Test 1 Flashcards
Diagnostic Process order
1) Identify the problem
2) Frame the differential diagnosis in a way that facilitates recall
3) Organize differential diagnosis
4) limit the differentials by using pivotal points to create a pt specific differential
5) Explore pt specific differentials - using history and physical exam findings
6) Rank the differentials using results of exploration
- select leading differential
- select must not miss
- select additional alternatives
7) Test
8) re-rank
9) Test
What is the most precise way of estimating pretest probability.
CDRs ( clinical decision rule )
which system reasoning is used based on memory
System 1
Which system reasoning is a more analytical approach
System 2
How should problem lists be organized?
Acute problems
chronic active problems
ending with inactive problems.
What are the components used for assessing pretest probability
use a validated clinical decision rule (CDR)
use prevalence data regarding the causes/etiologies of a symptom
use your overall clinical impression
probability above which the diagnosis is so likely you would treat the patient without further testing
treatment threshold
the probability below which the diagnosis is so unlikely it is excluded without further testing
test threshold
the probability of disease after the test is done
posttest probability
How likely can we “rule this in”
Sensitivity
the higher a sensitivity is (and the more symptoms/findings usually), the more likely we can
“rule in” a disease.
“rule this out”
Specificity
USPSTF levels of certainty regarding net benefit
net benefit = benefit – harm as implemented in a primary care population
Consistent results from well-designed studies in representative primary care populations that assess the effects of the preventive service on health outcomes; it is unlikely that these conclusions will change based on future studies.
USPSTF levels of certainty - High
Evidence sufficient to determine the effects of the preventive service on health outcomes, but methodologic issues such as limited generalizability, inconsistent findings, or inadequate size or number of studies exist; these conclusions could change based on future studies.
USPSTF levels of certainty - Moderate
Insufficient evidence to assess effects on health outcomes, due to limited number or size of studies, flaws in study designs, inconsistency of findings, lack of generalizability.
USPSTF levels of certainty - Low
The USPSTF recommends this service. There is high certainty that the net benefit is substantial.
Grades of recommendations - Grade A
The USPSTF recommends this service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial
Grades of recommendations - Grade B
The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.
Grades of recommendations - Grade C
The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
Grades of recommendations - Grade D
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Grades of recommendations - Grade I statement
higher the specificity is, the more likely we can
“rule out” a disease
OLDCARTS
onset location duration character aggravating or associated factors relieving factors temporal factors severity
are the physiological links, predisposing factors, and complications for this disease present in the patient?
coherence
Does the suspected disease encompass all of the patients normal and abnormal findings?
Adequacy
Is it the simplest explanation of the patients findings?
crucial step bc patients must find the treatment recommendations acceptable
Parsimony
is the diagnosis confirmed by a radiographic or lab tests?
Diagnostic probability
rules of thumb that guide the inductive or inferential process of diagnostic reasoning. Generally accurate and useful rules to make the task of information gathering more manageable.
Heuristics
“Are the physiological links, predisposing factors, and complications for this process present in the patient?”
(All the things present in the disease, does the patient have symptoms?)
Coherence
“Does the suspected disease encompass all of the patient’s normal and abnormal findings?”
(Symptoms patients have…does this match the disease?)
Adequacy
when the practitioner suspects a cause of symptoms based on previous clinical knowledge, practitioner gathers relevant information at a quicker speed
Diagnostic reasoning:
form of reasoning acknowledging that there are many variables (environmental & social) present in an actual clinical situation
Clinical reasoning
PICO
Problem
Intervention/exposure
Comparison
Outcome
ratio of risk in the experimental group compared with the risk in the control group
RElative Risk
Is the difference between groups large enough to be worth achieving
Clinical versus statistical significance
odds of previous exposure in a case divided by the odds of exposure in a control patient
Odds ratio
Measure of the precision of results
Confidence Intervals (CIs)
in Confidence intervals the wider the CIs indicate a ____ _____
lower precision
what source of evidence provides sound evidence of cause and effect and can control for bias
RCTS (Randomized controlled clinical trials)
what source of evidence examines a number of valid studies on a topic and mathematically combines the results to report them as if they were one large study
meta analysis
what source of evidence is based on clinical experience, collective experience and knowledge of professional organizations
Expert opinion
what level of prevention involves activities directed at improving general well-being while also providing specific protection for selected diseases.
Primary prevention
screening, counseling or preventive medicines such as vaccines or dental sealants is what level of prevention
primary
Common model used to guide behavioral counseling (5As)
Ask about the behavior
Advise about the health risks and benefits of change
Agree to set a goal
Assist with identifying and overcoming barriers
Arrange for a follow up
what level of prevention goal is to identify and detect disease in its earliest stages before symptoms appear
Secondary prevention
What level of prevention includes
screening interventions to identify elevated BP or risk of DM with A1C measurement
secondary prevention
What level of prevention aims to improve the quality of life for people with various conditions by limiting complications and disabilities, reducing the severity and progression of disease and providing rehab therapy to maximize functionality and self-sufficiency.
Tertiary prevention
What level of prevention includes
optimizing treatment for chronic conditions such as asthma, DM, physical or cognitive disability
Tertiary prevention
what type of screening includes all members of a population
Population screening
what type of screening is more selective and focuses on a population at risk
Targeted screening
ie) STI screening in sexually active adolescents and young adults in a specific age groups
Name that Bias
Considering easily remembered diagnoses more likely irrespective of prevalence
Availability
Name that Bias
Pursuing Zebras
Base Rate Neglect
Name that Bias
Ignoring atypical features that are inconsistent with the favored diagnosis
Representativeness
Name that Bias
Seeking data to confirm, rather than refute the initial hypothesis
Confirmation Bias
Name that Bias
Stopping the diagnostic process too soon
Premature closure
What does the term Pursuing zebras mean
People ignore base rate (what is more likely) in favor of given individual information (the way someone appears)
Pt comes in with cough 1-3 weeks
myalgias
low grade fevers
what are you thinking?
Acute Bronchitis
R/o flu, Covid, Pneumonia, RSV
Etiology for Acute bronchitis
Viral
Bacterial (<10%)
Noninfectious
Impaired mentation/swallowing
elderly
intoxicated (alcoholics)
poor dentition
think…
Aspiration pneumonia
Signs and symptoms Fever cough chest pain Putrid Sputum Evolved over days not acute Involves the basal segment of lower lobes can also involve posterior segments of upper lobes
think aspiration pneumonia
productive cough crackles higher fevers may have chest pain SOB Chills could be viral or bacterial
Community acquired pneumonia
what views for chest x ray for pneumonia
PA and Lat better than AP
What are your differentials for Acute cough and congestion
Common cold Sinusitis bronchitis influenza Pertusis Pneumonia -CAP -HAP -AP -TB -PJP (fungal)
If Pneumonia develops more than 48 hours post hospital admission
Hospital acquired pneumonia
If pt develops pneumonia more than 48 hrs post intubation
Ventilator acquired pneumonia
abrupt onset myalgia diffuse pain cough rhinitis pharyngitis high fevers (peaks within 12 hours 40-41C) Rigors chills headache
Influenza
when is flu season
December - march
time line of flu
1-5 days (3 typical)
If fever is increasing gradually over several days think
bacterial pneumonia
cough rhinorrhea sore throat sneezing but does not resolve after 3-7 days may have posttussive emesis
pertussis
side note Whooping at end of cough is rare in adults
median duration of pertussis
42 days
immunocompromised diagnosed/undiagnosed HIV Progressive SOB Dry cough 1-3 weeks Often before diagnosed to aids Chest x ray shows diffuse bilat pneumonia (diffuse symmetric bilat alveolar or interstitial infiltrates cough Progressive dyspnea Lung sounds may be normal CT scan shows patchy nodular ground glass appearance
PJP (Pneumocystis jirovecii pneumonia)
Mycobacteria in upper lobes chronic cough, fever, weigh loss, night sweats economically disadvantaged nursing homes drug dependent homeless prison inmates weeks to months
TB
People at high risk for TB
HIV AIDS Alcoholics immunocompromised Cancer Diabetes ESRD Transplants Malnutrition TB previously on x ray PPD+
Fever Consolidation Xray Lower middle lobes PPD may be negative may resolve on its own
Primary TB
Increased risk first 2 years
decline immune fx
typical tb symptoms
progresses unless pt is tx
Reactivated TB
Associated with at least 3 of the following:
- Easy fatigability
- Feeling restless or on edge
- Trouble concentrating
- Irritability
- Muscle tension
- Sleep disturbance
Daily functioning and performance is affected.
Symptoms cannot be explained by another psychiatric or medical condition.
Generalized anxiety disorder
Intense fear of social situations
Lifetime prevalence: 13%, 12-month prevalence: 7.4%
Social Anxiety disorder
Episodic attacks not brought on by a specific trigger
Characterized by an abrupt surge in fear or discomfort, peaking within a few minutes, accompanied by at least 4 of the following symptoms:
- Sweating
- Trembling or shaking
- Shortness of breath or feeling of smothering
- Chest pain or discomfort
- Feelings of choking
- Nausea or abdominal discomfort
- Feeling dizzy, lightheaded or faint
- Chills or heat sensations
- Paresthesias
- Feeling of feeling disconnected
- Fear of losing control
- Fear of dying
Lifetime prevalence: 6.8%, 12-month prevalence: 2.4%
Panic Disorder
Metabolic: Decreased metabolism that can lead to weight gain, cold intolerance, and increased total and low-density lipoprotein (LDL) cholesterol (due to decreased clearance)
Cardiac: Reduction in myocardial contractility and heart rate
Skin: Nonpitting edema, due to accumulation of glycosaminoglycans; dry skin; coarse, fragile hair
Central nervous system: fatigue, delayed relaxation phase of the deep tendon reflexes
Pulmonary: hypoventilation seen with severe hypothyroidism
Gastrointestinal: reduced intestinal motility causes constipation
Reproductive: menstrual abnormalities, reduced fertility, increased risk of miscarriage
Hypothyroidism
Labs for Hypothyroidism
TSH and free T4
screening questions for Insomnia
Difficulty initiating sleep, staying asleep, or both?
