Midterm Exam Review – NR511 / NR 511 (Latest 2024 / 2025) : Differential Diagnosis & Primary Care Practicum – Chamberlain

NR-511 Differential Diagnosis & Primary
Care Practicum
Midterm Exam Review
What is specificity of a test (equation)
✓ True negatives / #false pos + true neg
What is sensitivity of a test (equation)
✓ True positives / #false negative + true positives
What is the prevalence of a disease
✓ Number of cases at a given time
What is the incidence of a disease
✓ The number of new cases that occur over a period of time
What is the positive predictive value (definition not equation)
✓ How likely it is that the positive result is actually positive
What is the negative predictive value (definition not equation)
✓ How likely it is that the negative is really negative

What is the positive predictive value (equation)
✓ # True positives /total tested positives (false pos and true pos)
What is the negative predictive value (equation)
✓ True negatives / total tested negatives (false neg and true neg)
What does low specificity of a test mean?
✓ You get higher incidence of false positives
What does low sensitivity of a test mean
✓ High occurrence of false negatives
What does high specificity of a test mean
✓ Accurately identifies truly un-diseased people
What does a high sensitivity of a test mean
✓ Correctly identifies actually positive diseased patients
T or F: the HPI is a breakdown of the chief complaint
✓ True
What is needed to make sound clinical decision (3)
✓ EBP / research
✓ Clinical practice guideline
✓ Algorithms (evidence based)

Patients on Medicare usually have _ % out of pocket costs
✓ 20
How do traditional Medicare patients pay for the 20% out of pocket costs that they have
when on this plan
✓ Usually get secondary insurance
Medicare part a covers (4)
✓ Inpatient hospital
✓ SNF
✓ Hospice
✓ Home health
Medicare part b covers (7)
✓ Outpatient services, md visit, surgery, lab, equipment, preventative exams
Traditional Medicare includes which parts? Are they free?
✓ A and B; no – part b has a premium and usually both have 20% out of pocket
costs
Medicare part c includes
✓ Wellness services, vision, hearing, glasses, hearing aids and sometimes
dental

Medicare part d includes
✓ Prescriptions
Which parts of Medicare are part of the advantage plan
✓ A b and d are usually bundled and sometimes c
What is the difference between traditional Medicare and advantage plan
✓ Advantage – through a private insurance that follows Medicare standards –
usually part a b and d
Medicare – government run, usually only part a and d
Who qualifies for Medicare? (3)
✓ Persons 65 years or older
✓ People with permanent kidney failure
✓ Person who has been on some social security program for at least 24
months / disability
Who has lower copayments – Medicare traditional or Medicare advantage
✓ Advantage
How are Medicare advantage carriers paid by CMS?
✓ Subsidies per member / per patient
What is the reimbursement percentage for NPS
✓ 85% of physician reimbursement
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what is specificity of a test (equation)

true negatives / #false pos + true neg

what is sensitivity of a test (equation)

true positives / #false negative + true positives

what is the prevalence of a disease
number of cases at a given time

what is the incidence of a disease
the number of new cases that occur over a period of time

what is the positive predictive value (definition not equation)
how likely it is that the positive result is actually positive

what is the negative predictive value (definition not equation)
how likely it is that the negative is really negative

what is the positive predictive value (equation)

true positives /total tested positives (false pos and true pos)

what is the negative predictive value (equation)

true negatives / total tested negatives (false neg and true neg)

what does low specificity of a test mean?
you get higher incidence of false positives

what does low sensitivity of a test mean
high occurrence of false negatives

what does high specificity of a test mean
accurately identifies truly undiseased people

what does a high sensitivity of a test mean
correctly identifies actually positive diseased patients

