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Eyelid changes: crusting, greasy, scaling, red-rimming of eyelid and eyelash flaking along with dry eyes and associated seborrhea and rosacea History of blunt trauma, muscle entrapment, eyelid swelling, gaze restriction, double vision, decreased visual acuity, enophthalmos (sunken eye). Anesthesia/paresthesia in the gums, upper lips, and cheek due to damage to the infraorbital nerve Blurred vision over months or years, halos around lights. Clouding of the Lens (versus clouding of cornea = glaucoma). Fundoscopy "black on red background." A chalazion is a sterile painless (non-infectious) granuloma of the internal meibomian sebaceous gland, painless "cold" lid nodule
- Viral: copious watery discharge, scant mucoid discharge. Adenovirus (most common). Self-limiting associated with URI.
- Bacterial: Pt will present with purulent (yellow) discharge, crusting, usually worse in the morning. May be unilateral.
- S. pneumonia, S. aureus – acute mucopurulent
- M. catarrhalis, Gonococcal – copious purulent discharge, in a patient who is not responding to conventional treatment
- Chlamydia– newborn, giemsa stain - inclusion body, scant mucopurulent discharge
- Allergic: red eyes, itching and tearing, usually bilateral, cobblestone mucosa on the inner/upper eyelid.
Sudden onset of eye pain, photophobia, tearing, foreign body sensation, blurring of vision, and/or conjunctival injection, fluorescein dye - increased absorption in devoid area, antibiotic eye ointment, no patching. Contact lense wearers, caused by deep infection in the cornea by bacteria, viruses or fungi. White spot on surface of cornea that stains with fluorescein: round "ulceration" versus "dendritic" pattern like herpes Ectropion (eversion of the eyelid) occurs when the eyelid turns outward exposing the palpebral conjunctiva, conjunctiva will appear red from air exposure and inflammation Entropion (inversion of an eyelid) occurs when the eyelid turns inward. It is most commonly caused by age-related tissue relaxation, surgical correction is definitive Metallic foreign bodies may leave a rust ring, irrigation and removal with sterile swab. Intraocular foreign bodies require immediate surgical removal by an ophthalmologist
- Open angle glaucoma: most common, aqueous outflow obstruction, > 40 y/o, African Americans, often asymptomatic, peripheral to central gradual visual loss (versus macular degeneration which is central loss)
- Acute angle closure glaucoma: Iris against lens, dark environment, acute loss of vision, nausea, and vomiting. Classic triad: injected conjunctiva, steamy cornea, and fixed dilated pupil, this is an ophthalmic emergency
Painful, warm (hot), swollen red lump on the eyelid (different from a chalazion which is painless) Think “H” for Hot = Hordeolum. Most common organism S. aureus. Trauma causes blood in the anterior chamber of the eye (between the cornea and the iris). The blood may cover part or all of the iris (the colored part of the eye) and the pupil, and may partly or totally block vision in that eye. Treat with eye protection and rest with the head of the bed at 30 degrees all the time. Gradual painless loss of central vision. The macula is responsible for central visual acuity which is why macular degeneration causes gradual central field loss. Metamorphopsia (distortion on Amsler grid)
- Dry macular degeneration (85% of cases): atrophic changes with age – slow gradual breakdown of the macula (macular atrophy), with DRUSEN (DRY)= yellow retinal deposits.
- Wet macular degeneration: hemorrhage, neovascuration. New abnormal vessels grow under central retina which leak and bleed causing retinal scarring.
