Final Exam: NR569/ NR 569 (Latest 2024/ 2025 Update) Differential Diagnosis in Acute Care Practicum Review| Questions and Verified Answers| 100% Correct

Final Exam: NR569/ NR 569 (Latest 2024/ 2025 Update) Differential Diagnosis in Acute Care Practicum Review| Questions and Verified Answers| 100% Correct – Chamberlain

Final Exam: NR569/ NR 569 (Latest 2024/
2025 Update) Differential Diagnosis in Acute
Care Practicum Review| Questions and
Verified Answers| 100% Correct –
Chamberlain
Q: Hordeolum (Stye)
Answer:
The infection, and subsequent inflammation, of the eyelid. Though infection can occur on either
the outer or inner part of the eyelid, the term “stye” commonly refers to an infected eyelash
follicle on the external part of the eyelid.
After the initial infection, pus builds up in the eyelash follicle. The stye will continue to grow
and swell for a few days before it eventually bursts and drains. Most styes heal on their own, but
in rare occurrences, the pus may harden and progress into chalazion.

TREAT – Treatment involves warm compresses. The condition is usually self-limiting and
resolves on its own. If there is evidence of associated abscess or cellulitis, topical or oral
antibiotics may be required.
Q: Hordeolum (Stye) Etiology
Answer:
Caused by a bacterial infection in the oil-producing glands of the eyelid.
Q: Hordeolum (Stye) HPI
Answer:
Red, painful bump along the edge of the upper or lower eyelid near the base of the eyelashes.
Swelling of the eyelid (sometimes the entire eyelid).
Crusting along the eyelid.
Sensitivity to bright light.
Sore, scratchy, foreign body sensation in the eye.
Tearing.
History of blepharitis or skin conditions, such as acne rosacea or seborrheic dermatitis.
Diabetes.
Hormonal changes.
Elevated low-density lipoproteins (LDL)
Q: Hordeolum (Stye) Exam Findings
Answer:
A small, yellowish pustule typically devel- ops at the base of an eyelash, surrounded by
hyperemia, induration, and diffuse edema.
Within a few days, the abscess ruptures, draining exudate which tends to relieve the pain and
resolve the lesion.
Q: Periorbital/Preseptal Cellulitis
Answer:
Anatomy involved: Infection anterior to the orbital septum (eyelid and surrounding tissues).
Patho: May be caused by sinusitis, a break surrounding skin, or from the spread
of systemic infection through blood or lymph.
Complications: Usually minimal.
TREAT with empiric oral antibiotics based on likely pathogen.
Q: Periorbital/Preseptal Cellulitis Possible HPI
Answer:
Recent/current URI and sinusi- tis.
Penetrating lid trauma.
Dental infection.
Hordeolum (stye)
Insect bite
History of exposure to eye antibiotics causing allergic etiology as differential (this is usually
bilateral)
Q: Periorbital/Preseptal Cellulitis Clinical Presentation

Answer:

Unilateral erythema, swelling, warmth, and tenderness of eyelid.
May become life threatening.
No restriction of extraocular eye movements.
No proptosis
No chemosis
Normal visual acuity
Assess for sinusitis, dental infection, or skin redness
Q: Periorbital/Preseptal Cellulitis Diagnosis
Answer:
Based on history and clinical exam. Cultures are rarely needed.
Clinical Diagnosis
Q: Orbital Cellulitis
Answer:
Anatomy Involved: Infection is posterior to the orbital sep- tum, involving ocular muscles and
fat, BUT NOT THE GLOBE.
Patho: A complication of upper respiratory illness, dental abscess, rhinosinusitis, or
homogenous spread.
Complications: Cavernous sinus thrombosis, abscess, loss of vision, and possibly death.
TREAT – treatment includes hospitalization. Obtain cultures (blood, nasal and conjunctival).
CT/MRI to differentiate pre-septal and post-septal etiology, detect subperiosteal abscess,
evaluate for orbital abscess, evaluate for an intracranial extension, and evaluate potential space
for surgical drainage. Empiric, broad-spec- trum abx, such as ceftriaxone or cefotaxime, should
be initiated and tailored for pathogens. Metronidazole should be ordered to cover for anaerobic
pathogens. Consider use of IV steroids. After immediate treatment is established, consult ENT,
ophthalmology, and infectious disease specialists.
Q: Orbital Cellulitis Possible HPI
Answer:
Unilateral eye pain, redness, and swelling.
Pain with eye movement; blurred vision
Fever may occur
Inquire about etiologies to support diagnosis
Recent/current upper respiratory illness and sinusitis
Penetrating lid or orbital trauma
Dental infection
Hordeolum (stye)
Dacryocystitis
Ophthalmic surgery
Insect bite
Q: Orbital Cellulitis Clinical Presentation
Answer:
Painful swollen lid, typically unable to open for visualization.
If able to evaluate the eye, extraocular movements are restricted and potentially painful.
Proptosis
Chemosis
Visual impairment; diplopia
Sluggish or absent pupillary light reflex or Relative Afferent Pupillary Defect (RAPD)
indicates optic nerve involvement.
Fever may occur.
Q: Orbital Cellulitis Diagnosis
Answer:
Imaging necessary with CT/MRI to demonstrate orbital involvement, edema of extraocular
muscles, and sinusitis.
Q: Chemosis
Answer:
An abnormal edematous swelling of the mucous membrane cover- ing the eyeball and lining of
the eyelids. Usually the result of local trauma or infection, chemosis may also occur in acute
conjunctivitis,
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Allergic Conjunctivitis

Inflammation of the conjunctiva due to allergies is common, occurring in up to 40% of the population. Itching is the most consistent sign of allergic conjunctivitis; it is also characterized by red eyes and other allergic disease symptoms such as sneezing.
Symptoms: severe itching (MOST PROMINENT) , generalized hyperemia of the conjunctiva, & mild-moderate tearing. Rubbing of eyelids can lead to eyelid edema and temporary hyperpigmentation (allergic shiners/raccoon eyes). Allergic conjunctivitis often accompanied by s/s of allergic rhinitis, including the presence of a crease on the nose from frequent manipulation (toddler salute).
Treatment: Mild-moderate symptoms ma be managed with artificial tears and cool/cold compresses. Severe s/s may require an ophthalmology consultation, and immune modulation with topical antihistamine, mast cell stabilizer, or mild steroid.