Early awakening?
Nonrestorative sleep?
Daytime consequences? (Lack of daytime fatigue or sleepiness suggests the insomnia is not clinically significant.)
Frequency and duration?
follow up questions for insomnia
Precipitating events, progression, ameliorating or exacerbating factors?
Sleep-wake schedule?
Cognitive attitude toward sleep?
Negative expectations regarding the ability to sleep and distortions about the effects of insomnia lead to perpetuation of the insomnia.
Attitudes toward previous treatments are also important.
Psychiatric disorder present?
Substance misuse or medication use?
Medical illness with nocturnal symptoms?
Symptoms of sleep apnea, restless legs? (See discussion below.)
complain of daytime sleepiness or fatigue. Bed partners often note snoring or actual apneic episodes. Most patients are obese.
obstructive sleep apnea
obstructive sleep apnea is more common in what gender?
men
Is obstructive sleep apnea more common pre or post menopausal
post menopausal
what questions would you ask about fatigue for a focused history and why
Can you tell me what you mean by fatigue?
How old are you?
Do you notice other symptoms with feelings of fatigue?
what are some other things that get confused with fatigue?
Weakness
Frailty
frailty can be measured based on the presence of 5 symptoms
unintentional weight loss slow mobility weakness decreased reduced activities fatigue
Frailty increases the risk for
falls
5 key questions to tell if fatigue is physiologic?
Lifestyle habits? (exercise and diet) Sleep pattern? Do you require naps? how often? Do you feel rested when you wake up in the morning? Last menstrual period?
adequate amount of sleep for adults
6-8 hours
adequate amount of sleep for adolescents
8-9 hours
adequate amount of sleep for children
10 hours
sleep pattern related to depression
early-morning wakening and excessive sleeping during the day
Men over 50 with fatigue due to nocturia associated with
BPH
last normal menstrual period might tell us what about fatigue
early sign of pregnancy
symptom after childbirth
associated with menopause
perimenopausal adults as a r/o disrupted sleep due to hot flashes
what might finding out if someone practices safe sex tell us about fatigue
may be the initial and most prominent symptom of hepatitis, HIV, AIDS
What might finding out if someone takes medications have to do with fatigue
May be a side effect.
most common drugs that cause fatigue
antihypertensive drugs cardiovascular meds psychotropic meds opiates sedatives antihistamines
What will asking about drinking alcohol tell us about fatigue
Alcohol abuse and use of recreational drugs may be overlooked as a cause of chronic fatigue in adolescents and school age children.
usually alcohol or marijuana
useful screening tool to assess for alcohol abuse
CAGE questionnaire
what does appetite tell us about fatigue
increased appetite may indicate hypoglycemia or hyperglycemia
increased thirst - hyperglycemia
decreased appetite - infectious process
What does weight loss tell us about fatigue
weight loss - malignancy, infection, poor nutrition r/t depression or lack of info on a healthy diet
weight loss of greater than 10lbs in the past year and may be associated with other signs and symptoms
unintentional weight loss
what will joint tenderness or pain tell us about fatigue
In children with Juvenile RA - severe fatigue
young and middle aged patients - can involve multiple tender points on the body that are over joints
Increased urination and fatigue
Diabetes mellitus (esp type 2) often presents with fatigue along with Polydipsia, polyphagia and polyuria
Fatigue with specific symptoms that worsen over time such as dry skin, nails
Hypothyroid
Fatigue with shortness of breath with exertion or when laying flat
heart failure
what does fatigue have to do with where you work
occupational exposure - heavy metals and pesticides may cause fatigue and other neurologic symptoms
military returning from combat zones from unknown cause
what does fatigue have to do with if they have been camping
lyme disease is carried by the deer tick. They may present with weeks of malaise and chronic fatigue before any skin manifestations appear
fatigue that has a slow and progressive onset could be associated with ______
metabolic causes
What timeline is considered significant fatigue
greater than 2 weeks
what type of fatigue is usually worse in the morning
psychological fatigue
what will help relieve psychological fatigue
physical activity
what type of fatigue is not associated with intensity or duration of activity and is not relieved with rest or sleep
organic fatigue
why would you ask if they were a caregiver if they are having fatigue
Burnout
why would you ask if you or anyone in your family has a problem with anxiety or depression for someone with fatigue
children who have family members with depression are at a greater risk for depression.
Generally the first episode of major depression occurs between the ages of —– and effects ____-
20 and 30 and effects women and transgender individuals more often then men
cc - fatigue
fever
inflammation or infection
CC fatigue
elevated HR
anxiety
anemia
dehydration
hyperthyroidism
CC fatigue
abnormal BMI
poor nutritional status
cardiovascular risk
cc fatigue
coarse, dry hair and skin
thickening of nails
hypothyroidism
cc fatigue
fine, limp hair
warm skin
hyperthyroidsim
cc fatigue
faint maculopapular rash
mononucleosis
CC fatigue
macular lesion with a clear center
lyme disease
cc fatigue
atrophic skin of the lower extremities
arterial insufficiency and underlying areriovascular disease
cc fatigue
swelling of ankles
varicose veins
skin ulcers
venous stasis
CC fatigue
evidence of nail biting
self inflicted excoriation lesions
Anxiety disorders
CC fatigue
petechiae on the palate
mononucleosis
CC fatigue
dry, cracked, ulcerated mucosa
nutritional deficiency or dehydration
CC fatigue
audible third or fourth heart sounds (S3, S4) in an adult
Heart failure
cc fatigue
increased AP diameter of the thorax
COPD
CC fatigue
Bilateral basilar rales
Congestive heart failure
Most pneumonia is on what sides
unilaterally
Barely audible breath sounds are associated with
COPD
CC fatigue
generalized symmetrical abdominal distension
obesity
enlarged organs
fluid (ascites)
gas
CC fatigue
concave contour of abdomen
dehydration or malnutrition
CC fatigue
a change in deep tendon reflexes may indicate
thyroid dysfunction
CC fatigue
diet history shows inadequate dietary intake of iron
Anemia
Pt reports cold intolerance, constipation, weight gain, hoarseness, depression, fatigue
physical exam shows bradycardia, dry skin, generalized edema, delayed recovery of deep tendon reflexes.
Hypothyroidism (myxedema)
Pt has increased sweating, heat intolerance, weight loss, irritability, disturbed sleep, menstrual irregularity.
Physical exam shows tachycardia, a-fib, tremor, warm moist skin, lid lag, exophthalmos
Hyperthyroidism (Graves disease)
What antihypertensive med is often associated with fatigue
B blockers
associated with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, weight gain, cough with forthy sputum, palpitations and fatigue
heart failure
gradual onset of low grade fever sore throat posterior cervical lymphadenopathy fatigue malaise
mononucleosis
malaise fatigue flulike symptoms abd pain arthralgia aversion to smoking
hepatitis
occurs most often in women 20-50
chronic pain and stiffness of trunk and extremities esp in neck, shoulders, low back and hips
fatigue, headaches, sleep disturbance, bowel irritability
fibromyalgia
severe pain lasting longer than 6 mos and associated with impaired memory or concentration
sore throat, tender cervical or axillary lymph nodes
muscle pain
multiple joint pain
new onset headaches
nonrestorative sleep
postexertional malaise
chronic fatigue syndrome
Agitation and restlessness are common manifestations of
depression
anxiety
substance abuse
agitation, hypertension, and tachycardia occurring during the first 2 days after hospital admission
Alcohol withdrawal
Seizures may soon follow with delusions and delirium occurring during the first 3–5 days.
hallucinosis usually have a clear sensorium
Alcoholic hallucinosis (this is a distinguishing factor setting it apart from delirium)
Confusion, disorientation, and autonomic hyperactivity are hallmarks
delirium tremens (can be fatal)
Wernicke encephalopathy is not an alcohol withdrawal syndrome but is caused by
thiamine deficiency
Alcohol abuse is the most common cause of ___ deficeincy
Thiamine
Wernicke encephalopathy may occur when a patient, who is thiamine deficient, receives
intravenous glucose
Symptoms include the triad of confusion, disorders of ocular movement, and ataxia. The confusion commonly manifests as disorientation and indifference.
Wernicke encephalopathy
presents with memory problems and resulting confabulation
Korsakoff syndrome is the chronic form of Wernicke encephalopathy.
Adrenergic overactivity (hypertension, tachycardia, fever) is always present unless masked by medications.
delirium tremens
Alzheimer Disease most commonly occurs after the age of
65
Memory loss, behavioral or personality change, functional impairments, and social withdrawal
common early symptoms of AD.
most-evaluated instrument for diagnostic cognitive impairment
MMSE (mini mental status exam)
fluent aphasia, paraphasia, and word substitutions
language disturbances associated with AD
Highly educated patients are more likely or less likely to receive an early diagnosis for AD
less likely
3 tests for dementia
MMSE (mini mental status exam)
Mini-Cog
MoCA
IQCODE
which mental screening exam includes 3-item recall and clock drawing
mini-cog
which mental screening exam was Initially developed and validated as a screening test for MCI (mild cognitive impairment)
MoCA
which mental screening exam is a Short form is a 16-item questionnaire.