- Down/upbeat: CNS dysfunction
- Vestibular (horizontal): labyrinth or vestibular nerve dysfunction
- Gaze-evoked: most common and often benign
Acute inflammation and demyelination of the optic nerve leading to acute monocular vision loss/blurriness and pain on extraocular movements. Typically occurs over hours or days. Fundoscopy: inflammation of the optic disc. Associated with multiple sclerosis. Decreased extraocular movement, pain with movement of the eye and proptosis, signs of infection. Often associated with sinusitis. Occurs more often in children than adults. Hospitalization and IV broad-spectrum antibiotics. Optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks. Causes include brain tumor/abscess, meningitis, cerebral hemorrhage, encephalitis, pseudotumor cerebri. Immediate neuroimaging to rule out mass lesion, then CSF analysis. Treat underlying cause. Elevated, superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in inner corner/nasal side of the eye). Only surgically remove when vision is affected Vertical curtain coming down across the field of vision, may sense floaters or flashes at onset, loss of vision over several hours. Asymmetric red reflex. Consult ophthalmologist. Stay supine (lying face upward) with head turned towards the side of the detached retina. Sudden, painless, unilateral, and usually severe vision loss (Amaurosis fugax). Embolism from the same side (ipsilateral) carotid artery, ophthalmic artery, and heart, or giant cell arteritis. Rule out carotid artery stenosis by carotid ultrasound. Look for the cherry red spot. Leading cause of blindness, most common is diabetic retinopathy. Proliferative type is most severe. Fundoscopic exam cotton wool spots, hard exudates, blot and dot hemorrhages, neovascularization, flame hemorrhages, A/V nicking Strabismus is defined as any form of ocular misalignment, the cover/uncover test is used to diagnose strabismus. Exotropia is out-turning of eyes, esotropia is in-turning of eyes. Patch exercises, if untreated after age two, amblyopia results. Age 2 and under, limited mobility of the TM with pneumotoscopy. S. pneumoniae 25%, H. influenzae 20%, M. catarrhalis 10%, first line Amoxicillin, second line Augmentin, macrolides if pen allergic, complications mastoiditis and bullous myringitis. Benign tumor of the Schwann cells (the cells which produce myelin sheath) – most commonly affects the vestibular division of the 8'th cranial nerve. Slowly progressive unilateral hearing loss, tinnitus, disequilibrium. Diagnose with MRI treat with surgery or stereotactic radiation therapy Barotrauma presents with ear pain and hearing loss that persists past the inciting event, associated with pressure changes. Common injury in divers or while flying, sudden onset of pain that may resolve with a "pop." Painless otorrhea, brown/yellow discharge with strong odor, caused by chronic eustachian tube dysfunction which results in chronic negative pressure and inverts part of the TM causing granulation tissue that over time, erodes the ossicles and leads to conductive hearing loss. Surgical removal. Ear fullness, popping of ears, underwater feeling, intermittent sharp ear pain, fluctuating conductive hearing loss, tinnitus. All children < 7 years old have some ET dysfunction (based on the angle of the eustachian tube) will resolve with age Insects must be immobilized prior to removal. Drown insects with mineral oil or viscous lidocaine before attempting removal, After irrigation, if the child is uncomfortable, consider treating with topical pain agents such as benzocaine-antipyrine The most common causes of hearing impairment/loss are cerumen impaction, eustachian tube dysfunction (secondary to upper respiratory tract infection [URI]), and increasing age (presbycusis)
- Weber test: Tuning fork is placed on center of the head and see if sound lateralizes - Sound lateralizes to affected ear in conductive hearing loss, Sound lateralizes to unaffected ear in sensorineural hearing loss
- Rinne test: Tuning fork placed on mastoid and then up to the ear (should continue to hear) conductive hearing loss if bone > air, sensorineural hearing loss if air > bone
Blunt trauma to ear shearing forces to the anterior auricle lead to separation of the anterior auricle perichondrium from the underlying cartilage. May result in thickening of cartilage (cauliflower ear) if not treated promptly! Evacuate blood and cephalexin. Acute onset, vertigo + hearing loss, tinnitus of several days to a week. Usually, viral absence of neurologic deficits. Diazepam or meclizine vertigo, promethazine for nausea Complication of acute otitis media. Fever, otalgia, pain & erythema posterior to the ear, and forward displacement of the external ear. Organisms: S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus, S. pyogenes. IV antibiotics (ceftriaxone), drainage of middle ear fluid. Vertigo attacks lasting hours, classic triad of low-frequency hearing loss, tinnitus with aural (ear) fullness and vertigo, treat with low salt diet, diuretics (HCTZ + triamterene) to reduce aural pressure Edema with cheesy white discharge, palpation of the targus is painful, Pseudomonas aeruginosa (swimmer’s ear), S. aureus (digital trauma), malignant otitis externa is commonly seen in diabetics Perceived sensation of sound in the absence of an external acoustic stimulus; often described as a ringing, hissing, buzzing, or whooshing. 90% is associated with sensorineural hearing loss – caused by loud noise, presbycusis, medications (aspirin, antibiotics, aminoglycosides, loop diuretics and CCBs), Meniere's disease, acoustic neuroma. Pain, otorrhea, and hearing loss/reduction, most heal spontaneously, keep clean and dry, treat with antibiotics, the only class of antibiotics that are non-ototoxic are Floxin drops.Surgery if persists past 2 months.
