HEENT/Resp Flashcards
All of the following are age-related changes of the auditory system EXCEPT:
A) Cochlear hair cells in organ of Corti degenerate
B) Neurons innervating the cochlear and auditory centers in brain are lost
C) Degeneration, stiffening and calcification of basiliar membrane of cochlea
D) Increased vascularity of cochlea, capillaries of stria vascularis thicken
E) Degeneration of ossicular joints
C) Decreased vascularity of cochlea, capillaries of the stria vascularis (source of endolymph) thicken
Which of following are possible age-related changes of the auditory system: (multiple answers)
A) Inability to hear high-frequency sounds
B) Inability to hear low-frequency sounds
C) Inability to disseminate localization of sound
D) Increased risk of cerumen impaction
A) Inability to hear high-frequency sounds
C) Inability to disseminate localization of sound
D) Increased risk of cerumen impaction
True/False
Hearing loss is an inevitable consequence of aging
False
Most common cause of age-related hearing loss in older adult
Presbycusis
Describe characteristics of presbycusis (ie. laterality, SNHL, CHL, onset, frequency affected)
Insidious onset, symmetrical SNHL affecting high frequency tones
Which of the following are risk factors for hearing loss: A) older age B) Male sex C) Dark complexion D) Education level E) Exposure F) Medications
ALL except C)
Which exam that can be conducted in any primary care office has high specificity and sensitivity for hearing loss?
Whisper test
At age __, all people should have routine hearing tests every ___ years
60 years old
every 2 years
List common medications/classes that are ototoxic. Hint:
Don’t Loop and Snag My Plate Christine Quinn
Loop Diuretics Salicylate NSAIDs Antibiotics Amino-glycosides VancoMYcin Plate - cisplatin, carboplatin Cristine - vincristine Quin - Quinine
True/False
Antidepressants can cause tinnitus
True
What medications have reversible ototoxicity when stopped?
NSAIDs
Loop diuretics
Antimalarials (usually)
What is the gold standard exam to diagnose cataracts?
Slit lamp
Name that condition: Decreased visual acuity - blurry/foggy Sensitivity to light/glare Decreased color perception Decreased night vision/halos
Cataracts
Leading cause of blindness in the world
Cataracts
List 3 risk factors for cataracts
DM Long-term use steroids Prior intra-ocular surgery Myopia Age Family hx Smoking HTN
3 types of cataracts
Nuclear
Cortical
Posterior subscapular
Name that condition:
Most common type of cataract that develops over years
Nuclear sclerotic cataracts
Type of cataracts that is highest risk in DM
Cortical Cataracts
Type of cataracts that you are at risk for if you have DM or extreme nearsightedness or use steroids
Posterior subscapular cataracts
Cataract that develops quickly over months, NOT years
Posterior subscapular cataracts
Type of cataracts where you first notice your night vision changing and difficulty reading
Posterior Subcapsular Cataracts
True/False
Age related macular degeneration is reversible
False
Which of the following are risk factors for AMD?
- HTN
- DM
- Smoking
- ETOH
- Family Hx
- Male sex
- Age >65
- European descent
HTN Smoking Diabetes Family History of AMD Age >60 European decent Female sex
What home monitoring tool can be used for macular degeneration?
Amsler grid
Leading cause of irreversible vision loss
AMD
Two forms of AMD
Atropic/dry
Neovascular/wet
Type of AMD that is slow to progress, limited night vision and difficulty reading
Atropic/Dry/Non-exudative
characterized by large drusen and pigmentary abnormalities in the macula
early stage of dry age-related macular degeneration
What type of vision loss?
AMD - Center vision may appear blurry because parts of the macula have begun to die, leaving blank spots in vision. Straight lines may look wavy. Side or “peripheral” vision is rarely affected.
Mgmt of dry macular degeneration
BP control
Smoking cessation
Daily eye vitamins (C, E, letin, zinc, etc.)
All these medications have in common is:
sedatives, antipsychotics, antianginal agents, antidepressants, antihistamines, antihypertensives, antiparkinsonian agents, diuretics, anticholinergics
SE of Xerostoma
____ inhibits demineralization of the tooth surface and enhances remineralization
Saliva
What components are included in history of xerostoma?
