Module 4 Buttarro Ch52-83 Flashcards
A provider performs an eye examination during a health maintenance visit and notes a difference of 0.5 mm in size between the patient’s pupils. What does this finding indicate?
a. A relative afferent pupillary defect
b. Indication of a difference in intraocular pressure
c. Likely underlying neurological abnormality
d. Probable benign, physiologic anisocoria
d. Probable benign, physiologic anisocoria
A difference in diameter of less than 1 mm is usually benign. Afferent pupillary defects are paradoxical dilations of pupils in response to light. This does not indicate differences in intraocular pressure. A difference of more than 1 mm is more likely to represent an underlying neurological abnormality
. A patient comes to clinic with diffuse erythema in one eye without pain or history of trauma. The examination reveals a deep red, confluent hemorrhage in the conjunctiva of that eye. What is the most likely treatment for this condition? a. Order lubricating drops or ointments.
b. Prescribe ophthalmic antibiotic drops.
c. Reassure the patient that this will resolve.
d. Refer to an ophthalmologist.
c. Reassure the patient that this will resolve.
Most subconjunctival hemorrhage, occurring with trauma or Valsalva maneuvers, will self-resolve and are benign. Lubricating drops are used for chemosis. Antibiotic eye drops are not indicated. Referral is not indicated.
During an eye examination, the provider notes a red-light reflex in one eye but not the other. What is the significance of this finding?
a. Normal physiologic variant
b. Ocular disease requiring referral
c. Potential infection in the “red” eye
d. Potential vision loss in one eye
b. Ocular disease requiring referral
The red reflex should be elicited in normal eyes. Any asymmetry or opacity (cataract) suggests ocular disease, potentially retinoblastoma, and should be evaluated immediately.
red reflex is used to screen for abnormalities of the back of the eye
A primary care provider may suspect cataract formation in a patient with which finding?
a. Asymmetric red reflex
b. Corneal opacification
c. Excessive tearing
d. Injection of conjunctiva
a. Asymmetric red reflex
Cataract is cloudiness of the lens. the function of the lens is to reflect light to the retina if lens is cloudy it cannot do this and will lead to blindness
Which are risk factors for development of cataracts? (Select all that apply.)
a. Advancing age
b. Cholesterol
c. Conjunctivitis
d. Smoking
e. Ultraviolet light
a. Advancing age
d. Smoking
e. Ultraviolet light
other factors include medication (corticosteroids)
DM, radiation
cataracts gradually will happen with age in all people the other factors will hasten the progress.
A patient has a gradually enlarging nodule on one upper eyelid and reports that the lesion is painful. On examination, the lesion appears warm and erythematous. The provider knows that this is likely to be which type of lesion?
a. Blepharitis
b. Chalazion
c. Hordeolum
d. Meibomian
b. Chalazion
Chalazion and Hordeolum are both gradually enlarging nodules on the eyelids the difference is that a Chalazion an is very painful and Hordeolum is not.
Both are treated with warm compresses and lid message
blepharitis is general eyelid swelling
can be caused by staph which will need antibiotics sx will be reddened with fine ulcerative at base of lid
seborrheic is greasy flaky do not need antibiotic ointment may topical steroid.
A patient reports using artificial tears for comfort because of burning and itching in both eyes but reports worsening symptoms. The provider notes redness and discharge along the eyelid margins with clear conjunctivae. What is the recommended treatment?
a. Antibiotic solution drops four times daily
b. Warm compresses, lid scrubs, and antibiotic ointment
c. Oral antibiotics given prophylactically for several months
d. Reassurance that this is a self-limiting condition
b. Warm compresses, lid scrubs, and antibiotic ointment
This patient has symptoms of blepharitis caused by staf most likely based on appearance without conjunctivitis. Initial treatment involves lid hygiene and antibiotic ointment may be applied after lid scrubs. Antibiotic solution is used if conjunctivitis is present.
Oral antibiotics are used for severe cases. This disorder is generally chronic.
conjunctivitis’s will have like yellow tears with crustiness and which case antibiotic solution is needed
A child has a localized nodule on one eyelid which is warm, tender, and erythematous. On examination, the provider notes clear conjunctivae and no discharge. What is the recommended treatment?
a. Referral to an ophthalmologist
b. Surgical incision and drainage
c. Systemic antibiotics
d. Warm compresses and massage of the lesion
d. Warm compresses and massage of the lesion
based on description it is most likely a chalazion which case warm compress and messaging the lesion is the treatment.