IQCODE
Considered the clinical gold standard for diagnosing dementia
Neuropsychiatric testing
Reasons to explore for reversible dementia
CNS infections
Hypothyroidism
Vitamin B12 deficiency
CNS masses
Neoplasms
Subdural hematomas
Normal-pressure hydrocephalus
Medications
tests for dementia
CBC
Thyroid-stimulating hormone (TSH)
Basic metabolic panel and liver biochemical tests
Vitamin B12 level
Tests to exclude neurosyphilis
Consider neuroimaging (MRI or CT)
Imaging is not required in most patients with dementia.
In practice, most patients will undergo imaging both to assess for diagnoses other than AD and to detect brain atrophy that may support the diagnosis of AD.
manifests as inattention and confusion
Delirium
Several conditions are more likely to cause delirium than others.
Severe illness
Drug toxicity
Fluid and electrolyte disturbances (hyponatremia and azotemia)
Infections
Hypothermia or hyperthermia
Delirium is very common in
sick, hospitalized patients over the age of 65
The prognosis of delirium is
poor
patients who experienced delirium had a higher risk of death, institutionalization, and dementia during follow-up.
the best-validated and most widely used tool for diagnosing delirium.
The Confusion Assessment Method (CAM)
typically seen in a patient with Parkinson disease who has dementia. In patients without a previous diagnosis of Parkinson disease, motor symptoms similar to those seen in Parkinson disease are often present.
Dementia with Lewy Bodies (DLB)
screening tool for Validated for use in older adults to assist in depression diagnosis
PHQ-9 (Personal Health Questionaire):
what type of dementia - Visual hallucinations are common
Dementia with Lewy Bodies (DLB)
Mild extrapyramidal motor symptoms (rigidity and bradykinesis) are often seen early in this type of dementia
Dementia with Lewy Bodies (DLB)
Repeated falls
Syncope
Transient loss of consciousness
Neuroleptic sensitivity
Systematized delusions and hallucinations
Dementia with Lewy Bodies (DLB)
what does SOAP note include
Chief Complaint (subjective) History of Present Illness (subjective) Family/medical/surgical histories (subjective) Review of systems (subjective) Physical exam (objective) Assessment Plan
most likely diagnosis based on prevalence, demographics, risk factors, signs & symptoms
Leading hypothesis
Hypothesis generating starts with
patient’s demographics
most significant factor of pt demographics
Age
problem specific framework for Frequently used for chest pain
anatomic
problem specific framework Used for problems with very broad differentials such as fatigue
Organ based /system based
PQRST
P(provocative, palliative) What brings it on, what makes it better
Quality - what does it feel like
Region/radiate where is it at and where does it radiate
Severity and setting - how bad is it? What were you doing at the time
Temporal - when did it start, how long does it last, have you had it before
what framework?
What could be happening pathologically(what diseases could) to make this symptom happen
organic
VINDICATE
Vascular, Infection Neoplastic Degenerative, Idiopathic/Inflammatory Congenital Autoimmune, Traumatic Endocrine
MEDICINE
Metabolic/Medication Endocrine Degenerative, Infection/Ischemia/Infarction Congenital Neoplastic, Electrical( Neuro/Psych)
VITAMINCDE
Vascular Infection/Ischemic/Infarction Trauma/Toxin Autoimmune Metabolic/Medications Iatrogenic/Idiopathic, Neoplastic Congenital Degenerative Electrical (Neuro/psych)
What is the order problems should be listed in a problem list
begin with the acute problems, followed by chronic active problems, ending with inactive problems (past medical history)
Organic (chronic) causes of fatigue
sleep apnea, medications, HF, cancer, EBV, hepatitis, fibromyalgia, chronic fatigue syndrome
Organic (acute) causes of fatigue
infection, drugs/alcohol, anemia, hypothyroidism, hyperthyroidism
fatigue presentation in children
Withdrawn from social and recreational activities → mood disturbances
fatigue presentation in adolescents
Withdrawn from social/recreational activities → mood disturbances
Decreased academic performance and decreased productivity
Recreational drug and alcohol use, high caffeine intake
an older patient complaining of memory loss. Common complaints are difficulty remembering names and appointments or solving complex problems
mild cognitive impairment
people have memory loss and no other deficits
Single domain amnestic MCI
people have memory loss as well as other deficits
Multiple domain amnestic MCI
people have impairment in a single, non–memory-related, cognitive domain.
Single domain non-amnestic MCI
people have impairment in multiple, non–memory-related, cognitive domain.
Multiple domain non-amnestic MCI
may be abrupt or gradual. The patient usually has risk factors for, or has previously diagnosed, vascular disease. The patient may have gait disturbance during the neurologic exam.
Multi-infarct Dementia (Vascular Dementia, VaD)
the most common cause of dementia after AD.
Multi-infarct Dementia (Vascular Dementia, VaD)
Most common in patients with risk factors for vascular disease or an embolic stroke
Multi-infarct Dementia (Vascular Dementia, VaD)
Screening tool for Multi-infarct Dementia (Vascular Dementia, VaD)
DSM-5 criteria
Exaggeration of deep tendon reflexes
Extensor plantar response
Gait abnormalities (consider history of unsteadiness and frequent, unprovoked falls)
Pseudobulbar palsy (pathologic laughing, crying, grimacing; and weakness of the muscles associated with cranial nerves V, VII, IX, X, XI, and XII)
Focal neurologic signs
Multi-infarct Dementia (Vascular Dementia, VaD)
clinically useful test for determining whether ischemic disease is playing a role in a patient’s dementia.
Hachinski Ischemic Score
cc fever
why is it important to ask about recent head trauma?
recent head trauma esp at base of skull may provide entrance for infectious organisms
cc fever
why ask about recurrent ear infections
may have mastoiditis spreading to meninges
headache fever lethargy confusion vomiting stiff neck
meningitis
why is fever younger than 2 mos significant
neonates and young infants are less able to mount a febrile response so when they do it is significant
fevers in a neonate may also be an indication of an
underlying anatomical defect
URI and bacteremia is often the first indications of a structural abnormality of the urinary tract
genetic disorder that may present in the first weeks to 1 month of life with gram negative sepsis
galactosemia - rare genetic metabolic disorder (affects ability to metabolize the sugar (galactose) properly
all infants younger than 2 months with fever are considered to have ____ or ____ until proven otherwise
Sepsis or meningitis
in adults fevers from acute process usually resolves in
1-2 weeks
fevers that last > 3 weeks that exceed temp of 38.4 (101.1) and remain undiagnosed after 1 week of intensive diagnostic study are classified as
FUOS
fever in children with short duration, readily diagnosed and resolves within 1 week
short term fever
fever in children < 10 days that is not explained by findings on history or physical exam
fever without localizing signs
fever in children greater than 38.5 (101.2) that lasts longer than 2 weeks on more than 4 occasions
FUOs
Fever greater than 41.1C (106) are seen in
heat illness
CNS disease
infection
the higher the fever, the greater likelihood of
bacteremia
most common infection in girls younger than 2 years old who present with a high fever and in all infants younger than 90 days with a fever
UTI
fever
increased amount of vaginal discharge and bleeding after intercourse
PID
chills high fever urinary frequency and urgency perineal pain low back pain penile discharge
acute UTI in male
CC fever
joint pain
connective tissue disorder in adults and children older than 6.
osteomyelitis or septic arthritis
rash for hand foot mouth usually erupts on what day
3 days
rash for measles usually erupts on what day
4 days
Rash for roseola infantum usually erupts on what day
5 days
rash for scarlet fever usually erupts on what day
2 day
rash for varicella, rubella, erythema infectiosiosum usually erupts on what day
1
infections to r/o with history of travel outside the country
amebiasis malaria schistosomiasis typhoid fever hepatitis A or B Dengue
the most common vector borne disease worldwide and is a diff diagnosis for pt who live or have recently traveled to the tropics or subtropical areas of the US
Dengue
recent camping or exposure to wooded areas may indicate
exposure to ticks Q fever tularemia rocky mountain spotted fever giardia lyme disease
what overdose can cause fever
ASA
food poisoning fevers can occur up to ____ hours after ingestion of contaminated food
72
what plants can cause fever
plants containing the alkaloid atropine (deadly nightshade, jessamine, and thornapple)
cause dilated pupils, flushed skin and fever
bacterial infection transmitted by cats (changing kitty litter boxes. )
Cat-Scratch disease or toxoplasmosis (single node or regional adenopathy is the dominant clinical feature)
What is the etiologic agent of Cat Scratch disease
Gram neg bacillus
bacterial infection transmitted by dogs
brucellosis and leptospirosis
bacterial infection transmitted by rabbits
tularemia
bacterial infection transmitted by birds
ornithosis
histoplasmosis
psittacosis
bacterial infection transmitted by hamsters or cats
lymphocytic choriomeningitis
hyperthermia and change in LOC
classic heat stroke
causes of fever of unknown orgin in child
infectious disease (localized and systemic) collagen/inflammatory diseases neoplastic diseases drug fever factitious fever kawasaki disease inflammatory bowel disease immunodeficiency CNS dysfunction
CC fever
petechial eruptions on the hard and soft palate
mononucleosis
cc fever
splinter hemorrhages found in the nail beds and petechiae of the conjunctivae
endocarditis
cc fever
petechial skin rash
meningococcemia
rocky mountain spotted fever
anticoagulation treatment outside of therapeutic range
indicates a serious infection that requires immediate referral and hospitalization
inspecting the fontanel of an infant is best noted if the patient is in what position
sitting
cc fever
palpable anterior cervical lymph nodes
suspect viral or bacterial pharyngitis
cc fever
palpable preauricular or postauricular lymph nodes
suspect ear infection
cc fever
palpable submental and submandibular lymph nodes
suspect tooth abscess
cc fever
palpable posterior cervical lymph nodes
suspect mononucleosis
cc fever
palpable supraclavicular lymph nodes
suspect neoplasm
cc fever
palpable axillary lymph nodes
suspect breast inflammation, local infection or neoplasm
cc fever
palpable inguinal lymph nodes
Suspect a STI
cc fever
localized lymphadenopathy
suspect local infectious process
cc fever
generalized lymphadenopathy
suspect immunosuppression such as HIV positive or neoplasm
yellow green sputum
suspect bacterial infection
brown sputum
check smoking history
blood streaked sputum
Suspect URI or bronchitis
hemoptysis
suspect tumor, trauma, pneumonia, TB or PE
Clear sputum
COPD or emphysema without infection
cervical motion tenderness
discharge
adnexal tenderness
lower abd tenderness
PID
Penis with fever and discharge
STI
UTI
prostatitis
tenderness and discharge during a rectal exam
rectal abscess/infection
retrocecal appendicitis
If you suspect prostatitis, do not
perform a vigorous exam or massage the prostate bc this can release bacteria and produce septicemia
Osteomyelitis may occur in young children most commonly between ages
3-10
Septic arthritis can occur in children
under the age of 3 and in young women who are sexually active
Brudzinski sign
with the patient supine, attempt to flex the neck cause the knees and hips to rise from the bed to reduce the pull on the meninges. test for meningitis
kernig sign
attempt to extend the knee joint when the hip joint is flexed are resisted and the other limb may flex at the hip . - meningitis
disturbances in mentation irritability lethargy somnolence coma
indicates increased intracranial pressure
a seizure in a febrile infant younger than 6 months old is suggestive of
meningitis rather than simple febrile seizures
fever, sinuses that are tender to percussion or do not transilluminate. Pt often report a frontal headache that worsens as they lean forward. sometimes an upper incisor toothache, sore throat, cough from postnasal discharge
Acute sinusitis
a vasculitic syndrome affects infants and young children younger than age 9. Acute mucocutaneous lymph node syndrome. fevers range 38C-40C (100.4-104) and persist despite antibiotics and antipyretics. Seizures may be present …febrile phase lasting 5-25 days. Rash.