Xerostoma Inventory questionnaire
Med -
PMHx - infections, diabetes, Alzheimer’s disease, RA, HTN, Bell’s Palsy, depression and anxiety, sjogrens, chemo, irradiation of head/neck
Surgical Hx -
Most common opportunisitc infection with xerostoma
oral candidiasis
Tx for xerostoma
First line:
Mechanical - lozenges
Chemical - artificial saliva (ex. biotene)
Dental care
Second line:
Antimuscarinics
rise in intraocular pressure (IOP) that causes damage to the optic nerve
Glaucoma
Normal IOP between ___ and ___ mm Hg.
IOP is typically between 10-21mmHg
True/False
Initial diagnosis and treatment of glaucoma is done by NPs
False
Patient presents with the following symptoms. What do you suspect and what is your next step?
41 year old with: Aching eye and brow pain Deep dull, periocular headache Reduced visual acuity Eye redness Corneal edema Fixed dilated pupil
primary closed angle glaucoma
Referral to ophthalmologist for tonometry
Note: Fixed dilated pupil. Iris ischemia may cause the pupil to remain permanently fixed and dilated.
the IOP rises rapidly as a result of relatively sudden blockage of the trabecular meshwork by the iris via papillary block mechanism
Angle-closure glaucoma (ACG)
First line treatment of POAG
Prostaglandin analogues that increase uveoscleral outflow.
Ex. Latanoprost, Bimatoprost
Laser iridotomy is required for definitive treatment of what condition?
Closed-angle glaucoma
Open-angle glaucome with eye pressure within normal range.
Normal-Tension Glaucoma
Black and white dots on the tympanic membrane
Fungal infection
T/F- Tinnitus is a ringing, crackling, or buzzing sound that comes from within a person
True
T/F- Normal age related changes to ears include pendulous earlobes due to the loss of elasticity, and a more weight, doll, opaque Tympanic membrane
True
Ulcerated crusting Lesions on the pinna, that bleed, are slow to heal, have indurated base ——?
Think- carcinoma!
A 70-year-old patient complains of hearing that is getting worse, sounds are garbled and difficult to locate. What’s your response?
Normal age to changes in hearing – presbycusis
What cranial nerve transmits nerve impulses from the organ of Corti to the brain
VIII- Vestibulocochlear
Spinning sensations are due to what ear structure
Labyrinth
A form of hearing loss when sounds cause pain as volume increases
Recruitment
Movement of the extraocular muscles is controlled by what cranial nerves
III, IV, VI
Oculomotor, trochlear, abducens
The outer layer of the eye is made up of what structures?
Cornea and the sclera, sensitive to touch
Structures in the middle layer of the eye-
Inner layer lf the eye-
Middle- choroid
Inner- retina
Stimulation of the sympathetic branch of the autonomic nervous system does what to a pts eye?
Elevates the eye lid and dilates the pupil
Parasympathetic nervous system stimulation does what to the pupil?
Constricts pupil
The ciliary body controls what
Thickness of the lens
Intraocular pressure is determined by what
The balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber
Does accommodation cause-
pupillary constriction when looking at a near object, or
pupillary dilation when looking at a far object?
Constriction- near
Muscles in iris contract pupil in bright light and accomodate for near vision
What physiological changes responsible for presbyopia
The lens loses its elasticity and decreases its ability to change shape to accommodate for near vision
What causes floaters?
Condensed vitreous fibers, often insignificant
Snellen eye chart result is 20\30, what does that mean?
The patient reads at 20 feet what someone with normal vision can read at 30 ft
Normal findings of the diagnostics positions test?
Parallel tracking of the object with those eyes
T/F- In older adults pupils are small, pupillary light reflex is slowed, pupillary constriction is symmetric.
True- pupillary assymetry is not normal in older age!
What is Anisocoria?
Unequal pupils size
Person has shadows are diminished vision in one quadrant or 1/2 of the visual field
Retinal detachment
Differentiate hordeolum , chalazion, dacryocystitis, blepharitis
Hordeolum - painful, red, lid margin
chalazion- nontender, firm , nodule on eyelid
Dacryocystitis- lacrimal sac inflammation
Blepharitis- inflammation of the eyelids
Common presentation of macular degeneration
Lots of central vision but preserved peripheral vision, most common cause of blindness
Most common type of glaucoma, involves a gradual loss of peripheral vision
Chronic open-angle glaucoma
Older adults with tears rolling down face from left eye, lower lid is loose and rolling outward, complaints of dry and itchy Eye=
Ectropion
Normal ageing results in the progressive loss of elastic recoil of the lung parenchyma and conducting airways.