T or F : the HPI is a breakdown of the chief complaint
true

what is needed to make sound clinical decision (3)
EBP / research
Clinical practice guideline
algorithms (evidence based)

patients on medicare usually have _ % out of pocket costs
20

How do traditional medicare patients pay for the 20% out of pocket costs that they have when on this plan
usually get secondary insurance

medicare part A covers (4)
inpatient hospital
SNF
hospice
home health

medicare part B covers (7)
outpatient services, MD visit, surgery, lab, equipment, preventative exams

traditional medicare includes which parts ? are they free?
A and B ; no – part B has a premium and usually both have 20% out of pocket costs

medicare part c includes
wellness services, vision, hearing, glasses, hearing aids and sometimes dental

medicare part D includes
prescriptions

which parts of medicare are part of the advantage plan
A B and D are usually bundled and SOMETIMES C

what is the difference between traditional medicare and advantage plan
advantage – through a private insurance that follows medicare standards – usually part A B and D

medicare – government run, usually only part A and D

Who qualifies for Medicare? (3)
Persons 65 years or older

people with permanent kidney failure

person who has been on some social security program for at least 24 months / disability

who has lower copayments – medicare traditional or medicare advantage
advantage

how are medicare advantage carriers paid by CMS?
subsidies per member / per patient

what is the reimbursement percentage for NPs
85% of physician reimbursement

what are the 7 categories of third party payers
medicare
medicaid
indemnity (fee for service)
managed care orgs
workers comp
VA
auto liability

what is a third party payer system
An organization other than the patient and the provider (insurance company) is paying for services

what is a papule
A raised area of the skin that is generally smaller than 1 centimeter

What is a macule?
a flat lesion that differs in color from surrounding skin (<1 cm in diameter)

typically brown, red, white

what is a nodule
under the skin elevated mass <2cm

what is a plaque (skin)
a raised area > 1 cm

what is a vesicle
fluid filled sac <1cm

what is a blister AKA bullae
fluid filled sac >1cm

what is urticaria
wheal or hive

what is the difference between erosions and ulcers
ulcers = dermis and epidermis

erosion = epidermis

what are petechiae
tiny non-raised red or purple spots that appear on the skin from rupturing of the capillaries

what does skin atrophy look like
thinning skin, like paper

what is telangiectasia?
capillary ruptures

look like varicose veins or petichiae with lines

nummular versus annular
annular – circle with central clearing

nummular – circle with no central clearing

what are verrucous lesions
wart like

what is lichenification
thickening of the skin

what is a xanthoma
yellow tumor / yellow bump – can have fatty contents

most defining characteristic on assessment of fungal skin infections
papular rash with satellite lesions

how to diagnose fungal skin infection
presentation

most common fungal skin infection
candida albicans

nonspecific treatment for fungal infections
reduce moisture, antifungal

who is most at risk for fungal infections (10)
immunocompromised (with altered cell immunity)
AIDs
old
young
DM
on ABX
steroid treatment
chemo
invasive parenteral catheterization
internal monitoring device

tinea corporis
ringworm of the body (fungal)

tinea pedis
A ringworm fungus of the foot (athletes foot)

how tinea appears
annular lesions with scaly borders and central clearing

tinea cruris
ringworm of the groin / jock itch (fungus)

balanitis
candidiasis of glans penis

tinea vesicolor
fungal infection of skin caused by yeast (not ringworm fungus).

how does tinea versicolor present
flat to slightly elevated brown papules and plaques that scale when rubbed

have areas of hypopigmentation

where does tinea versicolor mostly occur
trunk and shoulders

what is onychomycosis or tinea unguium
fungal infection of the nail

how does onychomycosis present
white or yellow nail discoloration, thickening, and separation of nail from nail bed

treatment for onychomycosis (6)
Topicals:
nystatin (nyamyc pedi dry nystop,) clotrimazole, miconazole, naftifine (naftin), terbinafine, ciclopirox

who is at risk for dry skin and why
older adult ; dehydration, polypharmacy, diuretics

education for older adult with dry skin
tepid water with mild cleansing cream or soap

general presentation of bacterial skin infection
warm, red, pain, withOUT sharp demarcation

cellulitis
infection of epidermis and SQ
usually with skin break

folliculitis – what is it and its presentation
infection of hair follicle

papules common

impetigo
bacterial skin infection common to children

how does impetigo present
honey, colored crusted lesions filled with pus on nose, lips

progress from vesicle to pustule to lesion

what is the difference between impetigo and ecthyma
ecthyma – ulcerated with eschar , punched out appearance

impetigo – bullous or non bullous but not usually with eschar

organisms that cause impetigo and ecthyma
impetigo: group A or group B hemolytic strep

