leik HEENT Flashcards
herpes in the eyes
fluroescien dye shows fernlike lines on corneal surface,
crusty rash along CN 5 opthalmic branch or any where aroundthe eyes
ED referral
acute CLOSED angle glucoma case
elderly patient with acute onset severe eye pain accompanied by headache, NV, HALOS around lights,
decreased vision
acute CLOSED angle glucoma exam
oval mild dialated pupil, cornea is cloudy, CUPPING OF OPTIC NERVE ON FUNDOSCPOIC EXAM,
can be asymptomatic
emergency, refer to ED opto now
MS optic neuritis case
young female, new or intermittant vision loss in ONE eye
with NYSTAGMUS,
can have neuro symptoms-
daily fatigue that gets worse over the day
heat sensitivy and exacerbation of symptoms
recurrent episodes
send to neurologist
orbital cellulitis
acute onset erythematous swollen eye with proptosis (bulging eye) and pain LOOK FOR RECENT RHINOSINUSITUS OR URI lost full ROM of eye and has EOM more common in kids in young adults serious go to ED
retinal detachment
sudden onset, SHOWER OF FLOATERS, with LOOKING THROUGH CURTAIN sensation, sudden flashes of light, emergency go to ED
Cholesteatoma
cauiflower like growth with FOUL smelling discharge, hearing loss in affected ear, cant see tympanic membrane or ossicles cause tumor killed it
H/O chronic otitis media, not cancerous but can kill facial nerve CN 7, treat with ABX and surgical debridment,
refer to otolaryngologist
battle sign racoon eyes
periorbital ecchymosisand brusing behind the ears
2-3 days after trauma
clear or golden discharge from ear or nose first
R/O temporal or basilar boneskull fracture (urine dipstick, glucose + is CSF, plain mucous or mucopurlent is negative
go to ed, can cause intracranial hemmorhage
R/O temporal or basilar boneskull fracture (urine dipstick, glucose + is CSF, plain mucous or mucopurlent is negative
(urine dipstick, glucose + is CSF, plain mucous or mucopurlent is negative
peritonsillar abcess
odunophagia- pain on swallowing
SEVERE sore throat, HOT POTATO voice,
trismus-jaw muscle spasm making it difficult to open mouth
affected area is bulging red mass with uvula displaced away from the mass
malaise fever and chills
refer to ED
diptheria
BULL NECK- markedly swollen neck
sore throat
fever (low grade)
grey to yellow pseudomembrane on posterior pharynx, and soft palate
VERY CONTGEOUS- contact precautions, go to ED
eyes NORMAL
FUNDI veins are LARGER and darker than ARTERIES
CONES: for color
RODS for detecting light and shadow, night vision
Macula and FOVA- macula -central vision, fovea (holds lots of cones) in the middle determins sharpness of vision
presbyopia:
age realted visual change due to a decreased ability of the eye to accomadate stiffening of the lenses, starts at 40, near vision is affected with decreased ability to rea small print closely
Ears Normal
Bones- maleus, incus, stapes -smallest bone in body.