Kawasaki disease
fever lasting at least 5 days
and at least four of the following:
Bilat conjunctival hyperemia
mouth lesions: dry fissured lips, injected pharynx or strawberry tongue
changes in peripheral extremities (edema, erythema, desquamation of skin at 10-14 days)
Nonvesicular erythematous rash
cervical lymphadenopathy
Kawasaki disease
fever lasting at least 5 days
and at least four of the following:
Bilat conjunctival hyperemia
mouth lesions: dry fissured lips, injected pharynx or strawberry tongue
changes in peripheral extremities (edema, erythema, desquamation of skin at 10-14 days)
Non-vesicular erythematous rash
cervical lymphadenopathy
Kawasaki disease
the most common exanthema (skin rash) of children younger than 3 yrs old with irritability, high fever, rash that appears on day 3-4 and lasts 1-2 days
Roseola Infantum
mild nonspecific, febrile illness that lasts 2-5 days
herpangina
nonexudative pharyngitis with or without lymphadenopathy
enterovirus
fever in child older than 3 months who have pos blood cultures but do not have the usual clinical manifestations of sepsis.
occult bacteremia
occult means hidden
peak ages for bacteremia are ages
6-24 months
what organism is most commonly responsible for bacteremia in peak age group
streptococcus pneumoniae
condition characterized by an abrupt fever that occurs in children ages 2-5 on a regularly recurring basis every 6 weeks. Lasts average of 4 days. other symptoms include malaise, sore throat, cervical adenopathy and aphthous stomatitis
Periodic fever in children
no associated diseases or other physical exam or lab findings with normal growth and development
Weight loss after birth is normal, but expected to start to gain weight within the
first 2 weeks of life
In newborns Decrease in weight of more than ___ and necessitates _____
8% necessitates follow up within 48 hours and a bilirubin check
in newborns Loss of more than 10% of birth weight necessitates
careful assessment and potential hospital admission
Components of a Mental health history (
Acute (days to weeks) or chronic (weeks to months)
Alertness, orientation, attention, mood, judgement, affect, language, cognitive function, thought process/perception (unusual thoughts)
Use OLDCARTS/COLDSPA
Find out about developmental age (ex: prematurity, autism)
Academic history (ex: learning disabilities)
Difficulty with authority (ex: teachers, parents)
Pertinent past medical history (including mental health, medications)
Substance use (ex: drugs, alcohol, OTC, herbal, caffeine)
Culture/religion, coping/support systems
Sleep pattern (ex: hours/night, disrupted sleep)
somatic
Physical symptoms
Somatic symptoms are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings, and behaviors related to those symptoms. Symptoms should be specific if with predominant pain.
Somatic symptom disorder
Preoccupation with having or acquiring a serious illness where somatic symptoms, if present, are only mild in intensity.
Illness anxiety disorder
Syndrome of symptoms of deficits mimicking neurologic or medical illness in which psychological factors are judged to be of etiologic importance.
Conversion disorder
Presence of one or more clinically significant psychological or behavioral factors that adversely affect a medical condition by increasing the risk for suffering, death, or disability
Psychological factors affecting other medical conditions
Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. The individual presents himself or herself as ill, impaired, or injured even in the absence of external rewards.
Factitious disorder
Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others.
Body dysmorphic disorder
Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.
Dissociative disorder
for the five most common disorders in primary care: depression, anxiety, alcohol, somatoform, and eating disorders
however, it contains 26 questions and takes up to 10 minutes to complete
what is the shorter version?
PRIME-MD (Primary Care Evaluation of Mental Disorders);
PRIME-MD Patient Health Questionnaire, available as patient health questionnaire for self-rating; takes approximately 3 minutes.
high yield questions for Depression
Over the past 2 weeks, have you felt down, depressed, or hopeless?22,28,29
Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)?
High yield questions for anxiety
Over the past 2 weeks, have you been feeling nervous, anxious, or on edge?
Over the past 2 weeks, have you been unable to stop or control worrying?
Over the past 4 weeks, have you had an anxiety attack—suddenly feeling fear or panic?
screening tool for anxiety
Whiteley Index: 14-item self-rating scale
Distrust and suspiciousness
Detachment from social relations with a restricted emotional range
Eccentricities in behavior and cognitive distortions; acute discomfort in close relationships
Paranoid
Schizoid
Schizotypal
cluster personality type A for DSM 5
Disregard for, and violation of, the rights of others
Instability in interpersonal relationships, self-image and affective regulation; impulsivity
Excessive emotionality and attention seeking
Persisting grandiosity, need for admiration and lack of empathy
Antisocial
Borderline
Histrionic
Narcissistic
cluster personality type B for DSM 5
Social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation
Submissive and clinging behavior related to an excessive need to be taken care of
Preoccupation with orderliness, perfectionism, and control
Avoidant
Dependent
Obsessive–compulsive
cluster personality type C for DSM 5
These patients show “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.”[12] They make “frantic efforts to avoid real or imagined abandonment” and show recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Patients often report feeling depressed and empty, with mood swings that spiral out of control leading to feelings of rage, sadness, and anxiety. To clinicians, these patients may appear demanding, disruptive, or manipulative.
Borderline Personality Disorder
The ability to focus or concentrate over time on a particular stimulus or activity—an inattentive person is easily distractible and may have difficulty giving a history or responding to questions.
Attention
The process of registering or recording information, tested by asking for immediate repetition of material, followed by storage or retention of information. Recent or short-term memory covers minutes, hours, or days; remote or long-term memory refers to intervals of years.
Memory
Awareness of personal identity, place, and time; requires both memory and attention
Orientation
Sensory awareness of objects in the environment and their interrelationships (external stimuli); also refers to internal stimuli such as dreams or hallucinations.
Perceptions
The logic, coherence, and relevance of the patient’s thought as it leads to selected goals; how people think
Thought processes
What the patient thinks about, including level of insight and judgment
Thought content
Awareness that symptoms or disturbed behaviors are normal or abnormal; for example, distinguishing between daydreams and hallucinations that seem real.
Insight
Process of comparing and evaluating alternatives when deciding on a course of action; reflects values that may or may not be based on reality and social conventions or norms
Judgment
A fluctuating pattern of observable behaviors that expresses subjective feelings or emotions through tone of voice, facial expression, and demeanor. Disturbed affect may be flat, blunted, labile, or inappropriate.
Affect
A more pervasive and sustained emotion that colors the person’s perception of the world. (Affect is to mood as weather is to climate.) Mood may be euthymic (in the normal range), elevated, or dysphoric (unpleasant, possibly as sad, anxious, or irritable), for example.
Mood
A complex symbolic system for expressing, receiving, and comprehending words; as with consciousness, attention, and memory, language is essential for assessing other mental functions
Language
Assessed by vocabulary, fund of information, abstract thinking, calculations, construction of objects that have two or three dimensions
Higher cognitive functions
characterized by re-experiencing, avoidance,
posttraumatic stress disorder
with recurrent panic attacks followed by a period of anxiety about further attacks
panic disorder
depression is twice as common in what gender
women
loss of pleasure in daily activities
anhedonia
Mental Status Examination consists of five components
appearance and behavior; speech and language; mood; thoughts and perceptions; and cognitive function
Lethargic patients vs Obtunded
Lethargic patients are drowsy, but open their eyes and look at you, respond to questions, and then fall asleep.