ecthyma: group A hemolytic strep

bullous versus nonbullous impetigo
bullous: flaccid bullae with clear, yellow fluid, usually on trunk (can crust, but not as crusty as nonbullous)

nonbullous: papules that become vesicles but usually on face and extremities (usually more crusted appearance than bullous, more honey crusting)

nonskin symptoms of impetigo / ecthyma
regional lymphadenopathy

besides Group a and b strep, what other organisms can cause impetigo and ecthyma
less likely but:
Staph aureus
MRSA

treatment for S. Aureus impetigo or ecthyma
dicloxacillin

cephalexin

both 250mg to 500mg QID for 10 days

treatment for streptococcus impetigo or ecthyma
dicolaxillin

penicillin

cephalexin

treatment for MRSA impetigo or ecthyma
doxicycline

clindamycin

sulfamethoxazole/trimethoprim (Bactrim)

what is an epidermal inclusion cyst
benign nodule that contains normal , viable epidermis

what is the common presentation of an epidermal inclusion cyst
HX of present at site for months to years without change

what is inside an epidermal inclusion cyst
white cheesy odorous discharge

What is a furuncle?
deeper infxn at hair follicle aka hair follicle abscess

difference between furuncle and epidermal inclusion cyst
furuncle – very acute, inflammatory, few days to form

inclusion cyst – slow, not inflammatory

what is inside a furuncle or carbuncle
purulent yellow or green discharge (abscess)

what are cholinergic urticaria and where do they present
hives / wheals that are exercise, anxiety, heat induced

occur on trunk and arms

what is the treatment for urticaria
antihistamines

when should epi be given in hives situation
when rash around neck face or if symptomatic of anaphylaxis

what is the type of reaction that occurs in hives
type 1 hypersensitivity

what is a type 1 hypersensitivity

• IgE MEDIATED
• involves MAST CELLS and BASOPHILS
• URTICARIA, ANAPHYLAXIS, ASTHMA

what is atopic dermatitis
aka eczema

scaly patchy dry on elbows or knees

can be red and swollen

cardinal sign of atopic dermatitis
severe pruritis – itching comes before the rash

treatment for atopic dermatitis (nonpharmacologic)
avoid soap
apply emollient

common place for atopic dermatitis (esp in kids)
antecubital fossa
popliteal fossa

medication management for atopic dermatitis
topical corticosteroids
Burrows solution (aluminum triacetate)
silver nitrate

typically avoid antihistamines as they do not usually help

herpes simplex virus presentation
oral (type 1) genital (type 2) blistering / vesicular lesions

when to treat herpes simplex
in immunocompromised individuals with symptoms

what is the treatment for herpes simplex
famciclovir

valacyclovir

What is herpes zoster?
shingles

how does herpes zoster present

• Densely grouped vesicular rash.
• Erythema.
• Pain, tenderness and paraesthesia may precede rash.
• Vesicles become pustular and form crusts.

unilateral along a dermatome (nerve path)

which dermatome is most common in shingles
thoracic or lumbar

stages of shingles lesions
papular to vesicular to rupture to crust to scab

what is the first line treatment for acne
benzoyl peroxide

when are oral ABX indicated in acne
risk for scarring or pigment changes, have nodulocystic acne

havent responded to topical after 2-3 months or cant tolerate

especially if on back, arms

patient education for acne
sunscreen needed when treating with all medications for acne

wash face BID with antibacterial soap

who is most at risk for scarring from acne
hispanic males

acne is more common in _ and more severe in _
common in females

severe in males

mild acne presentation
non inflammatory
small papules occasionally

moderate acne presentation
inflammatory lesions
papules
pustules

severe acne presentation
nodules
cystic
scar formation

in a female with severe cystic acne, what should be ruled out
acne coblongata ; rule out PCOS

Acne fulminans presentation
only in young males; rare

acute, largely inflammatory, ulcerated lesions

• systemic fever, chills, flu symptoms

class of ABX used in oral treatment for acne
-cyclines / tetracyclines

esp minocycline

What is rosacea?
Condition characterized by redness and dilation of blood vessels

does rosacea have comedones
not usually but can have small pus filled bumps for a few months before subsiding

what are the causes of rosacea (9)
mites, stress, hormones, neurovascular, infection, sun exposure, alcohol, hot drinks , H. pylori

what is the main treatment for rosacea and what should the patient know about treatment
metronidazole cream ; takes up to 6 to 8 weeks to see change

patient education in rosacea when under treatment
sunscreen
protect face from cold air and wind and sun

common people affected by rosacea
some genetic link, more common women and in EURO descendent

seborrheic keratosis presentation
benign skin growth can appear as waxy, papule or warty crusted stuck on brown or grey