Bacterial Conjunctivitis
Bacterial conjunctivitis is the second most common cause of infectious conjunctivitis, Red, itchy eyes are associated with this condition, as is purulent or mucopurulent discharge in one or both eyes.

Symptoms: copious mucopurulent discharge (MOST PROMINENT), often unilateral (helps distinguish from allergic/viral etiology) but may spread to both eyes via hands when rubbing eyes, and pain/irritation with severe hyperemia. There should be NO frank vision loss.
Treatment: Usually with topical antibiotic ointments or drops.

**Otherwise immunocompetent patients with unilateral disease may be treated empirically with topical fluoroquinolones such as moxifloxacin or gatifloxixin. If no improvement within 48 hours, cultures should be repeated and ophthalmology should be consulted.

Toxic Conjunctivitis

Inflammation of the conjunctiva due to medications, chemicals, or toxins can cause red, itchy eyes.

Viral Conjunctivitis

Viral conjunctivitis is the most common cause of infectious conjunctivitis. Red, itchy eyes are associated with this condition, as is a watery discharge.

**65-90 % of viral conjunctivitis are caused by adenoviruses, which are highly contagious and spread through direct contact. Communicability is estimated to be 10-14 days. Topical ophthalmic antihistamines (preferably OTC) may be recommended to reduce itching and soothe the eyes.

Symptoms: Usually presents bilaterally, but symptoms often start in 1 eye 1-2 days prior. Pain and burning are the MOST PROMINENT symptoms, and eyes are very red with copious tearing. Preauricular lymph node may be palpated, which is relatively specific to viral etiology. Symptoms tend to worsen for the first few days, and generally resolve within 1-2 weeks.

Hand washing and contact precautions are imperative to prevent the spread of infection. If hospital staff become infected, they will have to be off for 7 days after symptoms start in SECOND eye.

Blepharitis

Blepharitis, or inflammation of the eyelids, is characterized by redness at the margins of the eyelids. Symptoms of blepharitis include: dry, red, itchy eyelids that may be crusted.
TREAT – Treatment involves supportive care and antibiotics. Supportive care: Use warm compresses to loosen the eyelid crusting. Gently scrub the eyelids with diluted baby shampoo at least twice daily. Use artificial tears to lubricate eyes as needed. Discontinue eye make-up until condition resolves and then re-start with new products. Topical antibiotics: Agents with gram positive coverage – erythromycin or ciprofloxacin ophthalmic ointment.

Corneal Abrasion

Corneal abrasion is characterized by an alteration in the epithelial layer of the cornea due to trauma, foreign bodies, or chemical exposure. This condition is characterized by redness; however, pain, tearing, and sensitivity to light are the more typical symptoms. Corneal abrasion is typically unilateral given the etiology.
TREAT – Treatment involves removal of foreign body and supportive care. Discontinue contact lens use. Consider topical ophthalmic antibiotics appropriate for the etiology of the abrasion (i.e., organic material, finger cat scratch), such as erythromycin ointment or trimethoprim-polyumyxin B. Consider pseudomonas with contact lens, mascara, organic material as a foreign body etiology: treat with topical fluoroquinolone. If evidence of bacterial keratitis, corneal opacification, or corneal infection, or globe penetration, EMERGENT OPHTHALMOLOGY CONSULTATION IS INDICATED.

Subconjunctival Hemorrhage
Subconjunctival hemorrhage is bleeding below the conjunctiva and is characterized by a red patch on the sclera of the eye, rather than generalized redness and/or itching.

TREAT – Treatment for subconjunctival hemorrhage is supportive care. Assess INR level if patient is on warfarin.

Uveitis
Inflammation of the uveal tract of the eye, including the iris, ciliary body, and choroid. It may be characterized by an irregularly shaped pupil, inflammation around the cornea, pus in the anterior chamber, opaque deposits on the cornea, pain, and lacrimation. The most common form of uveitis is iritis. Symptoms include: redness, pain, light sensitivity, blurred vision.

REFER – Uveitis is associated with loss of vision from retinal scarring; referral to ophthalmology is appropriate.

Chalazion
An inflamed nodule (lump) that develops on the eyelid. Chalazia are caused by the bacterial infection of glands in the eyelid. The infection may result from poor hygiene or an existing skin condition affecting the face, such as rosacea. Chalazia vary in size and location in the eyelid, depending on which type of gland is obstructed.

When a sebaceous gland in the eyelid becomes infected, bacterial and oily secretions initiate an inflammatory response that blocks the gland and causes a rounded bump to form.

Superficial chalazia form when glands along the edge of the eyelid become infected and blocked.

Deep chalazia form when meibomian glands in the conjunctival portion of the eyelid (lid lining) become infected and blocked.

Chalazia are usually painless.

TREAT – Treatment involves warm compresses and massage to promote drainage. Chalazions disappear without treatment within several weeks to a month, although they often recur. Surgical excision may be required if not resolved or if complications are present.

Chalazion Etiology
Caused by thickening of the fluid in the oil glands (meibomian glands) of the eyelid. Most commonly occurs on the UPPER eyelid, but can also affect the lower eyelid.

More common in adults than children; most frequently occurs in people 30-50

Chalazion HPI

Small red and swollen area of the eyelid forms a painless, slow-growing lump the size of a pea.
Gradual onset over several weeks.
Tearing and mild irritation may result as the obstructed glands are needed for healthy tears.
Blurred vision occurs if the chalazion is large enough to press against the eyeball.
Rarely, may be an indication of an infection or skin cancer.
Risk Factors: Acne rosacea, chronic blepharitis, seborrhea, tuberculosis, and viral infection.
Assess for symptoms and the presence of any possible contributing general health problems.

Chalazion Exam Findings

The eyelid will be diffusely swollen.
Within 1-2 days, a small non-tender nodule or lump develops.
A chalazion usually drains through the inner surface of the eyelid or is absorbed spontaneously over 2-8 weeks.