TM- appears translucent off whit to grey, with cone of light intact
Tympanogram, most effective method to test for fluid inside MIDDLE ear, in accute otitis media this wil show a STRAIGHT LINE vs a peaked shape
Pinna- large amount of cartilidge
cartilage dose not regenerate- refer injury to plastics
nose NORMAL
only inferior turbinates are visable
BLUE PALE or BOGGY are seenin allergic rhinitis
lower third of nose is cartilidge
SINUS NORMAL
Ethmoid
Maxillary both present at birth
Frontal - five years
Sphenoid- 12- at 12 they are all basically the size of an adults
MOUTH common issues 4
gingeval hyperplasia: white grey patch, on tongue, floor of mouth, or cheek- R/O oral cancer
Aphthous Stomatitis (canker sores):; painful shallow ulcers on soft tissue, usualy heal in 7-10 days, cause is unknown, tx with magic mouthwash
avulsed tooth: store in coo milk no ice, see dentist
vermillion border: on edgs of the lips,
tonsils
made of lymphoid tissue, butterfly shaped gland, with small pores that can secrete white exudate (MONO) or purulent exudate that is yellow green (STREP) penicillin Vk
posterior Pharynx
look for PNDL (acute sinusitis, allergic rhinitis) laying down supine makes postnasal drip cough worse,
evenly distributed posterior pharyngeal lymph nodes that are mildly enlarged can be allergies
benign variants tongue
tongue surface has a map like appearance, patches may move from day to day
can complain about sorness with acidic or spicy foods
Benign Variants torus plantis
fishtail uvula
physioligical gaze evoked nystagmus
painful bony protuberance midlin on the roof
uvula looks like fish tail
on extreme lateral vision but also watch out for brain lesions
papilledema
swollen optic disk with blurred edges sue to increased intracranial pressure ICP secondary to bleeding, brain tumor, abcess or pseudo tumor cerebri
hypertensive retinopathy
copper and silver wire aterioles caused by arteriosclerosis
arteriovenous nicking ( arteriole crosses the vein and dents it
retinal hemorrhages
diabetic retinopathy
microanurysms- new fragile arteries rupture
COTTON WOOL SPOTS- fluffy yellow white patches on the retina
Cataracts
opacity in lens of eye can be central(nuclear) or on he sides (cortical)
happens to 20% of older adults (65-74years) can happen at any time
sx include difficulty with glare (like headlights when driving at night) halos around lights, and blurred vision.
allergic rhinitis sx
blue tinged or pale and swollen (boggy) nasal turninates associated with increased cleard discharge
may have itchy nose and congestion
tx with antihistimines
koplik spots
clusters of small sized red papules with white centers inside the buccal mucosa by the lower molars
PATHOGNOMONIC for measles
treatment of measles
Medications. Fever reducers. You or your child may also take over-the-counter medications such as acetaminophen (Tylenol, others), ibuprofen (Advil, Children’s Motrin, others) or naproxen (Aleve) to help relieve the fever that accompanies measles. Don’t give aspirin to children or teenagers who have measles symptoms
nasal polops fun facts
painles soft round growth in the nose
increased risk of asa sensitivity
hairy leukoplakia
elongated papilla on the lateral aspects of the tongue that is related to HIV
caused by EPstien baar virus infection of the tongue
if on the cheek R/O ca
cheilosis (angualr, chelitis, perleche
painful skin fissures and maceration at the corners of the mouth from excessive moisture- more common in elderly with dentures, can be acute or chronic
check denture fit, determine cause, apply barrier cream with zinc or petroleum jelly at night- high rate of recurrene
secondary infection with candida albicans- yeast, tx with azole antifungal
secondary with bacteria staphylcoccus aureeus- C and S and then treat with mupirocin ointment bid
hyperopia
farsighted - distance vision is good, near is blurry
myopia
nearsighted - near vision intact but distance is blurry
snellen
central distance vision, if illiterate use tumbling E’s, pt stands 20 feet away
if pt wears glasses test vision with glasses in both then R OD, and L OS
abnormal is 2 line difference between each eye, less than four lettters out of six correct
legal blindness
defined as best corrected vision of 20/200 or tunnel vision or a visual field of less than 20 degrees
Weber and Rinne tests
normal -web no lateralization hears equally in both ears, AC is better than bone conduction
web sound is louder in “good ear” presbucusis or menieres disease ac is still more than bone conduction
web lateralization to bad ear, conductive loss, otitis media, ceruminosis, perfed membrain, BONE is better than Air
weber test
tuning fork midline on forhead
rinne
mastoid then at front, time each should hear longer in the front Air conduciton than on the bone
conductive hearing loss
outer and midde ear, like blockage Rinne BC is better than AC
sensorineural hearing loss
inner ear - aging damage, cn 8 acustic nerve, or ototox drugs, aminoglycosides, erythromycin,tetracyclines, high dose asa, dildenafil, and stroke usually permanently
rinne AC is greater than BC
contact lens abrasions are
round
if suspected Eye infection
C and S of drainage topical opthalmic ointment with pseudomonal coverage (gram negative) for contact users meaning cipro- froliquinolone ofloxacin same, do not patch eye-see agin in 24 hrs if no improvement go to ED
herpes kerititis
no steroids
hordeolum ‘stye”
abcess in eyelash follice/sebacious gland
“external hordeolum-upper or lower eyelid
interna hordeolum - meiobomian gland
hordeolum stye classic case
and tx
acute onset
swollen red one follicle on eyelid that slowly enlarges
may spont rupture purluent exudate or spread to adjoining tissue
tx hot compresses
systemic abx ifit spreads (erthromycin macrolide gram plus and minus,
or dicloxaillin - betal lactam, Gram-positive bacteria. It is active against beta-lactamase-producing organisms such as Staphylococcus aureus, which would otherwise be resistant to most penicillins.