Obtunded patients open their eyes and look at you, but respond slowly and are somewhat confused.
Grooming and personal hygiene may deteriorate in
depression, schizophrenia, and dementia.
One-sided neglect may result from
a lesion in the opposite parietal cortex, usually the nondominant side.
Watch for the anger, hostility, suspiciousness, or evasiveness of patients with
paranoia
flat affect and remoteness of
schizophrenia
the apathy (dulled affect with detachment and indifference) of
dementia
and anxiety or depression
Hallucinations occur in
schizophrenia, alcohol withdrawal, and systemic toxicity.
refers to defective articulation
Dysarthria
is a disorder of language.
Aphasia
results from impaired volume, quality, or pitch of the voice
Dysphonia
reflects the rate, flow, and melody of speech and the content and use of words.
Fluency
which phrases or sentences are substituted for a word the person cannot think of, such as “what you write with” for “pen”
Circumlocutions
in which words are malformed (“I write with a den”), wrong (“I write with a bar”), or invented (“I write with a dar”).
Paraphasias
The mildest thought disorder, consisting of speech with unnecessary detail, indirection, and delay in reaching the point. Some topics may have a meaningful connection. Many people without mental disorders have circumstantial speech.
Circumstantiality
“Tangential” speech with shifting topics that are loosely connected or unrelated. The patient is unaware of the lack of association.
Derailment (loosening of associations)
An almost continuous flow of accelerated speech with abrupt changes from one topic to the next. Changes are based on understandable associations, plays on words, or distracting stimuli, but ideas are not well connected
Flight of Ideas
Invented or distorted words, or words with new and highly idiosyncratic meanings.
Neologisms
Speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. Flight of ideas, when severe, may produce incoherence.
Incoherence
Sudden interruption of speech in midsentence or before the idea is completed, attributed to “losing the thought.” Blocking occurs in normal people.
Blocking
Fabrication of facts or events in response to questions, to fill in the gaps from impaired memory.
Confabulation
Persistent repetition of words or ideas.
Perseveration
Repetition of the words and phrases of others.
Echolalia
Speech with choice of words based on sound, rather than meaning, as in rhyming and punning. For example, “Look at my eyes and nose, wise eyes and rosy nose. Two to one, the ayes have it!”
Clanging
Circumstantiality occurs in people with
obsessions.
Derailment is seen in
schizophrenia, manic episodes, and other psychotic disorders.
Flight of ideas is most frequently noted in
manic episodes.
Neologisms are observed in
schizophrenia, psychotic disorders, and aphasia.
Incoherence is seen in
severe psychotic disturbances (usually schizophrenia).
Blocking may be striking in
schizophrenia.
Confabulation is seen in
Korsakoff syndrome from alcoholism.
Perseveration occurs in
schizophrenia and other psychotic disorders.
Echolalia occurs in
manic episodes and schizophrenia.
Clanging occurs in
schizophrenia and manic episodes.
A sense that one’s self or identity is different, changed, unreal; lost; or detached from one’s mind or body
Depersonalization
Compulsions, obsessions, phobias, and anxieties often occur in
anxiety disorders.
Misinterpretations of real external stimuli, such as mistaking rustling leaves for the sound of voices.1
Illusions
Perception-like experiences that seem real but, unlike illusions, lack actual external stimulation. The person may or may not recognize the experiences as false. Hallucinations may be auditory, visual, olfactory, gustatory, tactile, or somatic. False perceptions associated with dreaming, falling asleep, and awakening are not classified as hallucinations.
Hallucinations
Illusions may occur in
grief reactions, delirium, acute and posttraumatic stress disorders, and schizophrenia.
Hallucinations may occur in
delirium, dementia (less commonly), posttraumatic stress disorder, schizophrenia, and alcoholism.
Remote memory may be impaired in
(Inquire about birthdays, anniversaries, social security number, names of schools attended, jobs held, or past historical events such as wars relevant to the patient’s past. )
late stage of dementia.
Recent memory is impaired in
dementia and delirium
impair memory or new learning ability and reduce social or occupational functioning, but lack the global features of delirium or dementia
Amnestic disorders
delirium causes
acute onset
Metabolic (temp, electrolytes, dehydration), medication, infectious, psychiatric, or cardiac causes
High risk of developing delirium
poor vision, severe illness, cognitive impairment, high BUN/Cr
delirium vs dementia
Chronic over weeks to months, insidious in onset
dementia
delirium vs dementia
acute onset
delirium
delirium vs dementia
Attention intact with impaired cognition and may have CNS symptoms or risk factors
dementia
reversible causes of dementia
hydrocephalus, HIV, B12 deficiency, hypothyroidism, subdural hematoma
irreversible causes of dementia
Alzheimer’s, vascular dementia, Lewy bodies, TBI, Parkinson’s
screening tool
Less sensitive for mild dementia, better at detecting moderate to severe dementia
High sensitivity and specificity
Influenced by age and education level (highly educated are less likely to receive early diagnosis)
MMSE (mini mental status exam): most-evaluated instrument for diagnostic cognitive impairment
Test for dementia, MCI
Highly sensitive
MoCA (Montreal Cognitive Assessment):
screening tool
Validated for use in older adults to assist in depression diagnosis
PHQ-9 (Personal Health Questionnaire):
2 Questions for Suicide Screening:
In the past week have you wished you were dead or wished that you could fall asleep and not wake up?
In the past week, have you had any actual thoughts of killing yourself?
CAGE (substance abuse screen) what does this stand for
Cutting down, Annoyance, Guilty feeling, Eye openers
T-ACE, CRAFT screen for what
alcohol screen
Adolescent screen for situational stress, substance abuse, relationship, safety screening:
HEEADSSS
Relationship screening (domestic violence):
“Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?”
“Do you feel safe in your current relationship?”
“Is there a partner from a previous relationship who is making you feel unsafe now?”
BATHE model:
is for what
situational stress
BATHE
Background: context of the visit
Affect: elicits the emotional response and allows the patient to label the feeling
Trouble: determines the symbolic meaning of the situation for the patient
Handling: helps to assess patient’s resources and responses to the situation
Empathy: reflects an understanding that the patient’s response is reasonable under the circumstances
Issues affecting sleep in women
Menopause: causes sleep disturbances, hot-flashes can awaken from sleep, reduce total sleep time, prolonged time to initiate sleep, and reduced REM sleep
Allow children to fall asleep on their own using self-comforting measures so that they can
fall back asleep during the night on their own
recommendations for a bedtime routine
no vigorous activity before bedtime, no caffeine, too-early bedtime can lead to problems falling asleep
Children may use resistance to bedtime as an issue of
control or pattern of oppositional behavior
nocturnal episodes of inconsolability, screaming, crying for up to 30 minutes (age 3-10 years)
Night terrors -
viral causes of sore throat
Rhinovirus (common cold)
Coronavirus (common cold)
Adenovirus (Acute respiratory disease)
Herpes simplex virus (HSV) 1 & 2 (stomatitis, pharyngitis)
Influenza A and B (Influenza)
Parainfluenza virus (common cold)
Epstein-Barr Virus (EBV) (Infectious mononucleosis)
Cytomegalovirus (CMV) (Infectious mononucleosis)
Human Herpesvirus (HHV) 6
HIV (primary HIV infection)
Group A B-hemolytic streptococcus (pharyngitis, tonsillitis)
Fusobacterium Necrophorum (pharyngitis, peritonsillar abscess, Lemierre syndrome (rare))
Group C beta-hemolytic streptococci (pharyngitis, tonsillitis)
Neisseria gonorrhoeae (pharyngitis)
Corynebacterium diphtheria (Diphtheria)
Mycoplasma pneumoniae (pneumonia, bronchitis)
Chlamydophila pneumoniae (pneumonia, bronchitis)
bacterial causes of sore throat
noninfectious reasons for sore throat
Persistent cough Postnasal drip Gastroesophageal reflux disease Acute thyroiditis Neoplasm Allergies Smoking
Fever, sore throat, muffled hot potato voice, drooling, and stridor presenting symptoms
Airway obstruction causing- wheezing, stridor, and drooling
Caused by H influenzae (swelling of epiglottis) and other viruses
Airway emergency
Epiglottitis
Diagnostic for Epiglottitis
Direct or indirect laryngoscopy
Be prepared to intubate patient or trach
Patient sitting in an erect position with stridor big sign
“Thumb sign” of swollen epiglottis on lateral neck films, negative film does not rule it out.
Rapid onset of severe throat pain
Moderate fever (39-40.5C)
Malaise
Headaches
Throat Examination
Edema, erythema of posterior pharynx and tonsils are often covered with grey/white exudates
Tender anterior cervical lymph nodes
GI symptoms: nausea, vomiting, abdominal pain (especially in children)
Untreated last 8-10 days
Postinfectious symptoms: acute rheumatic fever and post-streptococcal glomerulonephritis
Group A Beta- Hemolytic Streptococci pharyngitis
diagnosing Group A Beta- Hemolytic Streptococci pharyngitis
Throat culture- high sensitivity, high specificity 24-72 delay in results RADT (rapid antigen detection test) Results a few minutes Sensitivity 70-90% Specificity 90-100%
S/S
Fever, malaise, chills, and sweats. The classic triad of severe sore throat, fever and lymphadenopathy
15-24 years of age
Usually caused by EBV, but can be caused by CMV or HHV 6
Shed via salivary secretions
90% of adults are EBV seropositive
Physical exam findings
Enlarged tonsils, pharyngeal erythema, thick coating, pharyngeal exudate, palatal petechiae, and tender anterior and/or posterior cervical adenopathy (very specific for EBV)
Infectious Mononucleosis
Diagnostic Testing
Infectious Mononucleosis
Monospot test
-Specificity 99%
-Sensitivity
-False negatives 25% in first week
Serum IgM antibody
-Highly accurate test, takes longer
-Used when mono suspected but negative monospot
Elevated aminotransferases
Lymphocytosis and the presence of atypical lymphocytes
Severe fever, respiratory illness, begins abruptly (hit by a train), diffuse pain, respiratory symptoms (cough, rhinitis, pharyngitis), may have chills and headache, crackles in 25%
Usually have cough but may not in the elderly
Winter months
Usually no GI symptoms
Influenza
Diagnostic flu
History, physical exam, and vaccination status, also flu season vs. non flu season time.
