A
  • Throat culture as backup when rapid is negative but suspicion of GAS is high in adults at high risk
    o Poorly controlled diabetes
    o HIV
    o Chronic corticosteroids
  • May also check CBC/diff
  • Also, where prevention is important; adults in contact with vulnerable persons – infants, immunocompromised persons, elderly
  • Endemic or epidemic rheumatic fever
60
Q

Infectious pharyngitis- history

A
  • Sudden onset sore throat
  • Fever
  • Malaise
  • Possibly cough
  • Headache
  • Myalgias (body aches)
  • Fatigue
  • And possibly . . .
    o Rhinitis
    o Conjunctivitis (adenovirus)
    o Congestion
    o Cough with sputum
  • **Absence of cough is suggestive of strep pharyngitis
61
Q

Group A Strep: s/s

A

o Fever, body aches
o Neck sore and tender; ++ adenopathy
o Oropharynx with exudate
o Body aches
o Absence of runny nose, cough
o You may also find:
* Palatal petechiae
* Scarlatiniform rash
* Strawberry tongue

62
Q

tx Group A strep

A

o Pen Vee K 500 mg BID or TID for 10 days
o Oral Amoxicillin 500 mg BID for 10 days, or 1000 mg immediate release daily for 10 days
o If allergic to penicillin, cephalosporin if mild; macrolide such as azithromycin, clarithromycin, erythromycin if severe; check your source for dosing
o Another option - Intramuscular benzathine penicillin G, one injection, for patients who might have difficulty completing 10 day oral course; e.g. homeless persons

63
Q

follow up Group A strep

A

o Should feel better in 48-72 hours; if not, return for further workup (possible incorrect diagnosis, or suppurative complication)
o In a few special cases, patients need test of cure
* Multiple family members with GAS (Group A strep)
* History of rheumatic fever
* Acute pharyngitis in the setting of acute rheumatic fever or glomerulonephritis

64
Q

Peritonsillar abscess or PTA: s/s

A
  • Pain and difficulty swallowing
  • Unilateral Ear pain
  • Fever and chills
  • Sick contacts
  • On exam:
    o Hot potato voice
    o Uvula deviates to one side
65
Q

Peritonsillar abscess or PTA: tx

A

o Urgent referral to Emergency Room, preferably by ambulance
o Surgical procedure, for example:
* needle aspiration (better tolerated)
* incision and drainage
* Tonsillectomy
o Single high dose IV steroid before antibiotics
o IV Antibiotic therapy
o Fluids
o Analgesia

66
Q

Peritonsillar abscess or PTA: Complications

A

o Airway obstruction
o Abscess rupture; infection to the neck muscle or deep spaces, and the mediastinum
o Internal jugular venous thrombosis with septic pulmonary embolism]
o Thrombophlebitis
o Chronic peritonsillar abscess
o Epiglottitis
o Septicemia
o Endocarditis
o Myocarditis

67
Q

Peritonsillar abscess or PTA: follow up

A

o If seen emergently and treated but not hospitalized, should be seen in f/up in the ED within 24-36 hours
o If hospitalized, should be seen within a few days of discharge
o Watch for warning signs. PTA can recur (listed in Buttaro; basically similar to onset sx)

68
Q

oral cancer

A
  • Review PMHx for risk factors including tobacco use, ETOH
  • In oral exam, watch for lesions such as leukoplakia or erythroplakia
  • Take any patient report of mouth symptoms seriously; examine and follow up
  • Ask patients to remove their dentures during annual exam

primary care midterm (12 decks)

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