“as if they could be picked off”

where does seborrheic keratosis occur mostly
trunk, face, arms

who most commonly gets seborrheic keratosis
white skin

are seborrheic keratosis cancerous or precancerous?
neither, they are benign, not precancerous or cancerous

what are the treatments for seborrheic keratosis if needed
treatment often not needed but can be removed with cryotherapy / liquid nitrogen, electrodessication and curettage

what are the DDX for seborrheic keratosis
pigmented nevi
basal cell carcinoma
melanoma

what are actinic keratosis / how do they present (AKA senile keratosis)
precancerous , sun exposure

can be pink, red, rough / sand paper like usually on sun exposed areas

what does actinic keratosis turn into if becomes cancerous and how long does progression typically take
squamous cell carcinoma

2 year transition

what should you do if you suspect actinic keratosis
refer to derm

high risk individual for actinic keratosis (6)
sun exposure
men
light skin
wrinkles
senile lentigines
over 50

what is the treatment for actinic keratosis
5-FU (flourouracil) cream (BID for 3-4 weeks) or liquid nitrogen cryotherapy or imiquimod (twice week for 16 weeks)

risk factors for malignant melanoma
age
immunosuppression
exposure to indoor tanning

if melanoma is > 4 mm deep prognosis is
bad

What are the ABCDEs of melanoma?
asymmetry
border
color
diameter (under 1 cm okay)
evolution

where can melanoma occur other than skin
subungual / under the nail especially of thumb and hallux

mucus membranes

conjunctiva

what is a lipoma
fatty tumor, benign

presentation of lipoma
rubbery, smooth, moveable, compressable

common areas for lipomas
neck, trunk, forearms, thigh and armpit

management of lipoma
watch for rapid growth

liposuction

excision

what is scabies
Contagious disease caused by the itch mite

sarcoptes scabies mite

how does scabies present
intense itching , worse at night

burrows

small 1-2mm red papules

transmission of scabies
direct contact

DDX for scabies
atopic dermatitis, contact dermatitis, folliculitis

treatment for scabies
topical permethrin is first line, followed by lindane or spinosad

systemic treatment – ivermectin

if ivermectin is required to treat scabies what is the dose
200 mcg per kg once with a repeat dose in 1-2 weeks

when would you use steroids for scabies
severe hypersensitivity to mites

where does scabies usually occur (7)
interdigit webs, groin fold, axillary fold, wrists, periumbilical, penis, ankles

where does scabies typically occur in small children
palms, soles, face, neck, scalp

what are the diagnostics for scabies
burrow ink test – felt tip blue or green pen over burrow – wipe away with alcohol – remaining ink will show borrow

scrapings – drop one drop mineral oil over burrow, scrape with scalpel put on slide with another drop oil and cover – will show mites or poop

if the patient develops a secondary bacterial infection from scabies, treat with
dicloxacillin
cephalex

what is pediculosis capitis
head lice

presentation of pediculosis capitis
nits on the hair shaft – like dandruff but the difference is the nits wont fall out like dandruff, need nit comb

patient education when treating pediculosis capitis
itching may continue a week after treatment because the inflammatory process takes a while to subside

treatment option for resistant lice
oral ivermectin 200mcg per kg 1 dose and repeat in 10 days

typical treatment for head lice
permethrin shampoo, malathion, lindane shampoo

all done once and repeat in 1 week if needed

what is a furuncle
staph abscess that forms in hair follicle

if a furuncle or carbuncle occurs in the axilla – what should you also consider as DDX
hidradenitis suppurativa