refer to opto for I and D
chalazion definition
case
tx
chronic inflamation of meibomian gland, my resolve spontaneously in 2-8 weeks
gradual onset, small superficial node upper eyefels like a discrete bead, painless, can slowly enlarge, can cause blurred vision (rare)
Tx is I and D, or steroid injecitons by opto
pinguecula vs pterygium
chronic sun exposure leads to formation of yellow
pinguecula- raised yellow to white round growth inn the bulbar conjunctiva
pterygium triangular wedge shaped thickinging of the cornae, sometimes called surfers eye
can get red or inflamed, may have foreign body sensation
pinguecula vs pterygium tx
if inflamed refer to opto
weak steroids for excerbations
artificial tears PRN for agitation
surgical dc if it starts to affectthe vision.
subconjunctival hemorhage
blood in the eye from cough sneese heavy lifitng, burst vessle, resolves like a bruise over a few weeks, worse with anticoags
cc is brigh red blood ineye after cough, no pain or visual loss
t is watchful waiting and f/u on resoution.
primary open angle glaucoma def
gradual onset of increased IOP greater than 22 due to blockage of drainage of aqueous huomor in the eye
the retina CN 2, undergoes ischemic changes and can be permenantly damaged, most common type of guac 60-70%
primary open angle glaucoma classic case
AA or Cauc elderly pt with DM, asymptomatic early then PERIPHERAL vision loss first, missing portions when reading, if fundoscope exam shows cupping IOP is too high, refer to opthalmologist
primary open angle glaucoma treatment plan
IOP with tonometer-8-21 is normal
if 30 or more urgent referal to ED or opto
primary open angle glaucoma meds
betimol- timolol : BB for eyes,, dec aqueous production
latanoprost xalatan: topical prostaglandin eye drops to promote aqueos outflow
BB same side effects bronchospasm depression fatigue heart failure brady
contraindicted in asthmatic, emphysema, copd and 2-3 heart block
primary closed angle glaucoma def
SUDDEN block of aqueous humor, marked increase in IOP, ischemia and permanaet damage to retina CN 2 causing vision loss
primary closed angle glaucoma
CC: old pt sudden decrease or blurred vision, SEVERE pain in EYE, frontal headace, Nausea and vomiting
Eyes are mid dialated, cloudy pupil 4-6mm, more OVAL than ROUND, slow reaction to light,
send to ED
Iritis- anterior uvitis from autoimmune disorders
red eyes no purluent drainage, though its serious and can lead to blindness, refer to opto
sarcoidosis classic
Common Signs and Symptoms Associated With Sarcoidosis
A common presentation is with the Lofgren syndrome (fever, bihilar lymphadenopathy [BHL], ankle swelling, and erythema nodosum [EN]). … A hallmark but relatively rare presentation of sarcoidosis is uveoparotid fever, also termed the Heerdfordt syndrome.
Erythema nodosum is a type of skin inflammation that is located in a part of the fatty layer of skin. Erythema nodosum results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees.Nov 5, 2019
Symptoms: Inflammation
AMD
asymptomatic early
gradual damage too pigment of macula (area for central vision)
LEADING CAUSE OF BLINDNESS IN THE ELDERLY
more common in smokers
AMD types
atrophc dry- 85-90% less severe,
exudative wet- 15%- responsible for 80% of AMD blindness choroidal neovascularization
AMD classic case and treatment
elderly smoker, sudden or painless loss of central vision, in one or both eyes, straight lines like doors or windows are curved, peripehral vision usually ok
tx is opto referral
AMSLER grid- focus eye on center and view 12 inches from eye to check visual field loss (blurry, dots,
may include ocular vitamins as directed by opto-lutein, zinc and zeaxthanin
Sjrogens syndrome def
chronic autoimmune- deceased frunciton of lacrimal and salivary gland, can occur alone or with other autoimmune like RA
sjrogens CC
dry eyes and xerostomia (dry mouth) for longer than THREE MONTHS, chronic dry eyes sandy gritty sensation (KERACONJUNCTIVA SICCA) have used otc drops more than three times a day, marked increase in dental caries, swollen and inflamed salivary glands
refer to opto-dentist and rheum
blepharitis def and tx
chronic condition caused by eyelid inflamation, assocatied with sebrorric dermatitis and roseca, may have staph bacteria colonizzatin, itchy red crusty gritty eyes.