Chalazion and Hordeolum are both gradually enlarging nodules on the eyelids the difference is that a Chalazion an is very painful and Hordeolum is not.
A patient reports bilateral burning and itching eyes for several days. The provider notes a boggy appearance to the conjunctivae, along with clear, watery discharge. The patient’s eyelids are thickened and discolored. There are no other symptoms. Which type of conjunctivitis is most likely?
a. Allergic
b. Bacterial
c. Chemical
d. Viral
a. Allergic
Allergic conjunctivitis generally presents simultaneously in both eyes with itching as a
predominant feature. Discharge is generally clear or stringy and white and the patient will have lid discoloration, thickening, and erythema.
Bacterial conjunctivitis is characterized by acute inflammation of the conjunctivae along with purulent discharge and is worse than morning
Chemical conjunctivitis will not have purulent discharge.
Viral conjunctivitis is usually in association with a URI. Will have excessive watery discharge and clear bumps (follicles) when pull down lower lid. may have cervical lymph node swelling (50%).
A patient who has symptoms of a cold develops conjunctivitis. The provider notes erythema of one eye with profuse, watery discharge and enlarged anterior cervical lymph nodes, along with a fever. Which treatment is indicated?
a. Antihistamine-vasoconstrictor drops
b. Artificial tears and cool compresses
c. Topical antibiotic eye drops
d. Topical corticosteroid drops
b. Artificial tears and cool compresses
Viral conjunctivitis accompanies upper respiratory tract infections and is generally self-limited, lasting 5 to 14 days. also associated with excessive watery discharge and swollen anterior cervical lymph nodes. Symptomatic treatment is recommended.
Viral conjunctivitis accompanies upper respiratory tract infections and is generally self-limited, lasting 5 to 14 days. Symptomatic treatment is recommended
Treatment first with artificial tears an cool compress
2nd antihistamine vasoconstrictor drops no longer than 3-7 days!
A patient diagnosed with allergic conjunctivitis and prescribed a topical antihistamine-vasoconstrictor medication reports worsening symptoms. What is the provider’s next step in managing this patient’s symptoms?
a. Consider prescribing a topical mast cell stabilizer.
b. Determine the duration of treatment with this medication.
c. Prescribe a non-sedating oral antihistamine.
d. Refer the patient to an ophthalmologist for further care
b. Determine the duration of treatment with this medication.
Allergic Conjunctivitis presents reddened, itchy with clear stringy discharge.
treated first with artificial tears then
Antibiotic-vasoconstrictor agents which can have a rebound effect with worsening symptoms if IF USED LONGER THAN 3-7 DAYS so the provider should determine whether this is the cause.
Topical mast cell stabilizers are useful as prophylaxis for recurrent or persistent allergic conjunctivitis and results do not occur for several weeks.
Oral antihistamines may be the next step if it is determined that the cause of worsening symptoms is re
A patient who works in a furniture manufacturing shop reports a sudden onset of severe eye pain while sanding a piece of wood and now has copious tearing, redness, and light sensitivity in the affected eye. On examination, the conjunctiva appears injected, but no foreign body is visualized. What is the practitioner’s next step?
a. Administration of antibiotic eye drops
b. Application of topical fluorescein dye
c. Instillation of cycloplegic eye drops
d. Irrigation of the eye with normal saline
b. Application of topical fluorescein dye
sx of corneal abrasions; copious tearing, severe acute pain, foreign body sensation, photophobia, blurry vision, swollen eyelids
The practitioner must determine if there is a corneal abrasion ONLY WAY TO DIAGNOSE and will instill fluorescein dye in order to examine the cornea under a Wood’s lamp. Antibiotic eye drops are not indicated as initial treatment. IF LACERATON OR ULCER IN EYE THEN YES Cycloplegic drops are used occasionally for pain control but should be used with caution BECAUSE THE HAVE VASOCONSTRICTIVE Irrigation of the eye is indicated for chemical burns
Which patients should be referred immediately to an ophthalmologist after eye injury and initial treatment? (Select all that apply.)