What is hidradenitis suppurativa?
condition of sweat gland infection chronically. results in sores, odor, drainage

furuncles are caused primarily by what organism
S. Aureus

treatment for furuncle / carbuncle
solitary furuncle: warm compress may be enough to promote drainage

large furuncle or carbuncle: treat like abscess. incision and drainage with oral abx if needed when MSSA. if MRSA may need IV ABX

warts are caused by
HPV

warts can spread by
abrading the skin, rubbing, shaving, nail biting

typical wart appearance
sharply demarcated, firm and rough. may be pedunculated (cauliflower like)

treatment for warts
irritants that encourage immune response (salicylic acid plasters or solutions) and:

bichloracetic acid

trichloracetic acid

podophyllum resin

electrocautery, cryotherapy

viral conjunctivitis often caused by
adenovirus

hallmark symptom of viral conjunctivitis
preauricular lymph node swelling

viral conjunctivitis symptoms especially in adenovirus (4)
may have cough, cold symptoms

may have itching but not bad, red eyes with clear or no drainage , profuse tearing bilateral

preauricular lymph node swelling

irritation or foreign body sensation in eye

herpes simplex conjunctivitis presentation
skin vesicles

preauricular lymphadenopathy

watery discharge

dendrite appearance

Herpes conjunctivitis Tx
opthalmic pyrimidine

oral acyclovir

does viral conjunctivitis need treatment
not usually except in herpes conjunctivitis

bacterial conjunctivitis presentation
patient wakes up and eye is shut with crust, will see strands of mucous in eye typically unilateral

allergic conjunctivitis
rhinorrhea
itching
watering eyes

when should you culture bacterial conjunctivitis

• no treatment after 2-3 weeks
• recurring
• severe

suspect chlamydia or gonorrhea

what is the treatment for chlamydial conjunctivitis
azithromycin 1G one dose

OR

doxycyline 100mg BID 7 days

what is the treatment for typical bacterial conjunctivitis
first line: broad spec topical agents (ointment or drop opthalmic)

polymycin and other mycins

floxacins

what is the treatment for allergic conjunctivitis (4 classes)
mast cell stabilizer drops

antihistamine drops

NSAID drops

combination mast/antihist drops

all the antihistamine eye drops end in
-astine

what is the NSAID drop for allergic conjunctivitis
ketorolac

what are the mast cell stabilizer eye drops for allergic conjunctivitis (3)
lidoxamide
nidocromil
pimurulast

what are the combo mast cell stab and antihistamine eye drops for allergic conjunctivitis (4)
olopatadine
azelastine
ketotifen
epinastine

what are cataracts
Partial or total opacity of the normally transparent lens

how does cataract progress
gradual , PAINLESS, progressive loss of vision

doe vita E, C, beta carotene prevent cataracts
nope

age related cataracts symptoms
bilateral, may have blurred or distorted vision, with a glare at night or in bright light

cataracts symptoms (general)
halos around light
gradual painless loss of vision
reduced color perception
myopia (loss distance vision)

treatments for cataracts
surgery

what is blepharitis
inflammation of the eyelid margins caused by staph

can be ulcerative or non

non ulcerative blephiritis
seborrhea and greasy scaling of eyelid margin

ulcerative blepharitis
involved follicles and Meibomian glands

has pustules at base of hair follicle that bleed and crust

symptoms of (both types) blepharitis
foreign body sensation

itchy

burning

photophobia

tearing

unilateral or bilateral

edema, erythema

what would you see in blepharitis if using a woods lamp
ulcerations, redness, scaling

treatment for blepharitis
initially bacitracin opthalmic or erythromycin qD or BID 7-10 days

if resistant treat with floroquinolone / floxacin OR sulfacetamide/corticosteroid combo

what is the sulfacetamide / corticosteroid combo used for blepharitis
10% sulfacetamide / prednisolone 0.2%

severe blepharitis associated with rosacea: treatment
doxycylcine 100mg BID or tetracycline 250mg QID

for several weeks then taper down

what is a chalazion
Cyst due to blockage of the meibomian gland. not painful

treatment for chalazion
warm compress, refer if more than 4 week duration (I/D, biopsy, injxn with glucocorticoid) , 1:1 dilution water and no tear shampoo to wash

what is a hordeolum
a stye — acute infection / block of meibomian gland (versus chalazion is chronic , not as inflammatory )