tx is johnsons baby shampoo or perhaps erythromycin macrolide gram pos and neg eye ointment
allergic rhinitis def, cc,
10-30% of adults, associated with allergies, chronic or seasonal congestoin with CLEAR MUCUS or pND worse on supine, clicking sound to clear mucus, BLUE OR PALE TURBINATES,
posterior oharynx has mucus that is thick, can be white yellow or green(R/O) sinusitis- cobbestone posterior pharynch from lymph nodes
allergic rhinitis tx
first: topical nasal sprays
topical nasal sprays discontinuation
use for more than three days and rebound sever nasal congestion rhinitis medicamentosa - severe congestion
nosebleed
anterior more commmon than posterior, most are self limiting
kisselbachs plexus anterior vascular area-
posterior can be severe- asa, nsaids, coke, htn
nosebleed cc
acute onset nasal bleed second to trauma, driect pressure to front of nose, affrin to shrink tissue, tripple abx or petrollium jelly for 3 days post.
posterior might need to go to ed
streptococcal pharyngitis/tonsilloparyngitis (strep throat) def and cc
strep bacteria (streptococcus pyrogenes) Gram-positive, nonmotile, nonsporeforming coccus that occurs in chains or in pairs of
most common pathogen is VIRAL (rhinovirus, adenovirus, RSV,
suspect virus if cough and sx like clear watery sputem, stuffy nose, watery eyes (coryza)
mostly childern- abrupt onset fever, sore throat pain on swallow, mildly large submandibular nodes, can have purulent exudate on tonsils, anterior cervical nodes can be big too,
centro critera: tonsillar exudate, tender anterior cervical nodes, fever, abscence of cough
streptococcal pharyngitis/tonsilloparyngitis (strep throat) treatment plan
rapid antigen detecting test RADT-
penicillin VK 500bid x10 days
or ammox
zpack for pcn allergy
repeat RADT post treatment for proof of cure
especialy for heart valve pts
streptococcal pharyngitis/tonsilloparyngitis (strep throat) complications
scarlet fever scarletina- sandpaper textured pink rash, straberry tongue, spreads from head to trunk then out thn skinn falls off, increased risk of rheumatic fever
rheumatic fever heart joints and brain
peritonsillar abces, displaced uvula, red bulging mass on anterior phartyngeal space, dysphagia and fever emergency to ed
poststreptococcal glomurlonephritis protien, hematuria, dark uring with casts, htn and edema
AOM
usually kids
outflow of eustaciean tubs blocked
usually unilateral
most have middle ear effusion
AOm in adults orginisms
S Pneumoniae 40% Streptococcus pneumoniae cells are Gram-positive with high rates of beta lactam resistance
haemophilus influenzae 50% gram neg
moraxella catarrhalis 20 gram neg
aom cc
otalgia ear pian, popping noise, muffled hearing, recent cold or allergic rintis , afebrile or low grade fever, adult infections are slower, PUS on pillow case from ruptured TM associated with reliefe of ear pain
bullous myringitis
type of AOM more painful due to presence of blisters, on red and bulging TM, conductive hearing loss webber fork on head and sound laterlizes to bad or affected ear indicated conductive hearing loss, rine test behind and in front of ear shows bone conduction is greater than air conduction
same bacteria as AOM
TM is bulging with displaced light reflex may look opaque
flat line tracing on tympanogram is most objective finding
AOM tx
amoxicillin Showing results for amoxicillin class Search instead for ammoxicillin class if no abx in the prior month,
Amoxicillin is in a class of medications called penicillin-like antibiotics- Amoxicillin covers a wide variety of gram-positive bacteria, with some added gram-negative coverage compared to penicillin.