a. A patient who was sprayed by lawn chemicals
b. A patient who works in a metal fabrication shop
c. A patient with a corneal abrasion
d. A patient with a full-thickness corneal laceration
e. A patient with irritation secondary to wood dust
a. A patient who was sprayed by lawn chemicals
b. A patient who works in a metal fabrication shop
d. A patient with a full-thickness corneal laceration
Patients with chemical eye injuries, any with possible metallic foreign bodies, and those with full-thickness corneal lacerations must have immediate referral. Corneal abrasions and irritation from wood dust may be managed by primary care providers.
most concerning complication is infection
Or if symptoms worsen sudden redness, sensitivity to light, decreased vision and/or pain.
A patient experiencing chronically dry eyes reports having a foreign body sensation, burning, and itching. A Schirmer test is abnormal. What is the suspected cause of this patient’s symptoms based on this test finding?
a. Aqueous deficiency
b. Corneal abrasion
c. Evaporative disorder
d. Poor eyelid closure
a. Aqueous deficiency
dry eye is caused by an abnormality of the tear film which is responsible for lubricating and protecting the eye
aqueous deficient is localized to the lacrimal gland either from disease or autoimmune
evaporated is caused by meibominangland disfunction or poor eyelid closing or blinking.
Schirmer test can help distinguish aqueous deficient dry eye from evaporative
An abnormal Schirmer test, which assesses aqueous production, indicates aqueous-deficient dry eye.
A corneal abrasion usually causes excessive tearing. An evaporative disorder is determined by an evaluation of tear breakup time test.
Poor eyelid closure causes increased corneal exposure and increased evaporation of tears.
A patient has evaporative dry eye syndrome with eyelid inflammation. What are some pharmacologic and nonpharmacologic measures the provider can recommend? (Select all that apply.)
a. Apply over-the-counter artificial tears as needed.
b. Avoid direct exposure to air conditioning
c. Topical steroid eye drops as a maintenance medication.
d. Use non-tearing baby shampoo to gently scrub the eyelids.
e. Use tetrahydrozoline drops for discomfort
a. Apply over-the-counter artificial tears as needed.
b. Avoid direct exposure to air conditioning
d. Use non-tearing baby shampoo to gently scrub the eyelids.
Patients with dry eye are encouraged to use OTC artificial tears to help moisten the eyes = FIRST LINE
Avoiding exposure to fans, air conditioning, and wind is recommended.
Non-tearing baby shampoo may be used to cleanse the lids in patients with eyelid inflammation. T
Topical steroid eye drops should be used sparingly and for short periods of time
do not use Tetrahydroline drops (visine) will make it worse
An adult patient with a history of recurrent sinusitis and allergic rhinitis reports chronic tearing in one eye, ocular discharge, and eyelid crusting. The provider suspects nasolacrimal duct obstruction. Which initial treatment will the provider recommend?
a. Antibiotic eye drops
b. Nasolacrimal duct probing
c. Systemic antibiotics
d. Warm compresses
d. Warm compresses
NasaLacriminal ductus obstruction can be caused by lacriminal, sinus or nose swelling which can cause obstruction/stasis of tear flow which increases risk of infection. (dacryocystitis, abscess
symptoms chronic tearing and ocular discharge with eyelid crusting
This is most likely acquired nasolacrimal duct obstruction. Initial treatment should include warm compresses.
Antibiotics are only used if infection is present.
- A patient is diagnosed with dacryocystitis. The provider notes a painful lacrimal sac abscess that appears to be coming to a head. Which treatment will be useful initially?
a. Eyelid scrubs with baby shampoo
b. Incision and drainage
c. Lacrimal bypass surgery
d. Topical antibiotic ointment
b. Incision and drainage
sign of infection
Which is the most common cause of orbital cellulitis in all age groups?
a. Bacteremic spread from remote infections
b. Inoculation from local trauma or bug bites
c. Local spread from the ethmoid sinus
d. Paranasal sinus inoculation
c. Local spread from the ethmoid sinus
Orbital cellulitis is infection of the eyeball that can lead to blindness. symptoms of orbital cellulitis include PAIN WITH EYE MOVEMENT, proptosis, lid swelling, restricted eye movement
may have decreased vision blurry vision. swelling goes beyond eye lid margin If there is any concern for orbital cellulitis must get CT.Most common organism is stag and strep and H. influenza (kids)
Because the membrane separating the ethmoid sinus from the orbit is literally paper-thin, this is the most common source of orbital infection in all age groups.