Hordeolum (Stye)
The infection, and subsequent inflammation, of the eyelid. Though infection can occur on either the outer or inner part of the eyelid, the term “stye” commonly refers to an infected eyelash follicle on the external part of the eyelid.

After the initial infection, pus builds up in the eyelash follicle. The stye will continue to grow and swell for a few days before it eventually bursts and drains. Most styes heal on their own, but in rare occurrences, the pus may harden and progress into chalazion.

TREAT – Treatment involves warm compresses. The condition is usually self-limiting and resolves on its own. If there is evidence of associated abscess or cellulitis, topical or oral antibiotics may be required.

Hordeolum (Stye) Etiology
Caused by a bacterial infection in the oil-producing glands of the eyelid.

Hordeolum (Stye) HPI

Red, painful bump along the edge of the upper or lower eyelid near the base of the eyelashes.
Swelling of the eyelid (sometimes the entire eyelid).
Crusting along the eyelid.
Sensitivity to bright light.
Sore, scratchy, foreign body sensation in the eye.
Tearing.
History of blepharitis or skin conditions, such as acne rosacea or seborrheic dermatitis.
Diabetes.
Hormonal changes.
Elevated low-density lipoproteins (LDL)

Hordeolum (Stye) Exam Findings

A small, yellowish pustule typically develops at the base of an eyelash, surrounded by hyperemia, induration, and diffuse edema.
Within a few days, the abscess ruptures, draining exudate which tends to relieve the pain and resolve the lesion.

Periorbital/Preseptal Cellulitis

Anatomy involved: Infection anterior to the orbital septum (eyelid and surrounding tissues).
Patho: May be caused by sinusitis, a break surrounding skin, or from the spread of systemic infection through blood or lymph.
Complications: Usually minimal.
TREAT with empiric oral antibiotics based on likely pathogen.

Periorbital/Preseptal Cellulitis Possible HPI

Recent/current URI and sinusitis.
Penetrating lid trauma.
Dental infection.
Hordeolum (stye)
Insect bite
History of exposure to eye antibiotics causing allergic etiology as differential (this is usually bilateral)

Periorbital/Preseptal Cellulitis Clinical Presentation

Unilateral erythema, swelling, warmth, and tenderness of eyelid.
May become life threatening.
No restriction of extraocular eye movements.
No proptosis
No chemosis
Normal visual acuity
Assess for sinusitis, dental infection, or skin redness

Periorbital/Preseptal Cellulitis Diagnosis

Based on history and clinical exam. Cultures are rarely needed.
Clinical Diagnosis

Orbital Cellulitis

Anatomy Involved: Infection is posterior to the orbital septum, involving ocular muscles and fat, BUT NOT THE GLOBE.
Patho: A complication of upper respiratory illness, dental abscess, rhinosinusitis, or homogenous spread.
Complications: Cavernous sinus thrombosis, abscess, loss of vision, and possibly death.
TREAT – treatment includes hospitalization. Obtain cultures (blood, nasal and conjunctival). CT/MRI to differentiate pre-septal and post-septal etiology, detect subperiosteal abscess, evaluate for orbital abscess, evaluate for an intracranial extension, and evaluate potential space for surgical drainage. Empiric, broad-spectrum abx, such as ceftriaxone or cefotaxime, should be initiated and tailored for pathogens. Metronidazole should be ordered to cover for anaerobic pathogens. Consider use of IV steroids. After immediate treatment is established, consult ENT, ophthalmology, and infectious disease specialists.

Orbital Cellulitis Possible HPI

Unilateral eye pain, redness, and swelling.
Pain with eye movement; blurred vision
Fever may occur
Inquire about etiologies to support diagnosis
Recent/current upper respiratory illness and sinusitis
Penetrating lid or orbital trauma
Dental infection
Hordeolum (stye)
Dacryocystitis
Ophthalmic surgery
Insect bite

Orbital Cellulitis Clinical Presentation

Painful swollen lid, typically unable to open for visualization.
If able to evaluate the eye, extraocular movements are restricted and potentially painful.
Proptosis
Chemosis
Visual impairment; diplopia
Sluggish or absent pupillary light reflex or Relative Afferent Pupillary Defect (RAPD) indicates optic nerve involvement.
Fever may occur.

Orbital Cellulitis Diagnosis

Imaging necessary with CT/MRI to demonstrate orbital involvement, edema of extraocular muscles, and sinusitis.

Chemosis
An abnormal edematous swelling of the mucous membrane covering the eyeball and lining of the eyelids. Usually the result of local trauma or infection, chemosis may also occur in acute conjunctivitis,

Ptosis
An abnormal condition of one or both upper eyelids in which the eyelid droops because of a congenital or acquired weakness of the levator muscle or or paralysis of the third cranial nerve.

Amblyopia
Impairment of vision not due to refractive errors, usually without an organic cause. Corrective lenses do not improve visual acuity.

Dacrocystitis
An infection of the lacrimal sac caused by obstruction of the nasolacrimal duct. It is characterized by tearing and discharge from the eyelid.

Relative Afferent Pupillary Defect (RAPD)

A condition in which pupils respond differently to light stimuli shone in one at a time due to unilateral or asymmetrical disease of the retina or optic nerve.
RAPD is assessed using the swinging penlight technique: A bright light source is directed back and forth at each eye. The eye with the afferent defect will paradoxically dilate when exposed to light after it had previously constricted consensually to the same light applied to the other eye.

Central Retinal Artery Occlusion

The sudden blockage of the central retinal artery, resulting in retinal hypoperfusion, rapidly progressive cellular damage, and vision loss.
REFER – This condition is an ophthalmic emergency. Prompt ophthalmology referral is required.

Acute Angle-Closure Glaucoma

An ocular emergency that results from a rapid increase in intraocular pressure due to outflow obstruction of aqueous humor.
REFER – This condition is an ophthalmic emergency. Prompt ophthalmology referral is required.

Central Retinal Vein Occlusion (CRVO)

An eye condition that affects the retina – the light-sensitive layer of tissue in the back of the eye. It happens when a blood clot blocks the main vein where blood flows out of the retina. It usually only affects one eye.
REFER – This condition is an ophthalmic emergency. Prompt ophthalmology referral is required.