This results in reduced vital capacity + increased residual volume- and what breathing pattern?
Shallow breathing
Theophyline levels are at risk of toxic levels with what behaviour?
Smoking
Early signs of a respiratory problem in older adult
Change in mental status ie. increased irritability
Why should the patient with peripheral arterial disease not use nicotine in any forms
Cause vasoconstriction
T/F- Carbohydrates should not make up more than 50% of the daily intake of calories in pts sith COPD- because they break down into carbon dioxide, worsening breathing
True
Heparin infusion per treatment of pulmonary embolism serves what purpose?
Prevents clot from getting bigger
Asthma can be exacerbated by what 2 medication classes
Beta blockers, NSAIDS
All of the following are examples of what? Aspiration Atelectasis Bronchiectasis MG Pulmonary fibrosis Pulmonary effusion
Restrictive lung diseases
Diagnostic test results for COPD
Spirometry FEV1/FVC < 70%
Diagnostic test results asthma
Spirometry - reversible airflow, 12% or greater improvement in FEV1 or FEV1 > 200 ml from baseline after bronchodilator
OR
+ methylcholine test
What does bibasilar crackles and finger clubbing indicate?
Pulmonary fibrosis
Diagnostic test results for Pulmonary Fibrosis
PFT - decreased FVC, normal FEV1/FVC ratio
CXR
High resolution CT
Bronchoscopy/lung biopsy if unable to diagnose by other means
CT can be used for screening for people at low risk of lung cancer. T/F?
False
What are high risk criteria for lung cancer?
Age -
Social -
Age 55-74
30 pack year history of smoking
Smoking within last 15 years
< 55 year old lose hearing @ ____ dB/decade
3
> 55 lose hearing at ___ dB/decade
9
According to Laurie Barnhart, what do all of the following medications have in common?
Aminoglycosides Gentamicin or Tobramycin.
Other antibiotics: erythromycin and tetracycline - more pronounced with renal impairment
Many chemotherapy drugs - notably cisplatin
Phosphodiesterase 5 inhibitors – limited evidence
High dose aspirin/salicylates - reversible upon cessation of drug
High dose NSAIDs (reversible)
Loop diuretics (reversible)
Antimalarial drugs: quinine and chloroquine (usually reversible)
Antidepressants - tinnitus
meds that were not ototoxic, but could cause irritating symptoms such as tinnitus.
Visual acuity and visual feild changes should be assessed how often after the age of 80 for driving?
Q 2 years
Eye exams are covered if < ___ years old or > ___ years old
< 18 or >65
Leading cause of severe vision loss in > 50 year old people
Age related macular degeneration
What is the most common type of glaucoma?
Primary open angle glaucoma
all of the following are risk factors for what condition: > 40 years 0.5 cup to disc ratio or larger African heritage \+ family history diseases affecting vasculature (ie. DM)
Primary open angle glaucoma
Lung diseases that prevent exhalation of air effectively
Obstructive
Lung diseases that prevent lungs from expanding fully
Restrictive
If CT + for lung cancer, what is your next step
Referral for management and biopsy
chest x-ray can be used screen for lung cancer, with or without sputum cytology. T/F?
False
What are the determined ages for asymptomatic screening for lung cancer and risk factors? What test is ordered? How many times can it be repeated?
55-74 years
RF - 30 pack year history or quit within last 15 years
Order CT with contrast
Can be repeated 3 times (CTF)
All of the following are risk factors for what? age >/= 70 smoking exposure (occupational or other) fhx radiation
Lung cancer
hyperopia
farsightedness
myopia
nearsightedness
presbyopia
increased age causes changes in lens curvature, decrease in elasticity of lens and decrease in strength of ciliary muscle
Impaired accommodation/focussing on near objects
Mneumonic to remember congenital cataracts causes
Toxoplasma Other (syphillis) Rubelle Cytomegalovirus Herpes
S&S of acute angle closure glaucoma
Sudden onset Painful Red eye Vision blurriness Dilated non-reactive pupil Seeing haloes frontal headache nausea/vomiting EMERGENCY!!
T/F
All alpha agonists are contraindicated in closed angle glaucoma.
True
Leukocoria
sign of congenital cataracts, white red reflex
Characterized by yellowish extracellular deposits of waste materials, known as “drusen”
Dry macular degeneration
Characterized by metamorphopsia (stright objects appear curved) or scotomas
dry macular degeneration
Rapid central vision loss over few weeks of months
Wet Age-related macular degeneration
Characterized by AV nicking, flame shaped retinal hemmorhages and macular stars in addition to cotton wool spots and microanyeruisms on fundoscopy
hypertensive retinopathy
Is your vision blurry or foggy?