Bacteremic spread, inoculation from localized trauma, and paranasal sinus spread all may occur, but are less common.
A child’s optic assessment data include unilateral eyelid edema, warmth, and erythema but no pain with ocular movement is reported. Which characteristic is most likely true about this child’s infection?
a. Decreased visual acuity may occur.
b. Increased intraocular pressure will be present.
c. Optic nerve compromise is a complication.
d. The eye is typically spared without conjunctivitis.
d. The eye is typically spared without conjunctivitis.
This child has symptoms of preseptal cellulitis.
Preseptal cellulitis involves eyelid edema, warmth and reddness, typically follows URI. DOES NOT have pain with eyemovement. may or may not have fever. may have blurry vision. Most common organism is stag and strep and H. influenza (kids)
in which the eye is typically spared. The other findings are consistent with orbital cellulitis.
A patient is experiencing eyelid swelling with erythema and warmth and reports pain with eye movement. Which diagnostic tests will be performed to confirm a diagnosis of orbital cellulitis? (Select all that apply.)
a. Blood cultures
b. Complete blood count
c. CT scan of orbits
d. Lumbar puncture
b. Complete blood count
c. CT scan of orbits
CBC can help distinguish between preseptal and orbital. 75% of cases of orbital cellulitis will have increased WBC. CT will also confirm opitc nerve edema.
blood cultures used to determine bactermia
LP is only used if meningitis is suspected. They will have neck stiffness. why you need to do neck ROM in exam.
- A patient has an elevated, yellowish-white lesion adjacent to the cornea at the 3 o’clock position of the right eye. The provider notes pinkish inflammation with dilated blood vessels surrounding the lesion. What information will the provider provide the patient about this lesion?
a. Artificial tear drops are contraindicated.
b. Spontaneous bleeding is likely.
c. UVB eye protection is especially important.
d. Visine may be used for symptomatic relief.
c. UVB eye protection is especially important.
pinguecula and ptergium are slow growing benign lesions that can be heredity caused by: UV B, chronic conjunctivitis or viral infecitons
sx dry eyes, itching, foreign body sensation, can be seen by naked eye either in 3’oclock positon or 9’o clock position medial to nasal may become inflamed
pinguecula-elevated yellow-whitish lesions immediately adjacent to cornea. DOES NOT HAVE ABNORMAL VASCULAR DOES NOT BLEED but can become inflamed and have dilated blood vessels
Pterygium- horizontal lesion that arises from pinguecula and has a widened wing appearance CAN INVOLVE CORNEA which can affect CENTRAL VISION
This patient has a pinguecula which has become inflamed. Wide-brimmed hats and sunglasses with UVB protection should be advised since UVB light will make this worse. Artificial tear drops are recommended to reduce irritation. These types of lesions typically do not bleed spontaneously. Visine is contraindicated because chronic vasoconstriction may lead to rebound inflammation.
A patient experiencing an inflamed pterygia lesion has been prescribed loteprednol topical steroid drops for 7 days. The patient shows no improvement in symptoms. What is the next course of action?
a. Consult with an ophthalmologist.
b. Continue the medication for 7 more days.
c. Prescribe a systemic corticosteroid.
d. Refer the patient to the emergency department.
a. Consult with an ophthalmologist.
Topical steroid medications (Loteprednol, fluromethalone- low potency) are used to treat pterygia but should not be used longer than 7 days without ophthalmic consultation. Systemic corticosteroids are not indicated, and an emergent referral is not necessary.
pinguecula and ptergium are slow growing benign lesions that can be heredity caused by: UV B, chronic conjunctivitis or viral infecitons
sx dry eyes, itching, foreign body sensation, can be seen by naked eye either in 3’oclock positon or 9’o clock position medial to nasal may become inflamed
pinguecula-elevated yellow-whitish lesions immediately adjacent to cornea. DOES NOT HAVE ABNORMAL VASCULAR DOES NOT BLEED but can become inflamed and have dilated blood vessels
Pterygium- horizontal lesion that arises from pinguecula and has a widened wing appearance CAN INVOLVE CORNEA which can affect CENTRAL VISION
A child sustains an ocular injury in which a shard of glass from a bottle penetrated the eye wall. The emergency department provider notes that the shard has remained in the eye. Which term best describes this type of injury? a. Intraocular foreign body
b. Penetrating eye injury
c. Perforating eye injury
d. Ruptured globe injury
a. Intraocular foreign body
When a portion of the insulting object enters and remains in the eye, the injury is correctly referred to as an intraocular foreign body.