Hyphema

Defined as accumulated red blood cells (RBCs) in the anterior chamber of the eye. Blood must be grossly visible, either on direct inspection or slit-lamp examination. Blood accumulates from disruption of the vessels of the iris or ciliary body, usually due to trauma or underlying medical conditions.
REFER – Hyphema is typically caused by trauma. Assess for other eye trauma and consider a CT scan to assess the orbit. Ophthalmology referral is appropriate for ongoing monitoring of ocular pressure.

Retinal Detachment

An eye problem that happens when the retina (the light-sensitive layer of tissue in the back of the eye) is pulled away from its normal position at the back of your eye.
REFER – This condition is an ophthalmic emergency. Prompt ophthalmology referral is required.

Miosis

An abnormal condition characterized by excessive constriction of the sphincter muscle of the iris, resulting in pinpoint pupils.

Corneal Ulcer

A defect in the surface of the epithelium of the cornea that involves the underlying stroma.
Corneal ulcers may cause severe and permanent vision loss.
REFER – The patient must be seen the same day by an ophthalmologist for culture of the corneal surface and broad-spectrum topical antibiotic therapy to prevent corneal perforation and endophthalmitis, which frequently will lead to to loss of an eye.

Stroma

The supporting tissue or the matrix of an organ, as distinguished from its parenchyma (the functional tissue or cells of an organ or gland)

Atopy

Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema). Atopy is typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens.

Common organisms causing bacterial conjunctivitis:

Neisseria
pneumococcus
Staphylococcus
haemophilus influenzae
Moraxella

Limbal Flush

Characteristic red ring of inflammation around the edges of the cornea (associated with iritis).

Iritis

Inflammation of the iris of the eye.
Symptoms: Photophobia (MOST PROMINENT), maybe unilateral or bilateral (more common), blurry vision, & limbal flush.

**Diagnosis a slit lamp because inflammation cannot be diagnosed accurately without. Thus, diagnosis requires ophthalmology consultation. Rheumatology consultation may also be required to evaluate potential autoimmune connection.

Acute Angle-Closure Glaucoma
A rare, vision threatening form of glaucoma characterized by narrowing or closure of the anterior chamber angle. The anterior chamber angle provides drainage for the aqueous humor, the fluid that fills the eyeball. When this pathway is narrowed or closed, inadequate drainage of the aqueous humor leads to increased intra-ocular pressure (IOP) and damage to the optic nerve.

PROMPT ophthalmology referral required to prevent permanent vision loss.

Symptoms: Usually always unilateral. Very painful and red eye with profoundly decreased vision in the affected eye. Commonly accompanied by severe headache on the affected side. The cornea could appear cloudy. Symptoms usually last minutes to hours; not days to weeks. No discharge or exudate should be present. The affected eye may feel significantly more hard due to severely increased IOP.
Treatment: This condition requires laser peripheral iridotomy in the affected eye ASAP, and in the fellow eye to prevent future episodes.

Diplopia

Technical term for double vision.
Evaluation must start with determining whether or not symptoms are binocular (double vision due to misalignment of the eyes).
Binocular diplopia virtually ALWAYS requires ophthalmologic evaluation for proper diagnosis and treatment.
“Does the double vision go away when you cover either eye?” – if the answer is yes, that is binocular diplopia and requires IMMEDIATE ophthalmologic consultation.

Acute Otitis Media

An acute, suppurative infectious process marked by the presence of infected middle ear fluid and inflammation of the mucosa lining the middle ear space. The infection is most frequently precipitated by impaired function of the Eustachian tube, resulting in the retention and suppuration of retained of retained secretions. AOM may be associated with purulent otorrhea if there is a ruptured tympanic membrane. AOM usually responds promptly to antimicrobial therapy.
Adults with AOM should be treated with antibiotics; first line agent is amoxicillin/clavulanate.
Recurrent cases that do not resolve despite treatment may need referral to ENT.

Otitis Media with Effusion (OME)

Fluid in the middle ear WITHOUT the presence of infection. Causes: Upper respiratory infection (URI), barotrauma, allergies, or a recent AOM infection. Mild pain and conductive hearing loss may be present. Air bubbles are seen behind the tympanic membrane.

Barotrauma
Discomfort in middle ear due to barometric changes (airplane, scuba). Worsened by URI. Vacuum in middle ear pulls tympanic membrane inward. Tympanic membrane can rupture resulting in hearing loss, bleeding and fluid leakage. Pain, pressure, decreased hearing, and dizziness can occur.

Tympanic membrane heals spontaneously but can take a few weeks.
Surgery may be indicated if the TM does not heal within 2 months, or with presence infections.
Antibiotics are indicated only if there is evidence of infection.
There is no evidence that decongestants, antihistamines or steroids are helpful in treating barotrauma.

Acute Otitis Externa (AOE)

An outer ear infection, also called “swimmer’s ear and otitis externa (OE), is the infection and inflammation of the auricle (the cartilaginous outer structure), external acoustic meatus (ear canal), or both. An outer ear infection may also spread to surrounding bone and tissue.

AOE is typically caused by a bacterial infection in the skin of the outer ear. Bacteria often invade under moist conditions (common in swimmers) or if the protective waxy coating of the ear canal has been removed or degraded (such as in aggressive cleaning).

In a mild to moderate outer ear infection, patients often experience redness, inflammation, swelling, itching, pain, and purulent discharge. As the ear infection progresses, symptoms may include severe pain, hearing loss, fever and swelling of the cervical lymph nodes.

Cholesteatoma

An abnormal, non-cancerous skin growth behind the tympanic membrane or from the tympanic membrane. It is like a cyst that contains skin cells and connective tissue. Without treatment, the mass continues growing.
Symptoms: Pain, foul-smelling drainage, hearing loss, pressure, and vertigo. May cause facial muscle paralysis.

Perichondrium

The connective tissue that envelops cartilage where it is not at a joint.