RT- PCR (gold standard)
Rapid test
Patients with pneumonia should have additional testing for co-infection including a sputum gram stain, sputum and blood cultures, and urine for streptococcal and legionella antigen.
Septic thrombophlebitis of the internal jugular vein
Lemierre Syndrome
High fevers, rigors, respiratory distress, and neck/throat pain
Exam may reveal ulceration, pseudomembrane or erythema
Tenderness and swelling may be observed overlying the jugular vein
May have no abnormal physical findings
Rare but life threatening
Usually caused by 81% F necrophorum
Some symptoms sometimes seen but not seen in pharyngitis is dyspnea, pleuritic chest pain, abdominal pain, and trismus
Can see emboli from septic thrombophlebitis also cause bone and joint complications, liver abscess, CNS complications
Septic thrombophlebitis and septic emboli can mask the initial complications of oropharyngeal symptoms
Lemierre Syndrome
Diagnostic for Lemierre Syndrome
Anaerobic primary infection of the oropharynx
Subsequent septicemia (1 positive blood culture)
Metastatic infection of 1 or more distant site
Thrombophlebitis of the internal jugular vein
CT scan of neck with contrast is best diagnostic modality
S/S- severe unilateral sore throat, fever, muffled hot potato voice, malaise,
dysphagia, otalgia, pain when swallowing, drooling of saliva, trismus (difficulty opening mouth d/t pain)
Exam reveals- extremely swollen tonsil with the displacement of the uvula to the unaffected side, bulging soft palate on the affected side, tender cervical lymphadenitis on the affected side
Peritonsillar Abscess
nonspecific and resolve spontaneously without treatment
Fever, lymphadenopathy, sore throat, rash, myalgia/arthralgia, headache, and mucocutaneous ulcers
Highest in men who have sex with men, injection drug users, commercial sex workers, high number of sexual partners
Primary HIV Infection- Acute Retroviral Syndrome
testing for Primary HIV Infection- Acute Retroviral Syndrome
Fourth generation HIV immunoassay
HIV viral load assay
Children and/or adults
Symptoms similar to epiglottitis but recent hx of upper respiratory infection or trauma from recent ingested material (bones) or procedures
Retropharyngeal Abscess
Epiglottitis vs retropharyngeal abscess
Sense lump in throat
Comfortable supine with neck extended (opposite of epiglottitis
Diagnosis of Retropharyngeal Abscess
Thickening of the retropharyngeal tissues is seen on lateral neck radiographs
If xray normal CT scan should be done to verify the diagnosis
viral vs bacterial pharyngitis
Cough, coryza, rhinorrhea, and hoarseness, congestion, conjunctivitis, sometimes diarrhea
Usually rhino, adeno, corona
viral
Fevers, throat pain, but usually associated with cough and myalgias
Influenza (Viral)
-fever, sore throat, ages 15-24, and associated with malaise and marked adenopathy
EBV
Nonspecific symptoms of pharyngitis, fever, mucocutaneous ulcers, adenopathy, fatigue, and should be considered in people with high risk behaviors
HIV (Viral)
Fever, tender anterior cervical lymphadenopathy, tonsillar erythema with or without tonsillar swelling and exudates.
Bacterial
Early stage
Signs- microaneurysms and retinal hemorrhages
Lack of perfusion leads to ischemia due to cotton wool spots, venous bleeding, and intraretinal vascular abnormalities
nonproliferative retinopathy
Advanced
New blood vessels on the retina or optic disk d/t ischemia
Vision loss occurs due to vitreous hemorrhage, fibrosis, or retinal detachment
Proliferative diabetic retinopathy
Happens at any stage of retinopathy
Leading cause of vision loss in persons with diabetes
Increased vascular permeability causes plasma leaks from the macular vessels, leading to swelling and formation of hard exudates at the central retina
Diabetic macular edema
Eye changes are more likely to occur when
risk factors are present such as duration of DM, elevated HbA1C level, hypertension, dyslipidemia, pregnancy, and nephropathy
Type 1 and 2 DM common complications
Retinopathy Peripheral neuropathy and foot ulcers Nephropathy Dyslipidemia Hypertension Smoking Obesity Coronary artery disease Cerebrovascular disease HHS DKA Peripheral arterial disease Foot ulcers Osteomyelitis
when do you screen for diabetic retinopathy in Type 1DM
within 5 years of dx onset and annual exams
when do you screen for diabetic retinopathy in Type 2DM
time of diagnosis and at least annual exams
Important physical examinations specific to individual with DM
Obesity, particularly central
Hypertension
Eye-hemorrhages, exudates, neovascularization
Skin-acanthosis nigricans (particularly in the dark skinned ethnic and racial groups) candida infections
Neurologic-decreased or absent light touch, temperature sensation and proprioception; loss of deep tendon reflexes in ankles
Feet-dry, muscle atrophy, claw toes, ulcers.
cc earache
why would you ask if anyone around them smokes
secondhand cigarette smoke exposure has been associated with a 2-3fold increased risk of otitis media (leads to functional eustachian tube obstruction and decreases the protective ciliary action in the tube.)
what does recent trip in airplane or scuba diving have to do with earrache
barotrauma is a cause of acute serous otitis r/t pressure changes from flying or scuba diving.
diabetes and earrache
predisposes adults to malignant otitis externa (cellulitis involving ear and surrounding tissue)
also at increased r/o otitis media, mastoiditis, osteomyelitis
immunosuppression and earrache
increased risk for malignant otitis externa (cellulitis involving ear and surrounding tissue)
also at increased r/o otitis media, mastoiditis, osteomyelitis
history of seborrheic dermatitis or psoriasis and earrache
overproduction of sebum in external canal can cause otitis externa
history of cleft palate and earrache
anomalies that are not repaired anatomically predispose a child to otitis media because of functional obstruction of eustachian tubes
jaw pain described as severe lasting a few min and returning 3-4 times per day sometimes associated with headache. worse in morning.
TMJ
infant crying when sucking
pain with compression and increased pressure in ears
itching or drainage from ear
infection or inflammation of external canal
Itching, burning or tingling of ear can be a precursor to
herpes zoster of the trigeminal nerve (cranial nerve V) which can cause paroxysmal pain of face and jaw and hyperalgesia to minimal stimulation such as tooth brushing, cold air and grimacing
foul smelling discharge from ear
perforation of TM
Why do you ask about recent trauma to ear, head trauma and how do you clean your ears?
in cc of earrache
perforation of eardrum can be caused by blunt or penetrating trauma. Blunt trauma might include a slap to ear, barotrauma. Penetrating trauma to canal or TM may be self induced with cotton tipped swabs or other sharp objects when trying to remove cerumen
hearing loss tinnitus pressure sensation vertigo infection
cerumen impaction
self cleaning can produce trauma
cerumen softening solutions can cause chemical irritation to canal tissue
ear pain and inflammation
foreign bodies such as feathers, beads, and insects (cockroaches) can produce ear pain and inflammation
exposure to high pitched and loud noises for a prolonged period of time destroys ____
cochlear hair cells. increases risk of injury and eventually hearing loss.
the most frequent cause of hearing loss is conductive hearing loss caused by
blockage of the external canal, usually by cerumen
presbycusis
age related hearing loss - adults older than 65
chronic otitis media in children causes a _____ hearing loss
conductive
negative middle ear pressure, presence of effusion in middle ear, or structural damage to the TM or ossicles
Hearing loss associated with dizziness, vertigo, tinnitus may indicate a
serious inner ear condition such as acoustic neuroma or Meniere disease
young infants irritability poor feeding congestion fever
otitis media
older infants and young toddlers
pull on the painful ear
bang their head on affected side
otitis media
battle sign
hemorrhage over mastoid bone - may occur with a basal skull fracture
appear as white or dark patches to ear
fungal or yeast infections
a hot swollen and erythemous ear and surrounding skin
cellulitis
redness and painful swelling over the mastoid process is a
sign of infection in the mastoid air cells
In mastoiditis the pinna is _______
displaced forward
pain on manipulation of the pinna and tragus
otitis externa
Postauricular swelling may indicate
extension of infection into the mastoid cavity
Vesicles on the external ear canal and auricle may indicate
herpes zoster (Ramsay hunt syndrome)
what kind of discharge can be seen with otitis externa
cheesy, green-blue or gray discharge
what does a normal TM look like
translucent and pearly gray in color
Mild diffuse redness of the tympanic membrane can occur from
cyring or coughing
scarring and effusion can cause what to the TM
whitening and opacification
the contour of the normal TM is somewhat
concave
fullness or bulging of the TM indicates
either
increased air pressure
increased hydrostatic pressure in the middle ear
Fullness of the eardrum is seen first around the
periphery of the TM. As pressure increases, central fullness becomes visible
what is associated with negative middle ear pressure or postinflammatory adhesions
concavity or retraction of the eardrum
As the eardrum retracts, the handle of the malleus short process becomes
more visible
red inflamed eardrum without effusion
myringitis
extremely painful condition of small blisters on the TM caused by bacterial otitis media
Bullous myringitis
chronic otitis media can lead to
cholesteatoma - a cyst like mass behind the eardrum
what cranial nerve is acoustic for hearing
CN VIII
which hearing test is performed with the tuning fork
Weber test
what type of hearing loss results when sound transmission is impaired through the external or middle ear
conductive hearing loss
what type of hearing loss results from a defect in the inner ear
sensorineural hearing loss
what tests help differentiate conductive hearing loss from sensorineural hearing loss
Webber and Rinne
how do you evaluate the trigeminal nerve (CNV)
observe jaw and facial muscle movement for symmetry and strength by palpating over the masseter muscles and ask the pt to bite and clench their teeth.