A penetrating injury occurs when something penetrates through the eye wall without an exit wound. A perforating injury occurs when the object has both an entry and an exit wound.
A ruptured globe injury occurs when blunt force causes the eye wall to rupture
closed injury is not as serious and not full thickness injury, lacerations and contusions
A patient experiences a penetrating injury to one eye caused by scissors. The provider notes a single laceration away from the iris that involves the anterior but not the posterior segment.
What is the prognosis for this injury?
a. Because the posterior segment is not involved, the prognosis is good.
b. Blindness is likely with this type of eye injury.
c. Massive hemorrhage and loss of intraocular contents is likely.
d. Retinal detachment is almost certain to occur
a. Because the posterior segment is not involved, the prognosis is good.
Mechanical energy imparted from sharp objects generally results in lacerations, with disruption that is more localized.
high velocity projection objects are more serious because the force can cause increased ocular pressure and cause GLOBE INJURY = VERY SERIOUS involves posterior portion of eye considered open injury can lead to retinal detachment, blindness or massive hemorrhage and permanent vision loss.
globe injuries can be subtle but may have irregular pupil shape- peaking pupil
** most important assessment of eye injuries is vision loss**
closed injury is not as serious and not full thickness injury
Which protective precaution is especially important in a metal fabrication workshop?
a. 2 mm polycarbonate safety glasses
b. Eyewash stations
c. Glasses with UVB protection
d. Polycarbonate goggles
d. Polycarbonate goggles
Polycarbonate goggles, which have better side protection, will protect from foreign bodies that can reach around other lenses and should be used in very high-risk activities, such as hammering metal on metal or grinding.
2 mm polycarbonate safety glasses are a minimum safety precaution.
Glasses with UVB protection are used in occupations where sunlight exposure is high. can prevent pingueculae an pterygium form occuring.
Eyewash stations are necessary where splash injuries or chemical exposures are possible.
A primary care provider notes painless, hard lesions on a patient’s external ears that expel a white crystalline substance when pressed. What diagnostic test is indicated?
a. Biopsy of the lesions
b. Endocrine studies
c. Rheumatoid factor
d. Uric acid chemical profile
d. Uric acid chemical profile
These lesions are consistent with gout and uric acid deposits. The provider should evaluate this by ordering a uric acid chemical profile. Biopsy is indicated for any small, crusted, ulcerated, or indurated lesion that does not heal. Rheumatoid nodules indicate a need for rheumatoid profiles. Endocrine studies are ordered for patients with calcification nodules.
During a routine physical examination, a provider notes a shiny, irregular, painless lesion on the top of one ear auricle and suspects skin cancer. What will the provider tell the patient about this lesion?
a. A biopsy should be performed.
b. Immediate surgery is recommended.
c. It is benign and will not need intervention.
d. This is most likely malignant.
a. A biopsy should be performed.
This lesion is characteristic of basal cell carcinoma, which is a slow-growing cancer least likely to metastasize. A biopsy should be performed to evaluate this. Immediate surgery is not necessary. Until a biopsy is performed, the provider cannot determine whether it is benign
.A child has recurrent impaction of cerumen in both ears and the parent asks what can be done to help prevent this. What suggestion will the provider provide?
a. Cleaning the outer ear and canal with a soft cloth
b. Removing cerumen with a cotton-tipped swab
c. Trying thermal-auricular therapy when needed
d. Using an oral irrigation tool to remove cerumen
a. Cleaning the outer ear and canal with a soft cloth
Parents should be instructed to use a soft cloth to clean the outer ear and canal only. Use of a
cotton-tipped swab or any other implement may push cerumen deeper into the canal and risk damaging the tympanic membrane. Thermal-auricular therapy is not recommended. Oral irrigation tools have high pressure and a risk of damage to the tympanic membrane.