Auricular Hematoma

A collection of blood underneath the perichondrium of the ear and typically secondary to trauma. An auricular deformity, commonly referred to as “cauliflower ear” is the result of intreated or inadequately treated auricular hematoma.
Treatment: Incision and drainage (likely). Bolster dressing to reduce dead space, and compress to prevent re-accumulating blood. Requires close follow-up.
Hematomas lasting more than 7 days need an urgent referral to an ENT.
Referral to plastic surgery may be necessary if cosmetic appearance is a concern.

Ramsey Hunt Syndrome (RHS)

Herpes zoster with vesicular rash, ipsilateral facial paralysis, and ear pain with vesicles in auditory canal and auricle. May cause vertigo, headache, fever, and/or malaise.
Risk Factors: Past varicella infection, age, being immunocompromised, and autoimmune disorders.

Malignant Otitis Externa (MOE)

Necrotizing external otitis. Symptoms include severe otalgia and otorrhea with unresponsiveness to treatment. Pain is worse at night and with chewing,
Risk factors: Age, Diabetes Mellitus, and being immunocompromised.

Treatment for Acute Otitis Externa (AOE)

Topical antibiotics are the treatment of choice for AOE, with or without steroids.
Topical antibiotics are the preferred therapy because a higher concentration of the antimicrobial can be delivered to the infected tissue that systemic antibiotics.
An ear wick may be inserted in the ear to facilitate installation of antibiotic drops in a tight canal.
Systemic antibiotics are NOT indicated unless the patient also has a co-existing AOM infection.

Treatment of Ramsey Hunt Syndrome (RHS)

Antiviral therapy (acyclovir, valacyclovir)
Close follow-up to monitor for worsening neurological complications, such as meningeal inflammation and subsequent meningitis, encephalitis, and rarely peripheral motor neuropathy, myelitis, or Guillain-Barre Syndrome (RARE).
Avoid contact with pregnant females who are varicella naive, as well as immunocompromised persons, and premature/low birth weight infants.
There is no evidence to support utilizing glucocorticoids, gabapentin or tricyclic antidepressants, although several studies do show glucocorticoids may be beneficial with RHS.

Treatment of Cholesteatoma

Urgent referral to ENT specialist
CT if extracranial complications are suspected.
MRI (in addition to CT) if extracranial complications are suspected.
IV antibiotics to empirically cover for intracranial complications.
IMPORTANT: CULTURE BEFORE ABX****

Insect in the Ear

Common but removal can be challenging.
Live insect movement and sounds can be very painful and uncomfortable.
Placing a drop or two of mineral, baby, or olive oil inside the ear canal can kill the insect and provide a significant amount of relief.
Some ED providers use xylocaine to paralyze the bug. This can help you to avoid stinging and eardrum rupture from scratching or biting.
If the insect does not come out easily with manual removal, refer the patient to ENT. Insects that do not come out easily can result in small pieces being left behind.

Education for Patients with Ear Disorders Includes:

Ear pain may be treated with OTC analgesics.
Avoid scratching, tugging, or inserting anything into the ear, including cotton-tipped swabs.
Reinforce water precautions with ruptured tympanic membrane.
Avoid getting water in the ear during bathing/shower.
Avoid submerging ear under water.

Group A B hemolytic streptococci infection (GABHS) “Strep Throat”

Strep throat is a common condition caused by a bacterial infection of the mouth and back of oral cavity.
Strep throat is caused by an infection of Streptococcus pyogenes bacteria. Streptococcus bacteria are sphere-shaped and can travel to infect other individuals through airborne droplets, such as through a cough or sneeze.
Symptoms: severe sore throat, painful swallowing, red and inflamed tonsils and uvula, fever, body aches, and swollen lymph nodes in the neck. Patients with strep throat may also exhibit characteristic white patches of infected tissue on the tonsil surface.
If left untreated, strep throat can lead to serious conditions such as kidney disease or rheumatic fever.

Mononucleosis

Viral infection typically caused by Epstein Barr virus (EBV), but may also be caused by other viruses. Mononucleosis is spread through shared saliva.
Symptoms: Extreme fatigue, fever, sore throat, swollen lymph nodes, swollen liver and spleen, rash, and body aches.

Viral Nasopharyngitis (Common Cold)

Viral infection of the posterior nasopharynx. Often misdiagnosed as GABHS and antibiotics are inappropriately prescribed.
Similar subjective complaints as GABHS. Exudate is possible but less commonly seen in viral pharyngitis.
Rhinorrhea, coryza, and and cough are commonly reported.

Coryza

Acute inflammation of the mucous membrane of the nose, with discharge of mucus

Epiglottitis

Cellulitis of the supraglottis caused by bacterial, viral, or fungal infection or trauma.
Common signs include rapid onset of high fever, sore throat, drooling stridor, hoarseness, and respiratory comprise.
Risk Factor: Lack of immunizations.

Peritonsillar Abscess

A purulent collection between the pharyngeal muscles and the palatine tonsil.
Symptoms: common symptoms include fever, sore throat (usually unilateral), painful swallowing or dysphagia, and muffled voice.

Ludwig Angina

Characteristically an aggressive, rapidly spreading “woody” or brawny cellulitis involving the bilateral submandibular, sublingual, and submental spaces. The infection most commonly arises from an infected second or third mandibular molar tooth. Ludwig angina is characterized by its lack of lymphadenopathy and abscess formation.

ENT signs and symptoms indicating need for IMMEDIATE INTERVENTION?

Upper Airway Obstruction
Stridor
Respiratory Distress
Drooling

“Thumb Sign” in Epiglottitis

An enlarged epiglottis protruding from the anterior wall of the hypopharynx.

Treatment of Epiglottitis

Depends HEAVILY on the patient’s stability.
“Thumb sign” may be seen on a lateral soft tissue of the neck x-ray, indicating epiglottal edema.
Diagnostics: Nonspecific elevation of WBCs on complete blood count (CBC). Blood cultures should be drawn.
Treatment:
IV antibiotics – ceftriaxone or cefotaxime

PLUS

Vancomycin, clindamycin, oxacillin or nafcillin for patients with sepsis, severe infection, or immunocompromise.
Consider antifungals.
ICU Admission.