Do you have decreased night vision or see halos around lights?
Do colours appear dull or muted?
Are your glasses no longer working?
Does sunlight or other light seem overly bright or glaring?
What would you be suspecting with the following questions?
Cataracts
Type of cataracts that is most common in diabetics
Cortical cataracts
most common type of cataract
Nuclear
Type of cataracts that people with DM, extreme nearsightedness or use of steroids are at higher risk for
Posterior subcapsular cataracts
* Develops over months NOT years
True/False
Age-related macular degeneration is reversible with some therapies
False, there is no reversibility of this condition.
CI to dix hallpike
Absolute contraindications:
cervical instability
vascular problems like vertebrobasilar insufficiency
carotid sinus syncope
acute neck trauma
cervical disc prolapse
What type of hearing loss is present with menieres disease?
low frequency SNHL
All of the followig conditions are considered risk factors for what oral condition:
infections, diabetes, Alzheimer’s disease, RA, HTN, Bell’s Palsy, depression and anxiety
Xerostomia
Medications which commonly have a side effect of xerostomia
sedatives, antipsychotics, antianginal agents, antidepressants, antihistamines, antihypertensives, antiparkinsonian agents, diuretics, anticholinergics
ICS must always be used with _____ in COPD and is NEVER used as monotherapy
LABA
Factors to consider when starting ICS for COPD
Hospitalizations
Exacerbations
Eosinophil level
Hx of concurrent asthma
Strong support for ICS in COPD
> /= 1 hospitalization
/= 2 moderate exacerbations/ year
Eosinophil level >/= 300
Hx of asthma
What COPD Group requires LAMA in monotherapy
Group C
If CAT > 20 and >/= 1 hospitalization or >/= 2 exacerbations, what medicaiton to add
LABA
What two screening tools are used to determine symptoms for COPD initial treatment
mMRC
CAT
mMRC and CAT scores for group A & C
mMRC 0-1
CAT < 10
mMRC and CAT scores for group B&D
mMRC >/=2, CAT >10
What medication for COPD for EXACERBATIONS is indicated if eos <100 and not controlled with LAMA+ LABA
Roflumilast, FEV1 < 50% or chronic bronchitis
OR
Azithromycin for chronic smokers
Secondary Glaucoma causes:
Idopathic Uveitis Trauma Keratoplasty or surgery Pseudoexfoliation occurs when deposits of unknown origin and composition are seen on the lens surface
Uncomplicated corneal abraision treatment
Polymyxin B sulfate drops or erythromycin ophthalmic ointment 0.5% QID for 3-5 days.
When to reassess corneal abraisions
24 hours
Treatment of corneal abraision for contact wearer
ciprofloxacin 0.3%, gentamycin 0.3%, or tobramycin ointment or drops.
When to refer to opthamology for corneal abrasision
if symptoms persist > 48 hours
*Immediate referral to an ophthalmologist is required for large or central lesions, deep or penetrating wounds, open globe, or hyphema
The acronym RULE and what it is used for
Can help with lesions that at greater than 3 weeks in duration to determine if should be biopsied
●Red or red and white lesion
●Ulcer
●Lump
●Especially when in combination or if indurated (firm on palpation)
Name that condition
Pre-malignant leukoplakia
Ranges from slightly raises, white translucent areas to dense, white opaque plaques
Benign condition but may develop into oral cancer
Erythroplakia/ premalignant
Fiery red, sharp, demarcated patch, non-blanchable
Floor of mouth ventral tongue, or soft palate
High risk of malignant transformation
Oral Lichen Planus
Variable presentation: lacelike on the buccal mucosa to erosions on the gingival margin, tongue or mucosa
Potentially malignant condition
Where are melanomas commonly found in the mouth?
hard palate
Canadian cancer society recommends adults >40 are screened ______ for oral lesions
annually
Outline component of CURB 65
How to interpret CURB 65
Treatment based on CURB 65
True/False Bronchoalveolar lavage (BAL) fluids in healthy older subjects have consistently shown an increased proportion of neutrophils and lower percentage of macrophages compared with younger adults.
True
RF for narrow angle (closed)
female
Asian
hyperopia
RF for wide angle glaucoma (open)
male
african
myopia