treatment for hordeolum
warm compress
clean with 1:1 baby shampoo and water,

if signs of infection occur, erythromycin, cipro, or sulfacetamide ointments can be used

treatment for resistant or recurrent hordeolum / stye
oral cephalexin

dry eyes are often reported as
feeling of sand in the eyes especially with blinking

what is important when assessing a patient with dry eyes
good history taking

diagnostic for dry eyes
slit lamp exam
Schirmer test

slit lamp test
Similar to a microscope that is used to examine the structures of your eye. This can help diagnose cataracts and ensures all parts of your eye are working correctly

schirmer test
a test that measures lacrimal gland flow by placing special filter paper strips inside the lower eyelid for 5 minutes

quantify lacrimal secretion

education for dry eyes
goggles when swimming, preservative free artifical tears, rest from electronics, dont rub it

What is keratoconjunctivitis sicca?
dry eyes

what is the TRIAD for dry eyes
burning , itching, foreign body sensation

what is epiphora
excessive tearing

who is at risk for epiphora
elderly

allergies

treatment for epiphora if caused by trauma or infection
topical ABX

what should not be used in epiphora and why
corticosteroid eye drops, anesthetic drops – may block healing

causes of epiphora
obstruction of duct

paradox to dry eye

what is subconjunctival hemorrhage
Hemorrhage over the sclera.
Painless
Normal vision
DT minor trauma: cough, sneeze

risk factors for subconjunctival hemorrhage
valsalva / constipation, blood thinners, DM, HTN

herpes zoster ophtalmicus
shingles of the eye

presentation of herpes zoster opthalmicus
rash forehead
swelling eyelid
pain
redness
inflammation of conjunctiva, cornea
photophobia

treatment for herpes zoster opthalmicus
Acyclovir 800 mg 5x/day

start within 72 hours of onset

what is sinusitis
inflammation of the sinuses

presentation of sinusitis – ethmoid
behind eye pain

presentation of sinusitis – maxillary
cheek pain, nasal discharge, poor response to decongestant,

DX of sinusitis
URI for 7 days, then 2 of the following

colored nasal discharge
facial pain
poor response to decongestants
headache

if the patient meets the 7 day criteria for sinusitis – they likely have what type of sinusitis
bacterial

risk factors for sinusitis
smoking, asthma, deviated septum

preceded by URI

treatment for bacterial sinusitis
Amoxicillin/clauv (augmentin) 875mg q12H

doxycycline

steam

otitis externa presentation
itching and drainage from the external auditory canal, difficult to visualize the tympanic membrane bc of swelling, manipulation of tragus is painful; associated w swimming, foreign bodies

otitis media presentation
red, bulging TM, possible effusion, light reflex diminished, mobility is decreased

pediatric treatment for otitis media
amoxicillin 40-45mg/kg/day in 2 divided doses

treatment of otitis externa
dry ears
no swimming 4-6 weeks

traimcinolone to outer ear

if bacterial suspected use acetic acid / aluminum acetate or cipro/hydrocortisone or neomyc/polymyx B/hydrocortisone or ofloxacin

if patient immunocompromised or DM how do you treat otitis externa
systemic ABX :
cephalosporins
penicillins

treatment for uncomplicated otitis media
can observe and wait to treat if symptoms persist after 48 to 72 hours

treat with tylenol / ibuprofen

treatment for otitis media if no daycare attendance and no ABX within 90
amoxcillin 40-45mg/kg/day in 2 doses x 10 days

treatment for otitis media if daycare attendance and no ABX within past 90 days (HIGHER RISK OF RESISTANT ORGANISM)
high dose;

80-90mg/kg/day in 2 doses x 10 days amoxicillin

not to exceed 1000mg per dose

What is acute angle closure glaucoma?
immediate medical intervention required

• increased intraocular pressure due to decreased outflow of aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness

symptoms of acute angle closure glaucoma
PAIN
Headache
Significant blur
Nausea/vomiting
Red eye
halos around lights
loss of peripheral vision, can progress to loss of central vision

acute angle closure glaucoma most often occur in persons who are
Asian descent , Eskimo descent