Treatment for Ludwig Angina

Airway management.
Antibiotics in Immunocompetent Patients:
Clindamycin and Levofloxacin for pts allergic to PCN.
Ampicillin/Sulbactam
Ceftriaxone + Metronidazole
PCN + Metronidazole
Antibiotics in Immunocompromised Patients:

-Piperacillin/Tazobactam

Imipenem/Cilastatin
Cefepime + Metronidazole
Meropenem
Consider Vancomycin for MRSA.

ENT consult for possible surgical decompression, needle aspiration, and culture.

Main Symptoms of Mononucleosis

Systemic: High fever, chills, & aches
Visual: Photophobia
Throat: Soreness, and redness
Lymph Nodes: Swelling
Respiratory: Cough
Central: Fatigue, loss of appetite, malaise, & headache
Tonsils: Reddening, swelling, & white patches
Spleen: Enlargement, & abdominal pain
Stomach: Nausea & vomiting

Treatment for Peritonsillar Abscess

Rapid strep test
Needle aspiration for fluid; send culture to the lab.
Antibiotics:
Pipericillin/tazobactam

Consider vancomycin or linezoid
Consider steroids – Decadron
Imaging is not indicated unless the provider wants to differentiate cellulitis from an abscess in which a bedside ultrasound can be performed.
Surgical intervention is indicated with airway compromise or complications.

Treatment for Mononucleosis

Serum diagnostics: lymphocytosis, possible thrombocytopenia, mild relative & absolute neutropenia, and elevated aminotransferases.
Consider rapid strep test because s/s mirror GABHS.
Monospot test will not become positive until symptoms have been present approximately 10 days.
Confirmatory testing is utilized to acknowledge disease and explain symptoms.
Diagnostic confirmation via heterophile antibody tests or EBV specific antibodies.
Risks of Splenic Rupture are Concerning:
Educate patient and family on when to seek healthcare.
Avoid contact sports.
If EBV testing is negative, further evaluation is warranted to rule out HIV, cytomegalovirus, and toxoplasmosis.
THERE IS NO SPECIFIC ANTIVIRAL THERAPY USED TO TREAT THE DISEASE.

Allergy Symptoms

Rash
Itching
Runny nose
Sneezing
Abdominal pain
Red eyes/lacrimation
Headache
Vomiting
Diarrhea

Allery Triggers

Food
Pollen of plants
Genetics
Particles of animal skin
Insects
Household chemicals
Medications
Stress
Dust

Rhinitis

Etiology: Inflammation to the nose and sinuses with rhinitis and sinusitis occurring together.
History:
Sneezing, rhinorrhea, itchy eyes, and palate.
Postnasal drip, cough, and fatigue.
Symptoms can be intermittent to persistent, and range from mild to severe.
Typically occurs seasonally with hay fever, and pollen allergies.
Also occurs with some indoor allergens such as animal dander, mold, dust mites, and cockroaches.
Seasonal/episodic history is reproducible year-to-year.
Exam:
Nasal mucosa with pallor, pale bluish hue, and turbinate edema.
Clear rhinorrhea, may see postnasal drip in posterior pharynx.
Cobblestone appearance (hyperplastic lymphoid tissue from drainage).
Tympanic membranes may be retracted, secondary to Eustachian tube dysfunction.
Associated Conditions:
Allergic conjunctivitis
Asthma
Atopic Dermatitis
Sinusitis
Diagnosis:
Diagnosis made clinically, through history and physical exam.
Diagnostic tests are not typically useful.
Treatment:
Allergen avoidance.
Referral to allergy skin testing if dx is unclear or if symptoms are poorly controlled.

Sinusitis

Etiology:
Symptomatic inflammation of the paranasal sinuses and nasal cavity.
Acute sinusitis is generally up to 4 weeks duration.
Chronic sinusitis is greater than 12 weeks duration.
History:
Nasal congestion/obstruction
Purulent nasal discharge
discolored discharge is a sign of inflammation, not infection
Maxillary tooth discomfort
Facial pain, worse when bending forward
Eustachian tube dysfunction (ear pain, hearing loss, fullness, pressure, and feeling the ear cannot “pop”)
Must determine the length of symptoms that are present and the course of illness in order to differentiate bacterial from viral etiology
Viral: Most symptoms improve within 7-10 days, with a peak in severity around days # 3-6, and no fever.

-Bacterial: Symptoms >10 days, initial improvement can be reported followed by an acute worsening of symptoms, and fever is possible.

Exam:
Erythema/edema over periorbital cheek region.
Upper teeth/molar tenderness to percussion
Purulent drainage in nasal cavity or posterior pharynx.
Examine ears to assess for coexisting disease.
Assess for complications of sinusitis such as: meningitis, intracranial abscess, periorbital and orbital cellulitis, subperiosteal abscess, osteomyelitis of sinus bone, septic cavernous sinus thrombosis, and presence of cranial nerve palsy.

Treatment of Sinusitis

Imaging, nasal cultures, and diagnostics are not indicated unless there are complications.
Symptomatic Tx of Viral Sinusitis:
Over the counter analgesics, antipyretics, and saline irrigation.
Consider intranasal glucocorticoids
Consider intranasal decongestants.: 1. Helpful with eustachian tube dysfunction, symptomatic relief of congestion & 2. Us no more than 3 days in a row to avoid rhinitis medicamentosa (rebound congestion and addiction).
Consider oral decongestants with eustachian tube dysfunction. *Caution with patients w/ cardiovascular disease, angle-closure glaucoma, HTN, or bladder neck obstruction.
Consider antihistamines. 1. Helpful for drying effect. 2. Can be sedating. 3. Can worsen sinusitis due to an inability to clear secretions because of the over-drying effect.
Prescribe antibiotics for suspected acute bacterial sinusitis:
Pathogens are likely to be Streptococcus pneumoniae or Haemophilus influenzae.
Initial empiric treatment with amoxicillin or amoxicillian-clavulanate. Those with risk factors for pneumococcal resistance should have high dose amoxicillin-clavulanate.
PCN allergy patients should be treated with doxycycline or 3rd generation cephalosporin.