if no response in two days switch to second line augumentin (PCN) Amoxicillin is a semisynthetic antibiotic with a broad spectrum of bactericidal activity against many gram-positive and gram-negative microorganisms. … Thus, AUGMENTIN possesses the distinctive properties of a broad-spectrum antibiotic and a β-lactamase inhibitor
cephalosprin and or floriquinolone for gram plus inus coverage
MEE after aom
can last for 8 weeks
ARBS acute bacterial rinosinutis def
max and frontal sinus most common, if frontal pain is over frontal sinus, may report hyposomia- reduced smell, fluid gets trapped in sinus causing secondary bacterial infection
s. pneumonea gram positive
H. influenzae gram negative
or viral
ARBS acute bacterial rinosinutis cc
unlateral face pain, or molar pain (mailary sinus) nasal congestion over 10 days, purulent drip, no symptom releife with self tx, recent bad cold or rinitis flare
ARBS acute bacterial rinosinutis findings pearls
post pharynx: dark yellow or green PND
tender sinus on palpation
fever more in children
transillumination ofsinus, (front and MX) positive = duller glow of light on affected sinus compared with normal sinus
ARBS acute bacterial rinosinutis tx
symptomatic: mild- uncomplicatd and healthy f/u in 10 days high rate of spontaneous resolution
toxic, high fever, pain purulent pND, for 2-3 days or more or sx for 10 days use abx
1st augmentin-
pcn allergy- levofloxacin floriquinolone
ARBS acute bacterial rinosinutis symptom tx
no systemic steroids
decongest and promote drainage
if abx fails try another, if it keeps failing refer to otolaryngologist
ARBS acute bacterial rinosinutis symptom need for emergent ed referral
mastoiditis- red swollen behind the ear
orbital cellulitis- double or imparied vision, and fever, abnormal EOM
meningitis- brudzinski does sit ups, kernigs does kicks
cavernous sinus thrombosis- acute ha and change in neuro exam, life theratining and hihg mortality
OM with effusion aka serous otitis media def and cc
sterile serous fluid in middle ear, TM NOT RED,
tx with oral decongestants, steroid nasal spray or zyrtc for allergic rhinitis
otitis externa def and cc
bacterial infection of skin of external ear, rarely fungal, more common in summer, Pseudomonas aeruginosa gram negative or staph areus gram positive
cc is swimmer ear pain swelling discharge, pruts, heairng loss,
EAR PAIN WITH MANIPULATION OF TRAGUS, purulent green dischagre, red tender swollen ear canal
otitis externa tx
polymixin B and neomycin hydrocorticsone- cortisporin - for 7 days or cipro
keep dry- propholayx iwth otic domeboro or alcohol and vinegar.
infectious mononucleosis
EBV herpesvirs family, peak is between 15-24 years, after acute infection EBV is latent in oropharyngeal tissue but can reactivate
virsu shed thru saliva
TRIAD IS
fever
pharyngitis
lymphadenopathy
mono cc
smooching teen, sore throat and posterior servical node enlargment for a few weeks, fatigue, may be ab pain hepato or splenomegaly,
mono labs
cbc- lymphocytosis over 50%
LFT’s abnomal ALT. 7 to 55 units per liter (U/L)
AST. 8 to 48 U/L.
Bilirubin. 0.1 to 1.2 milligrams per deciliter
off white color tonsils sometimes
occasionally generalized red maculopapular rash
mono acute tx
limit activity-for 4 weeks
ab us for splenomegaly/hepatomegaly
repeat in 4 weeks abnormal initially to document resolution
treat symptoms (virus)
avoid AMOXICILLIN if pt has ‘strep throat as well” 70% get drug rash, no smoocing
mono complication s
spleen rupture
airway obstruction
GB, aseptic meningitis, optic nuritis,
blood ddyscrasias particularrly lymphocytes
diff on cbc values
Neutrophils: 6300 40-60% Lymphocytes: 4100 20-40% Monocytes: 1800 4-8% Eosinophils: 250 1-3% Basophils: 60 0-1% Bands 0 0-5%