A patient reports symptoms of otalgia and difficulty hearing from one ear. The provider performs an otoscopic exam and notes a dark brown mass in the lower portion of the external canal blocking the patient’s tympanic membrane. What is the initial action?
a. Ask the patient about previous problems with that ear.
b. Irrigate the canal with normal saline.
c. Prescribe a ceruminolytic agent for that ear.
d. Use a curette to attempt to dislodge the mass.
a. Ask the patient about previous problems with that ear.
Before attempting to remove impacted cerumen, the provider must determine whether the tympanic membrane (TM) is intact and should ask about pressure equalizing ear tubes, a history of ruptured TM, and previous ear surgeries. ** cerumen removal involves irrigation with solutions, want to make sure they have an intact TM*
Strategies for removal: cerumnolytic agents (debrox), hydrogen peroxide, baby oil or mineral oil
patients with very dry ears should not use hydrogen peroxide containing agents r/t drying
A provider is recommending a cerumenolytic for a patient who has chronic cerumen buildup. The provider notes that the patient has dry skin in the ear canal. Which preparation is US Food and Drug Administration (FDA) approved for this use?
a. Carbamide peroxide
b. Hydrogen peroxide
c. Liquid docusate sodium
d. Mineral oil
a. Carbamide peroxide
Any preparation with carbamide peroxide is FDA approved as a cerumenolytic. Patients with dry skin in the ear canal should not use any product containing hydrogen peroxide. Liquid docusate sodium and mineral oil are often used, but do not have specific FDA approval.
A young child has a pale, whitish discoloration behind the tympanic membrane. The provider notes no scarring on the tympanic membrane (TM) and no retraction of the pars flaccida. The parent states that the child has never had an ear infection. What do these findings most likely represent?
a. Chronic cholesteatoma
b. Congenital cholesteatoma
c. Primary acquired cholesteatoma
d. Secondary acquired cholesteatoma
b. Congenital cholesteatoma
Chelesteoma - abnormal collection of epithelial cells in the middle ear or mastoid that caused the formation of a benign tumor may be acquired or congenital. treated with antibiotics, surgery or removal of debris from canal
Congenital- pale, white discoloration behind intact TM
aquired cholesteotoma - shows pockets of debrin and retraction of pars flaccida, purulent drainage and granulation tissue
Patients without history of otitis media or perforation of the TM most likely have congenital cholesteatoma. Primary acquired cholesteatoma will include retraction of the pars flaccida. Secondary acquired cholesteatoma has findings associated with the underlying etiology.
MULTIPLE RESPONSE
A child is diagnosed as having a congenital cholesteatoma. What is included in management of this condition? (Select all that apply.)
a. Antibacterial treatment
b. Insertion of pressure equalizing tubes (PETs)
c. Irrigation of the ear canal
d. Removal of debris from the ear canal
e. Surgery to remove the lesion
a. Antibacterial treatment
d. Removal of debris from the ear canal
e. Surgery to remove the lesion
Cholesteatoma is treated with antibiotics, removal of debris from the ear canal, and possibly surgery. PETs and irrigation of the ear canal are not part of treatment for cholesteatoma
A child who has recurrent otitis media fails a hearing screen at school. The provider suspects which type of hearing loss in this child?
a. Central
b. Conductive
c. Mixed type
d. Sensorineural
b. Conductive
conductive hearing loss results from sounds waves not being able to be attenuated to middle ear structures as a result of things like cerumen, fluid, cholesteoma, infections
Central hearing loss is related to CNS disorders. Mixed-type hearing loss is related to causes of both conductive and sensorineural hearing loss.
Sensorineural hearing loss is caused by damage to the structures in the inner ear (chochlea) that decreasing electrical impulses from getting to the auditory nerve usually caused by infection, barotrauma, or trauma. noise trauma
A result of screening audiogram on a patient is abnormal. Which test may the primary provider perform next to further evaluate the cause of this finding?
a. Impedance audiometry
b. Pure tone audiogram
c. Speech reception test
d. Tympanogram
d. Tympanogram = a test of middle ear functioning
A screening tympanogram may be performed by a primary provider to determine tympanic membrane mobility and may help in identifying the presence of infection, fluid, or changes in middle ear pressure. The other tests are performed by audiologists, not primary care providers.
