Ophtho/Environmental

Question 1

A patient comes in with pain, foreign body sensation, photophobia, tearing. They note relief of pain with topic anesthetics. What’s the dx, how would you dx, and tx?

Answer 1

Corneal abrasion

Slit lamp exam w/ flourescin stain: ““ice rink”” or linear abrasians

Question 2

+ seidel test

Answer 2

corneal laceration

Question 3

To dx this:
Tonometry: increased IOP
Fundoscopy :optic blurring or cloudy “steamy” cornea”

Answer 3

Acute angle-closure glaucoma

Question 4

Progressive, painful vision loss over hours to days
Loss of color vision (desaturation)
Deep ocular pain worse with movement, often relieved at rest
Afferent pupillary defect, papilledema, ↓ visual acuity, normal IOP, red desaturation test (red dot appears lighter)
Often unilateral

Answer 4

Optic neuritis

Question 5

Marcus-Gunn Pupil (relative afferent pupillary defect): swinging flashlight test from unaffected to affected eye = pupils appear to dialte

Tx?

Answer 5

optic neuritis

IV methylpredinsolone

Question 6

What must you not do with a global rupture?

Answer 6

Don’t measure IOP

Instead:
"Emergent ophtho consult = OR
-Eye shield, elevate HOB
-IV abx (ceftazidime, gentamycin, vancomycin)
-Tetanus prophylaxis
-Analgesia, antiemetics, NPO"

Question 7

“-Sudden, profound, painless, monocular vision loss & APD

-Often preceding episodes of amaurosis fugax”

Answer 7

Central retinal artery occlusion

Question 8

-Fundoscopy: Pale retina with “cherry red” macula showing retinal ischemia

Answer 8

Central retinal artery occlusion

Question 9

Fundoscopy: “Blood-and-thunder fundus” showing extensive retinal hemorrhage

Answer 9

Central retinal venous occlusion

Question 10

“-Photopsa (flashing lights) followed by floaters, visual field cuts, +/- reduced visual acuity
-Progressive unilateral peripheral vision loss ““curtain coming down”””

Answer 10

Retinal detachment

-Keep pt supine w/ head turn to affected side

Question 11

Heat edema- swelling of hands and feet. Tx?

Answer 11

Nothing

Leg elevation, tight support hose

Question 12

“-Maculopapular, pruritic, erythematous rash occurs in clothed areas
-Predominate symptom is pruritis”

Name and tx

Answer 12

Prickly heat

Antihistamines/topical cream

Question 13

“-Exercise associated muscle cramps

• Intermittent, painful, and involuntary spasmodic contractions of skeletal muscles
• Relieved by stretching and massage, resolve spontaneously “

Name and tx

Population mostly affected

Answer 13

Heat cramps

Electrolytes

“-Typically unacclimated individuals or athletes with extended periods of exercise
-Commonly seen in roofers, firefighter, military personnel, athletes, steel workers, and field workers. “

Question 14

“-Headache, vertigo, ataxia, impaired judgement, dizziness, nausea, and muscle cramps

-Patients can develop heat stroke after removal from heat-stress environment”

Name and tx

Population mostly affected

Answer 14

Heat Exhaustion

“-Aggressive cooling of nonresponders is indicated to a core temp of 39℃ (102.2℉)

-Laborers, athletes, elderly individuals exerting themselves in hot environments, without adequate fluid intake

Question 15

“-Total loss of thermoregulatory function
-Prognosis worsens if initial core temperature exceeds 42℃ (107.6℉), acute renal failure, massively elevated liver enzymes, significant hyperkalemia “

Answer 15

Heat stroke

Question 16

-Triad: Exposure to heat stress, CNS dysfunction, core temperature > 40.5 ℃

Answer 16

Heat stroke

Question 17

ong periods of high ambient temperature and humidity (heat waves)
–Skin feels hot and dry to the touch

Answer 17

Classic heat stroke

Question 18

often young and previously health individuals (i.e athletes, laborers, military recruits)
–d/t strenuous exercise skin may feel dry and moist

Answer 18

Exertional heat stroke

Question 19

“EKG

• Bradycardia- Osborn (J) wave
• Artial or ventricular dysrhythmias

TSH and Cortisol may be elevated
-Consider a toxicology screen

-Esophageal probe: device of choice to monitor core body temp”

Name and tx

Answer 19

Hypothermia

“Essential that resuscitative efforts be continued until patient is rewarmed: Unless severe injuries incompatible with life, changes present in prolonged death

Airway:

• Orotracheal intubation unless patient able to manage airway
• Orogastric tube

Breathing:
-Mechanical ventilation with warmth

Circulation:

• Crystalloids should be warmed and infused
• Serially assess volume status

Rewarming

• Remove any wet clothing
• Passive warming (with a blanket)
• Rewarm at rate of 0.5 - 2℃ /H in mild cases without significant hemodynamic instability
• Active rewarming if cardiac instability, temp below 32℃, peripheral vasodilation, endocrine insufficiency “

Question 20

“-Clumsiness of extremity (“chunk of wood”) sensation

• Numbness/paresthesias
• Sensory deficit: Hands, feet, nose, ears, face especially susceptible
• appears waxy, mottled, yellow, or violaceous-white
• Advanced cases/delayed presentation: bullous and Eschar formation, Tissue necrosis “

Answer 20

Frostbite

Question 21

“-Potential for limb-threatening local reactions

• Coagulopathy, bleeding
• Rhabdomyolysis
• Capillary leak with intravascular volume depletion and shock
• Metallic taste, nerve paralysis and respiratory failure”

Answer 21

Crotalidae

“-Crotalus (Rattlesnakes)

• Agkistrodon (Copperheads)
• Cottonmouths”

-Treat systemic changes

Question 22

“-Minor local reactions

• N/V, headache, paresthesia, numbness
• Neurotoxicity
• Paralysis
• Respiratory depression”

Answer 22

Elapide

Coral snakes

-Limited antivenom: if presence of systemic signs

Question 23

-Vomiting, tachycardia, hypertension, local pain, paresthesias, muscle jerking, rhabdomyolysis, respiratory failure

Answer 23

Scorption Stings

“-Supportive management: Analgesia, Benzos, IV Fluids
-Severe systemic symptoms: Administration of antivenom, immune F(ab’)2 (equine) injection, with readministration at 30-minute serial evaluations if symptoms persist”

Question 24

Electric Shock tx

Answer 24

• Advance cardiac and mechanical respiratory support
• Surgical consultation and management: Deep tissue injury, compartment syndrome, bone fracture, osteonecrosis, spinal injury
• Adequate volume infusions: Rhabdomyolysis, AKI
• Burn management center”

Question 25

“-Cardiopulmonary arrest, cardiac arrythmias, seizures, deafness, confusion, amnesia, blindness, paralysis

• TM ruptures in >50% of victims
• Burns may result from vaporization of sweat or moist clothing, heating of clothing or metal objects (belt buckles, bra wiring), direct effects of strike
• Secondary blunt trauma: Myocardial contusion”

Answer 25

Lightening Injury

ABCs