Neer Test (Passive Painful Arc)

The “passive painful arc maneuver” (passively flexing the glenohumeral joint while simultaneously preventing shoulder shrugging) is used to assess the degree of impingement. Voluntary guarding by the patient while the maneuver is performed often manifests as shoulder shrugging.
The severity of impingement and rotator cuff tendinopathy is determined by the angle at which the arc becomes painful.
Pain at 90 degrees is consistent with mild impingement.
Pain at 60-70 degrees is consistent with moderate impingement.
Pain at 45 degrees is consistent with severe impingement.

Hawkins-Kennedy Test (Flexion with Internal Rotation)

In this test, the clinician stabilizes the shoulder with one hand and, with the patient’s elbow flexed 90 degrees, internally rotates the shoulder using the other hand. Shoulder pain elicited by internal rotation represents a positive test

Rotator Cuff Tear

Torn rotator cuff is a musculoskeletal injury that results from damage to the rotator cuff muscles or tendons.
The “rotator cuff” muscles (supraspinatus, infraspinatus, and teres minor) connect the scapula and humerus and help rotate and abduct the arm. These muscles form a common tendon around the shoulder joint.
The rotator cuff can be damaged by overuse or disease. Direct trauma can cause the tear or rupture of a tendon, most commonly in the supraspinatus tendon. Patients with a torn rotator cuff often experience pain or weakness in the affected shoulder and have difficulty raising the affected arm above their head.
A torn rotator cuff may be treated with medication, physical therapy, or surgery.

Adhesive Capsulitis

Inflamed glenohumeral joint tissue. Initial diffuse shoulder pain, worse at night, increasing stiffness and gradual loss of ROM. Often no precipitating cause. Often resolves in 1-2 years.
Risk Factors: Age >50, DM II, thyroid disorders, and cervical neck disorders.

Impingement Syndrome

Space between acromion and rotator cuff narrows and compresses bursa tendon. Inflammation, gradual onset pain worse with overhead activity. Described as “catching” sensation, may radiate to elbow.

Acromioclavicular (AC) Sprain

Pain in clavicular area after direct trauma or excessive pushing/pulling of upper extremity. Common in young males; typically associated with fall with arm abduction. Pain increases with lying on arm, adduction/abduction past 90 degrees, and heavy lifting.

Bicipital Tendon Rupture

Long head bicep tendon tears from proximal shoulder insertion, usually from lifting heavy objects. Presents with sudden pain, swelling and bruising.

Calcific Tendonitis

Formation of calcium deposits on rotator cuff tendons. Unknown etiology. Chronic pain that worsens with overhead reach.

Treatments for Shoulder Pain

Options include:
Rest
NSAIDs
Ice or Heat
Steroid Injection
Physical Therapy
Referral to an orthopedic specialist should be considered immediately for severe injuries. For mild to moderate injuries, referral is warranted if symptoms continue after 4-6 weeks of conservative treatment..

Which kinds of shoulder injuries are steroid injections an appropriate treatment for?

Adhesive Capsulitis
Rotator Cuff Tear
Calcific Tendonitis

Lateral Epicondylitis (Tennis Elbow)

Develops with repetitive or forceful arm motion damages the muscle tendons (tendinosis) around the elbow joint. Abnormal neurovascular growth occurs in the muscle tissue in response to the repetitive strain, resulting in pain.
Sharp, radiating pain down the OUTSIDE of the elbow.
Pain occurs with extension of wrist and gripping.
May have weakness in forearm or weak grip.
Treatment:
Rest

-NSAIDS

Use of forearm brace

*Repetitive motion should be limited.

Medial Epicondylitis (Golfer’s Elbow)

Develops with repetitive or forceful arm motion damages the muscle tendons (tendinosis) around the elbow joint. Abnormal neurovascular growth occurs in the muscle tissue in response to the repetitive strain, resulting in pain.
Sharp, radiating pain down INSIDE of the elbow.
Pain occurs with supination of forearm and gripping motions.
May have weakness in hand or wrist, numbness or tingling in ring/little fingers.
Treatment:
Rest

-NSAIDS

Use of forearm brace

*Repetitive motion should be limited.

Carpal Tunnel Syndrome (CTS)

Occurs when the median nerve, which runs from the forearm into the palm, becomes constricted. The carpal tunnel is a narrow passageway of the ligaments and bones at the base of the hand that houses the median nerves and the tendons that bend the fingers. The median nerve provides feeling to the palm side of the thumb and the index, middle, and ring fingers but not the little finger.
A common cause of CTS is a repetitive activity with the hands that cause irritated tendons, causing compression of the median nerve.

De Quervain’s Tenosynovitis (DQS) aka “Gamer’s Thumb”

An inflammation of tendons on the side of the wrist at the base of the thumb. These tendons include the abductor pollicis brevis and extensor pollicis brevis tendons. These tendons pass through a tunnel located on the thumb side of the wrist. Any swelling of the tendons results in increased friction and pain with certain wrist movements. Like CTS, de Quervain’s tendinosis may be caused by repetitive movements but is also associated with pregnancy and rheumatoid disease. It is most common in middle-aged women.

Trigger Finger aka Jersey Finger

A condition where the tendons in the fingers or thumb are inflamed, making it difficult for the finger to slide through the tendon sheath. Any finger can be affected, although it most commonly occurs in the middle and ring fingers. Trigger finger limits finger movement, and when the patient tries to straighten the digit, it will lock or catch before popping out straight and often involves a disruption of the flexor digitorum profundus tendon near the distal interphalangeal joint. Trigger finger may be idiopathic or associated with rheumatoid arthritis and diabetes. It is more common in women than men and occurs most frequently in people between the ages of 40-60.

Phalen Test

Performed by having the patient hold both wrists in complete and forced flexion (pushing the dorsal surfaces of both hands together) for 30-60 seconds.
The test is considered POSITIVE (abnormal) if the patient experiences characteristic symptoms of carpal tunnel syndrome (pain and paresthesias alone the distribution of the median nervem i.e., thumb, index, and middle finger).

Tinel Test

A simple, noninvasive test that checks for nerve problems. It involves tapping a finger along the problem nerve, which can produce tingling or pain. This sensation is a sign of nerve damage.