Assess intactness of sensation to pain and light touch using a sharp and dull stimulus over the 3 branches of CN V
how do you evaluate CN VII and CN IX
taste and sensation to tongue and sensation to external ear. Have pt protrude the tongue and apply sweet and salty substances separately to each half of the tongue to test CN VII and bitter and sour substances to test CN IX
most often occurs in children younger than 6 and associated with URIs
Acute otitis media
painless ear infection caused by a mechanical process or eustachian tube blockage that leads to inadequate ventilation of middle ear
otitis media with effusion
anterior cervical lymphadenitis is a common cause of
referred ear pain in children. may be seen with strep throat and mono
what cranial nerves are associated with referred ear pain
V, VII, IX and X
CN V
trigeminal
CN VII
facial
CN X
vagus
CN IX
glossopharyngeal
chronic laryngitis (longer than 2 weeks) needs to be evaluated for
neoplasm - most often squamous cell carcinoma. Chronic laryngitis rarely has an infectious cause
recurrent episodes of hoarseness may indicate
allergies
sinusitis with postnasal drip
laryngeal reflux
systemic disease
progressive hoarseness usually indicates
lesion such as laryngeal or hypopharyngeal cyst
hoarseness from birth may indicate
a congenital problem such as laryngeal web cyst palsy angioma congenital anomaly papilloma vocal cord paralysis
hoarseness or voice change is a sign of what cranial nerve
X (vagus nerve)
damage to CN X can be the result of
hormone imbalance
bacterial infection
tumor
voice surgery by transgender population can injure the tissues of the vocal fold
children with epiglottitis are not hoarse but as the epiglottis swells the voice becomes
muffled and drooling is observed
Chronic consumption of smoking and hard liquor is a direct irritant and associated with
laryngeal cancer
what should be considered in patients with hoarseness who have failed to update their diphtheria and acellular pertussis (Td/Tdap) vaccination
Laryngeal diphtheria
Td/Tdap vaccination is recommended once then Td boosters every
10 years, pregnant women are advised to get Tdap during each pregnancy
Hoarseness that is altered by a position change suggests
a mobile lesion such as a pedunculated polyp
pt who has normal voice in the morning with progressive hoarseness throughout the day
Myasthenia Gravis
the presence of cough , sob, weight loss, dysphagia, ear pain or throat pain should raise concerns about
neoplasm
Hoarseness and thyroid
associated with late sign of hypothyroidism
dysphagia hoarseness vomiting chronic cough in child
GERD
habit of frequent throat clearing and sensation of lump in the throat
chronic cough or throat clearing. hoarseness in morning and coughing at night
GERD
voice or whisper test assesses what cranial nerve
VIII
adults will report severe and rapidly progressing symptoms of sore throat, dyspnea and hoarseness. In children there is no cough or hoarseness but drooling with a forward leaning posture. Voice quality is froglike
Acute epiglottitis
croup is most often caused by
parainfluenza virus 1
croup is most common in children ages
3mos - 3 years
leukoplakia (white scaly appearance to vocal cords)
do not usually report pain
laryngeal cancer
pain secondary to ulceration is late and often perceived as ear pain, esp when swallowing
associated with a low gravelly voice
hypothyroidism - the degree of hoarseness depends on the severity of thyroid deficiency
weak, breathy voice
vocal cord paralysis
usually unilateral caused by pressure on the vagus or recurrent laryngeal nerve by a mass of malignant glands in the superior mediastinum or carcinoma of thyroid or esophagus
low breathy voice with no found cause usually after a traumatic event
psychogenic hoarseness
most common laryngeal lesions in childhood between ages 2-7
laryngeal papilloma
can be seen in newborn caused by HPV
acute symptoms of rhinitis or sinus congestion usually lasts and caused by
48 - 72 hrs
caused by edematous mucosa obstructing the sinus ostia
fever
myalgias
chills
acute infectious rhinitis are caused by
rhinoviruses
Parainfluenza virus
adults with symptoms that last more than 3 weeks
upper molar pain or headache
postnasal drip
nausea
chronic rhinitis rarely infectious
anatomical abnormalities that impair sinus drainage system
in children chronic sinusitis is defined as presence of symptoms for longer than
30 days
produces pain that worsens with bending or leaning forward. The postnasal produces a cough that worsens when laying down
Maxillary sinusitis
chronic sinusitis can be attributed to
infection
growths in the sinuses (polyps)
deviation in nasal septum
seropurulent nasal discharge is often present with
acute bacterial infection of the nasal and sinus mucosa
sneezing
nasal congestion
clear and profuse rhinorrhea
pruritis of nose, palate, pharynx, and middle ear
conjunctival irritation
feeling of fullness in ears
pressure or pain of cheeks, forehead or behind eyes
allergic rhinitis
unilateral rhinitis symptoms are more indicative of
anatomical cause or foreign body
the use of topical sympathomimetic sprays or drops for more than 1 week can lead to
rebound congestion or vasodilation after short periods of vasoconstriction
what medications may cause nasal congestion
oral contraceptives
phenothiazines
ACE inhibitors
B blockers
what rec drug can cause rebound nasal congestion
chronic or acute cocaine use
facial inspection for rhinitis/sinusitis
allergic salute - a crease on nose from continued wiping up of nasal drainage
allergic shiners - dark circles under eyes suggestive of venous congestion and stasis
halitosis can be a sign of
dental abscess or sinusitis
lymphoid hyperplasia or cobblestoning
may be seen on the posterior pharynx with chronic allergies
pale swollen and wet turbinates are seen with
allergic rhinitis
produces a violet colored mucous membrane
allergic rhinitis
foul smelling unilateral purlent discharge may indicate
a foreign body in the nasal cavity
how do you identify CSF leak
test nasal drainage for glucose and protein levels
foul smelling nasal discharge is characteristic of
sinusitis of dental orgin
light will pass through
air filled sinuses
normal transillumination of the frontal sinus r/o _____ in 90% of cases
frontal sinusitis
presence of yellow or green purulent discharge and red nasal mucosa
Infectious rhinitis
recurrent rhinorrhea with clear watery mucus, sneezing and pruritis
allergic rhinitis
associated with eosinophilia on a nasal smear
nonallergic rhinitis
drug induced rebound congestion that can follow the use of topical nasal decongestants
rhinitis medicamentosa
purulent nasal discharge, postnasal drip and localized facial pain over the sinus involved. often follows a URI
Acute sinusitis
the diagnosis of sinusitis in children requires
2/3 major criterion
- cough
- purulent nasal discharge
- purulent pharyngeal drainage
or 1 major and 2 minor
- sore throat
- wheezing
- foul breath
- facial pain
- periorbital edema
- headache
- earache
- fever
- toothache
persistent symptoms of low grade infection and intermittent acute exacerbations typical of acute sinusitis
chronic sinusitis
this syndrome has multiple causative factors including history of asthma and aspirin intolerance.
nasal polyposis
the polyps are translucent, grape like growths that are mobile, rarely bleed and prolapse into nasal cavity. any suspicious polyps should be biopsied
can occur as a complication of sinusitis. may also follow head trauma or scuba diving
osteomyelitis of frontal bone
pt appear severely ill and may have edema of upper eyelid and puffy swelling over the frontal bone
osteomyelitis of frontal bone
what type of chemical burn is worse to the eye
alkali more damage than acid burns because they penetrate ocular tissues more rapidly
what do you do for a chemical burn
immediate and profuse irrigation to eye with water or saline wash for at least 15 min
referral to ophthalmology
acute redness can be caused by infection of the conjunctiva or eyelids
conjunctivitis
unilateral eye redness is more likely to indicate
trauma or infection
bilateral eye redness is more likely to indicate
allergy or underlying systemic pprocess
inflammation of the eyelids
causes itching and crusting of the lash line
usually bilat
Blepharitis
produces redness at base of eyelashes and usually unilateral
Hordeolum (stye)
chronic granulomatous inflammation of the meibomian gland which is in the middle of the eyelid, often on the conjunctival side. Usually unilateral but may involve both eyes
chalazion
unilateral painful, inflamed eye with photophobia and often a foreign body sensation without a history of significant trauma may indicate
glaucoma
keratitis with corneal ulceration
constant, boring, throbbing pain often severe enough to interfere with sleep can result from
ocular inflammation associated with iritis
acute glaucoma
scleritis
produce a gritty sensation in eye
viral causes of conjuncivitis
vision changes in conjunctivitis?