55 to 70 year olds

more often in females

Causes of acute angle closure glaucoma
can be induced by rapid dilation

treatment for acute angle closure glaucoma
IV mannitol
acetazolamide
topical pilocarpine

follow by peripheral iridectomy
or laser iridotomy

what are the fundoscopic findings of acute angle closure glaucoma
pale optic disc
excavated cupping
increased cup to disc ratio

strategy to relieve middle ear pressure due to barotrauma
nasal steroid
oral decongestant

hallmark of viral conjunctivitis
preauricular lymph node

when does sinusitis need referral to specialist
mastoiditis, meningitis, infection of surrounding structures other than the sinus

ethmoid sinusitis pain location
behind the eye, high on the nose

most common sinus affected in sinusitis
maxillary

poor response to decongestants, purulent nasal discharge, pressure over the cheek indicate
sinusitis

confirmation symptoms of sinusitis
URI for 7 days prior to having at least 2 of the following:
colored discharge
poor response to decongestants
facial pain
headache

causes of sensorineural hearing loss
Aging (presbycusis)*
Acustic injury from sudden or prolonged exposure to loud noises
Perilymph fistula
Congenital (TORCHES)
Meniere’s disease
Drug/toxin-induced
Acoustic neuroma
Pseudotumor cerebri
CNS disease
Endocrine disorders
Sarcoidosis

causes of conductive hearing loss
excess cerumen, otosclerosis, otitis media

type of hearing loss involving the 8th cranial nerve
sensorineural

what is the Weber test
tuning fork on top of head

what does the weber test show
shows which ear is affected :

if sensorineural loss – it is better heard on the GOOD ear

if conductive loss – it is better heard on the BAD ear

what is the rinne test
Vibrating tuning fork held from ear and then placed on mastoid. wait until patient cant hear it then move to beside the ear and see if they can hear it

what do the results of the rinne test mean
if can hear beside ear after moved away from mastoid then AC > BC which is normal

if cant hear beside ear after moved away from mastoid then BC > AC which indicates conductive loss of hearing

when to refer hearing loss to otolaryngology
if a patient presents with sudden sensorineural hearing loss what should you do

type of hearing loss in presbycusis
sensorineural

what is the Schwabach test
fork on patient mastoid and yours – if patient hears shorter than you – this is suggestive of SNHL, if patient hears longer than you, this is suggestive of CHL

what is tinnitus
ringing or buzzing in the ears

ear sound that can be heard with severe HTN (DBP over 120)
tinnitus

foods to avoid in tinnitus
caffeine, salt, chocolate, alcohol

causes of tinnitus
loud noise, vascular, paraganglioma, schwannoma, ototoxic drugs, presbycusis,

high pitched tinnitus is typically a result of….
SNHL – may suggest cochlear injury

low pitched tinnitus is typically a result of
Meniere or idiopathic

medications used in tinnitus (5)
misoprostol
lidocaine
benzodiazepines
carbamazepine
dexamethasone

*note that efficacy of drugs is not yet identified and treatment is typically aimed and lessening impact and living with it

What is mononucleosis?
viral disease caused by Epstein-Barr virus, attacks B lymphocytes

symptoms of mononucleosis
fever
pharyngitis
adenopathy
fatigue
atypical lymphocytosis

lab results seen in mononucleosis
WBC – 10 – 20

50% lymphocytes

absolute lymphocyte > 4500

abnormal LFTs

10% abnormal lymphocytes

what test is used for mononucleosis
heterophile test
monospot
EBV

incubation time for mono
4 to 8 weeks

transmission of mononucleosis
saliva

exam findings in mononucleosis
posterior cervical lymph nodes inflamed

erythema on pharynx

tonsillar exudate

What is the epiglotitis?
inflammation of elastic cartilage that covers the laryngeal inlet during swallowing

rapidly progressive cellulitis of the epiglottis that may cause complete airway obstruction

symptoms of epiglottitis (7)
throat pain
dysphagia
copious oral secretions
drooling
respiratory difficulty
stridor
fever
NO pharyngeal erythema or cough

if a patient presents with sudden sensorineural hearing loss what should you do
refer to otorhinolaryngologist for further treatment and diagnosis

sensorineural hearing loss (nerve deafness)
hearing loss caused by damage to the auditory receptors of the cochlea or to the auditory nerve due to disease, aging, or prolonged exposure to ear-splitting noise

s/s of epiglottitis in children
stridor
restlessness
nasal flaring
accessory muscle use