Finkelstein’s Sign

A provocative test for the diagnosis of De Quervain’s disease that can easily be performed in an office setting or at the bedside. Finkelstein’s test produces severe tenderness and usually pain on the radial aspect of the wrist when the thumb is flexed into the palm and the wrist is ulnar deviated.

Meniscus Tear

A meniscus tear is one of the most common knee injuries. Though typically caused by acute rotational trauma, meniscus tears can also result from chronic conditions such as degenerative arthritis. Tears are classified based on their complexity, position, shape, and nature of occurrence.
Tears of the medical meniscus are more common than those of the lateral meniscus, possibly due to the rigid attachment of the medial meniscus to the medial collateral ligament.
Patients with a torn medial meniscus often experience pain, swelling, and mechanical issues (clicking or locking) of the affected knee joint.

Sprain of Medial Collateral Ligament (MCL)

Sprain or tear of the MCL.
Presents as acute pain, swelling, stiffness, popping, or buckling.
Common injury from sports or falls.

Bursitis

Inflammation of a bursa, typically one in the knee.
Pain in front of knee and around patella. Dull, aching pain over anterior knee.
Common in patients who kneel frequently or from penetrating injury.

Sprain of Lateral Collateral Ligament (LCL)

Sprain or tear of LCL.
Acute pain, swelling, stiffness, popping, or buckling.
Common injury from sports or falls.

Anterior Cruciate Ligament (ACL) Tear

One of the most common knee injuries. Though typically caused by non-contact pivot trauma (e.g., “planting and twisting”), ACL tears can also result from direct contact. The severity of an ACL is based on if the ligament is partially or completely torn, and on the degree of damage to nearby structures.
Patients with a torn ACL often experience pain and a “popping” sound when the tear occurs. After the initial injury, swelling may occur and the knee may be too unstable or too painful to bear weight,.

Rheumatoid Arthritis (RA)

A chronic, systemic inflammatory condition that primarily affects the synovial joints. If the knee is involved, the disease is most likely at an advanced stage. RA can also affect other parts of the body, including the skin, lungs, and eyes.
Though the underlying cause is unknown, RA results from immune cells attacking the synovial membrane, which leads to joint pain and swelling.
The progression of RA in the knee tends to progress symmetrically. It erodes the cartilage, tendon, and bone, resulting in the destruction of the knee joints.
The most common symptoms of RA is pain and stiffness in the joints. Patients may experience fever, general malaise, and weakness, in addition to symmetric joint pain and inflammation of the hands or feet.

Osgood-Schlatter Disease

A common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the tibia.
Most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly. Because physical activity puts additional stress on bones and muscles, children who participate in athletics – especially running and jumping sports – are at an increased risk for this condition. However, less active adolescents may also experience this problem.
In most cases simple measures like rest, ice, OTC medication, and stretching and strengthening exercises will relieve pain and allow a return to daily activities.

Sprain of Posterior Cruciate Ligament (PCL)

Sprain or tear of posterior cruciate ligatment.
Acute pain, swelling, stiffness, popping, or buckling.
Common in car crash injuries and contact sports.

McMurray Test

A series of movements to check for the presence of a meniscal tear within the knee.
Technique:
The patient is positioned supine with knee completely flexed.
Provider is positioned on the side of the patient being tested.
The provider uses their proximal hand to hold the knee and palpate the joint line, thumb on one side and fingers on the other.
The provider uses their distal hand to hold the sole of the foot and acts to support the limb and provide the required movement through range.
From a position of maximal flexion, the provider extends the knee with internal rotation of the tibia and a VARUS stress, then returns to maximal flexion and extends the knee with external rotation of the tibia and a VALGUS stress.

VARUS stress

A force applied to a joint that causes the distal aspect of a limb to be moved towards the midline of the body.

VALGUS stress

The VALGUS stress is used to assess the integrity of the medial collateral ligament (MCL) of the knee.

Anterior Drawer Test

A knee assessment used to check for injury to the ACL.
Technique:
The patient lays on their back with their knee at a 90-degree angle and the foot in a neutral position.
The provider sits at the patient’s foot.
The provider wraps their hands around the back of the patient’s knee, placing their thumbs on the front of the kneecap, and then pulls the knee forward.
The provider rotates the patient’s foot medially and externally as they pull the knee forward.
This test is performed on the uninjured knee first to compare the two.
If the tibia, has move movement, or if the ligament is loose compared to the uninjured knee, the anterior drawer test is considered to be positive.

Posterior Drawer Test

The purpose of this test is to test the integrity of the posterior cruciate ligament (PCL).
Technique:
The patient is supine and the knee to be tested is flexed to approximately 90 degrees. The examiner then sits at the toes of the tested extremity to help stabilize it. The examiner grasps the proximal lower leg, approximately at the tibial plateau or joint line with the thumbs placed on the tibial tuberosity. Then the examiner attempts to translate the lower leg posteriorly. The test is considered positive if there is a lack of end feel or excessive posterior translation.

Lachman Test

A passive accessory movement of the knee performed to identify the integrity of the anterior cruciate ligament (ACL). The test is designed to assess single and sagittal plane instability.
Technique:
Lie the patient supine on the bed. Place the patient’s knee in about 20-30 degree flexion. According to Bates’ Guide to Physical Examination, the leg should also be externally rotated slightly. The examiner should place one hand behind the tibia and the other on the patient’s thigh. It is important that the examiner’s thumb be on the tibial tuberosity. On pulling the tibia anteriorly, an intact ACL should prevent forward translational movement of the tibia on the femur (“Firm end-feel”).

Anterior translation of the tibia associated with a soft or mushy end-feel indicates a positive test. More than about 2mm anterior translation compared to the uninvolved knee suggests a torn ACL (“soft end-feel”), as does 10 mm of total anterior translation. An instrument called a “KT-1000” can be used to determine the magnitude of movement in millimeters.

Grades of Knee Sprains

Treatment of ligamentous injuries to the knee is based on the grade of injury. Sprains are graded according to the severity and degree of a tear.
Grades of Knee Sprains:
Grade 1: Minor injury without tear.
Grade 2: Moderate injury with partial tear.
Grade 3: Severe injury with complete or near-complete tear

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