no
vision is mildly decreased in
iritis
vision is markedly decreased with
acute glaucoma, corneal abrasions or ulcers
sudden diminution in or loss of visual acuity is
an ocular emergency and may indicate corneal or uveal tract disorders
retinal tears or detachment
acute glaucoma
orbital cellulitis
true double vision becomes single vision when
one eye is covered
visual halos
corneal edema
water drops in cornea or lens (seen in corneal edema or cataract)
visual floaters or flashing lights
may occur with vitreo-retinal traction. May progress to a retinal tear or detachment
patients will give a history of blurred or blackened vision over several hours that progresses to complete or partial monocular blindness often described as curtains dropping
retinal detachment
copious purulent discharge to eyes
N. gonorrhoeae infection
watery discharge that may affect only one eye
viral conjunctivitis
a neonate who is 24 hours old with mucoid or purlent ocular discharge indicates
chemical conjunctivitis from prophylactic instillation of erythromycin ophthalmic ointment
severe bilat purulent conjunctivitis 3-7 days after birth may indicate
gonococcal infection of the eye
discharge 5-30 days postpartum may indicate
chlamydial conjunctivitis
photophobia indicates
ocular inflamation or irritation
in infants and young children, photophobia signals
a serious condition such as juvenile arthritis intraocular tumors congenital glaucoma keratitis trauma
Epiphora
excessive production of tears is common with viral conjunctivitis, corneal abrasions, infantile glaucoma, nasal lacrimal duct stenosis
itching and tearing disproportionate to findings are hallmark of
allergic conjunctivitis
low grade to moderate fever,
mucopurulent rhinorrhea
cough
crusting of eyelashes
otitis-conjunctivitis syndrome
what virus has emerged as an infection contracted in warmer climates and may appear as viral conjunctivitis and often accompanied by fever, rash and arthralgia
Zika Virus
for young children or adults not able to use the snellen or sloan chart, use
HOTV characters or LEA symbols
visual acuity chart for children older than 3 1/2 and adults
use snellen, tumbling E or Lippman chart
in children the referral standard for visual acuity is
20/40 or worse in both eyes or a 2 line difference between eyes
infection of the lacrimal sac that occurs secondary to obstruction
Dacryocystitis
scratchy sensation, no photophobia, purulent discharge and matted eyelids
bacterial conjunctivitis
scratchy sensation
watery discharge
eyelids may have follicular changes in the palpebral conjunctiva
viral conjunctivitis
chronic seasonal condition caused by hypersensitivity to a specific allergen
bilat
itchy
painless
ropy, mucoid discharge
palpebral conjunctiva has a cobblestone appearance
allergic conjunctivitis
blood in the anterior chamber of eye, usually produced by trauma to eye. Marked decrease in vision with RBCs present. pupil is irregular and poorly reactive
Hyphema
no discharge
lacrimation
photophobia
visual acuity unimpaired
episcleritis
inflammation of sclera can result in severe destructive disease. unilateral associated with RA, or other autoimmune
pain
Lacrimation is present
visual acuity is variable
Scleritis
bacterial, fungal and viral organisms can cause infection to the cornea, which leads to corneal ulceration and potential destruction of the cornea moderate to severe eye pain some discharge visual acuity decreased cornea appears cloudy
keratitis
moderate to severe pain with discharge present
photophobia
corneal abrasion
fluorescein stain is taken into the ulcer and can be seen under a wood lamp
pain photophobia diffuse or ciliary injection possibly discharge visual acuity markely decreased dendritic lesions seen with fluorescein staining
Herpetic infection cause by herpes simplex virus
severe or chronic outbreaks of herpes zoster may cause
glaucoma
cataract formation
double vision
scarring of cornea
unilateral eyelid swelling
redness
fever
Conjunctiva is clear,
periorbital cellulitis
unilateral eyelid swelling fever pain proptosis chemosis conjunctivitis
orbital cellulitis
life threatening and requires immediate attention
inflammation of iris and ciliary body
iritis
chronic glaucoma
open-angle glaucoma
acute glaucoma
angle -closure glaucoma
unilateral deep eye pain photophobia halos around visualized objects decreased visual acuity pupil is mid dilated and decreased reactivity to light cornea is cloudy
angle closure glaucoma
emergency
doughnut lesions (red, raised hemorrhagic lesions with yellow center)
streptococcal pharyngitis
a bright red uvula and presence of petechiae on posterior pharynx and palate indicate
group A streptococcal pharyngitis
curdlike patches that bleed on scraping are characteristic of
oral candidiasis
in ____ ____ the anterior cervical lymph nodes are often enlarged and tender
streptococcal pharyngitis
in ____ _____ the posterior cervical nodes are often enlarged
viral infections
what type of pneumonia is associated with sore throat
mycoplasma pneumoniae
splenomegaly is found in about half the cases of
mononucleosis
history of resp symptoms difficulty swallowing otalgia malaise fever toxic appearance refusal to swallow - drooling, stridor
peritonsillar or retropharyngeal abscess
fever temp 38.5/101.5 or higher
tonsillar exudate
anterior cervical adenopathy
history of recent exposure
streptococcal pharyngitis
causative agent for mononucleosis is
EBV
low grade fever mild sore throat posterior cervical lymphadenopathy weight loss pronounced malaise and fatigue
Mononucleosis
Diagnosis for mononucleosis
monospot
CBC
splenomegaly
exudative pharyngitis
bilat cervical lymphadenopathy
history of orogenital sexual activity
may have no symptoms
gonococcal pharyngitis
gram staining or culture to confirm diagnosis
herpangina caused by
cox sackievirus
painful sore throat fever malaise headache anorexia neck, abd and extremity pain may occur small grayis papulovesicular lesions on solft palate, pharynce
cox sackievirus
caused by a fusospirochetal infection that results in necrotizing ulcerative gingivostomatitis
painful ulcers foul breath bleeding gums usually no fever gray necrotic ulcers without vesicles on the gingivae and interdental papillae
vincent angina
to confirm do gram staining to show spirochetes
discrete ulcers without preceding vesicles
located on inner lip, tongue and buccal mucosa
lasts 1-2 weeks
Aphthous stomatitis “canker sores”
fever
headache
sore throat
lymphadenitis
characteristic clusters of yellow vesicles appear on the palate, pharynx and gingiva that last 2-3 weeks
recurrent lesions have prodromal symptoms of burning, tingling, or itching
Herpes simplex virus type I
yeast infection that produces white plaques over tongue and oral mucosa with erythema . Bleeds when scraped
candidiasis
who do you see oral candidiasis in
infants in the first 5 weeks of life
immunocompromised people
diabetics
people taking abx or using inhaled steroids
device that measures intraocular pressure
tonometer
IOP > 21 is high risk for glaucoma
the most common cause of vision loss in children is
amblyopia (lazy eye) and strabismus (2 eyes do not point in the same direction)
when the cornea and lens of the eye focus on the image in front of the retina
myopia (nearsightedness)
a refractive error where the focus of an image is behind the retina
hyperopia (farsightednes)
an irregularity in the refractive system of the eye that prevents light from being focused onto the retina
astigmatism
any opacity of the crystalline lens of the eye
cataracts
first sign of opacity
the inability to focus on near objects (presbyopia) and altered color vision
associated with MS, after viral infection and with granulomatous inflammatory conditions. Seen in adults 20-50.
vision loss occurs over a few hous to days. Pain precedes vision loss in most patients
optic neuritis
some have loss of peripheral vision and others lose central vision
affects optic nerve
optic nerve hypoplasia
most common intraocular tumor of childhood
retinoblastoma
common symptom is strabismus
can spread to brain through optic nerve or into bone marrow
retinoblastoma
seen in premature infants
refers to changes of ischemia, blood vessel growth and fibrosis that occur bc of inadequate oxygen delivery to peripheral retina.
Retinopathy of prematurity
what infants are at greatest risk for retinopathy of prematurity
infants who weigh less than 1500g
sudden onset of severe vision loss in one eye. no associated pain. caused by plaque lodging at level of the lamina cribrosa
a few hours later the retina becomes edematous and white or opaque. There is a reddish-orange reflex from the intact choroidal vascular and foveola that creates a cherry red spot
central retinal artery occlusion
with time the retinal artery opens and the retinal edema clears.
loss of vision caused by increased pressure in the eye. characterized by defects in the visual field and optic nerve damage.
glaucoma
leading cause of blindness in the US
glaucoma
what type of glaucoma is associated with another ocular or nonocular event
secondary glaucoma
brief flashes of light (photopsia) or floaters (entopsia)
retinal detachement
risk factors for macular degeneration
advanced age family history cigarette smoking hyperopia hypertension
rapid vision loss caused by development of abnormal blood vessels that grow from the choroid into the macular portion of the retina. leak blood and fluid.
blurred vision is common early symptom. vision loss may be rapid and severe
Wet (exudative) macular degeneration
associated with breakdown of light sensitive macular cells and gradual loss of central vision. distortion upon testing with amsler grid
dry (nonexudative) macular degeneration
micro aneurysms
macular edema
lipid exudates
intraretinal hemorrhages
may be asymptomatic or have decreased vision or floaters
diabetic retinopathy
inflammatory activity of the iris, ciliary body and choroid
decrease in vision
light sensitivity
tearing
uveitis
inflammation of the cornea that creates pain, redness and blurred vision
keratitis
optic nerve gliomas present as what in adults
malignant glioblastomas
optic nerve gliomas present as what in children
benign pilocytic astrocytomas
optic nerve gliomas that appear in children younger than 10 are highly associated with
neurofibromatosis - associated with cafe au lait lesions of the skin
in children
rapid onset of vision loss with headache
optic nerve glioma
tumors that arise from squamous epithelial cells of the brain
craniopharyngioma
headache visual disturbance caused by increased intracranial pressure nystagmus bitemporal hemianopsia children
craniopharyngioma
infants
retinitis
optic nerve hypoplasia
maternal exposure to measles
Congenial TORCH infections
screening tool for depression
PHQ - 9
what pneumonic do you use to dig into depression more
Sleep disorder interest deficit guilt energy deficit concentration deficit, appetite disorder, psychomotor retardation agitation suicidality