Pharyngitis
inflammation of the pharynx that causes discomfort, scratchiness, pain and difficulty swallowing

If pharyngitis is accompanied by fatigue, fever, and cervical lymphadenopathy you should evaluate the patient with what
monospot
rapid 10 minute strep test
throat culture

Treatment in adults with NKA to OCN who are suspected of having Group A beta hemolytic streptococcal pharyngitis
10-day course of penicillin V potassium (Pen-vee K 500mg PO BID or 250mg PO QID)

or

benzathine penicillin (Bicillin 1.2 million units IM once)

or azithromycin 500mg PO if allergic to penicillin

what commonly occurs with pharyngitis
tonsillitis

when do group A beta-hemolytic streptococcal infection
in the winter and spring

when does viral pharyngitis typically occurs
fall and winter

what age do infectious pharyngitis and tonsillitis typically occur
5-10

pharyngitis s/s
mild to severe throat pain
pruritus of the throat
fever
swollen throat
dysphagia
red throat
tonsillar exudates

how is herpangia and hand-foot-mouth disease diagnosed
coxasackie viral cultures and serologies

viral pharyngitis treatment
mostly supportive care unless influenza a symptoms then you can give amantadine 100mg BID and oseltamivir 75mg BID x 5 days

If streptococcal pharyngitis is not treated it can cause and _.
scarlet fever and rheumatic fever

Dysphonia
hoarseness; voice with harsh quality and low pitch; weakness, raspiness, change from usual quality

Dysphonia is caused by?
viral infection of the larynx (laryngitis)
natural aging process
laryngeal cancer
GERD
growths on vocal cords like cysts, papillomas, polyps, and nodules

dysphonia is a cardinal sign of what type of cancer
laryngeal cancer

why does dysphonia occur
vocal cord inflammation and edema result in vocal fold movement that is asymmetrical with reduced waves and incomplete vibratory closure

when should dysphonia be worked up for cancer
hoarseness persisting for more than several weeks (2)
or if the patient has
SOB
Stridor
cough
hemoptysis
throat pain
unilateral otalgia
weight loss

If dysphonia lasts more than 2 weeks and is not caused by an infection what should you do
refer to otolaryngologist for Laryngoscopy

Dysphonia differential diagnosis
papillomatosis; related to an infection

acute pharyngeal infections most common among adolescents and youth (2)
peritonisilar cellulitis and peritonsilar abcess

location of pertionsial abcess
unilateral between the tonsil and the superior pharyngeal constrictor muscle

s/s of peritonsillar abscess
severe unilateral sore throat
odynophagia
fever
otalgia
asymmetric cervical adenopathy
Trismus (lock jaw or “hot potato voice”)
toxic appearance (poor eye contact, unable to recognize parents, irritability, drooling, inability to be consoled, exudates, halitosis)
deviation of soft palate and uvula if severe

strep tonsils infection always has the potential for progressing to…….
peritonisllar abscess

Rhinitis
inflammation of the nasal mucosa; hay fever

allergic rhinitis (hay fever) results from
immunoglobulin E (IgE) mediated type 1 hypersensitivity

causes of allergic rhinitis
airborne irritants affecting eyes, nose, sinuses, throat, bronchi

S/S of allergic rhinitis
pale or violaceous, boggy turbinites
nasal congestion
rhinorrhea
sneezing
pruritus of nasal passage, conjunctiva, and roof of mouth
postnasal drainage
dennie lines

usually persist and are seasonal in nature

treatment for allergic rhinitis
antihistamines
intranasal corticosteroids (takes 2 weeks for full relief)
avoidance of triggers

viral rhinitis s/s
watery rhinorrhea
nasal congestion/speech
forced mouth breathing

Rebound rhinitis
can occur with overuse of nasal decongestants

nasal congestion without rhinorrhea

how to treat rebound rhinitis
immediately stop all topical decongestants use; takes 2-3 weeks

atopic triad is used to determine
genetic predisposition toward allergic reactivity in all atopic conditions

atopic triad consists of
asthma
allergic rhinitis
eczema

a patient that has the atopic triad is assumed to have a preferential production of what