- Central vertigo: more gradual onset and vertical nystagmus. Unlike peripheral vertigo, it does not present with auditory symptoms. Romberg Sign. Brainstem vascular disease, arteriovenous malformations, tumors, multiple sclerosis, and vertebrobasilar migraine.
- Peripheral (inner ear) sudden onset, nausea/vomiting, tinnitus, hearing loss, and horizontal nystagmus. Labyrinthitis, benign paroxysmal positional vertigo, endolymphatic hydrops (Ménière syndrome), vestibular neuritis, and head injury.
After URI. Sinus pain/pressure (worse with bending down and leaning forward). Facial tap elicits pain. Viral: Most common, symptoms < 7 days. Bacterial: Symptoms 7+ days and associated with bilateral purulent nasal discharge. Indications for antibiotics in rhinosinusitis include duration of symptoms >10 days without improvement, Augmentin 875 BID, kids Amoxicillin x 10-14 days. Organisms: S. pneumoniae, H. influenzae, M.catarhalis. Chronic: Plainview X-ray (waters view) is a good initial screening, CT is the Gold Standard. Clear nasal drainage, pruritus, pale, bluish, boggy mucosa, allergic shiners, IgE mediated mast cell histamine release, intranasal decongestants not to be used more than 3-5 days may cause rhinitis medicamentosa Kiesselbach's Plexus or Little's Area is the most common site for anterior bleeds, sphenopalatine artery (Woodruff’s plexus) is generally the source of severe posterior nosebleed, direct pressure for 15 minutes, posterior balloon packing is used to treat posterior epistaxis Purulent, foul-smelling nasal discharge Teardrop-shaped growths that form in the nose or sinuses, usually benign, associated with allergic rhinitis. Samter's triad: Asthma, Aspirin sensitivity, and nasal polyps. Consider Cystic Fibrosis when multiple polyps are seen
- Viral - Adenovirus most common
- Mononucleosis: Epstein Barr virus, fever, sore throat, lymphadenopathy, splenomegaly, atypical lymphocytes, + heterophile agglutination test (monospot). Symptomatic and avoid contact sports, antibiotics such as amoxicillin or ampicillin may cause a rash.
- Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis
- Fungal causes in patients using inhaled steroids
- Group A Streptococcal pharyngitis: S. pyogenes. Centor Criteria: Absence of cough, Exudates, Fever, Cervical lymphadenopathy. Throat culture is gold standard, Penicillin is first line, Azithromycin if Pen allergic. Complications: Rheumatic fever and post-strep glomerulonephritis.
Single or multiple small, shallow ulcers with yellow-gray fibrinoid center with red halos, biopsy should be considered for ulcers lasting more than 3 weeks, viscous lidocaine 2–5% applied to ulcer QID after meals until healed
- Gingivitis: patient should be counseled about increases risk for cardiovascular events
- Gingival Hyperplasia: Overgrowing of gums so that it blocks the teeth, commonly caused by medications. phenytoin, CCB's and cyclosporine
- Vincent's Angina: “Trench Mouth” necrotizing gingivitis: characterized by the “punched-out” appearance of the gingival papillae
- Dental abscess: Poor dental health is a risk factor for dental abscess or facial cellulitis, treat with IM ceftriaxone and amoxicillin
Unvaccinated patient leaning forward, drooling, stridor and distress (tripod position, muffled voice), H. influenza type B (Hib). Lateral radiograph: Thumbprint sign. Secure airway, IV Ceftriaxone, and IV fluids. Almost always viral, hoarseness following a URI, consider squamous cell carcinoma if hoarseness persists > 2 weeks, history of ETOH and or smoking, laryngoscopy is required for symptoms persisting > 3 wks. Immunocompromised, young patients. Painful, white fluffy patches that can be scraped off and may bleed when scraped (candidiasis can "come off"), leaving an erythematous, friable base. Diagnose with Potassium Hydroxide (KOH) prep HSV type 1, vesicular lesions all in the same stage of development, prodromal period of tingling discomfort or itching Smokers, AIDs, alcohol abuse. Painless, precancerous white lesions on the side of the tongue that cannot be scraped off Hot potato (muffled) voice and deviation of the uvula to one side Mumps is caused by Paramyxovirus (Mumps), in adult males look for an associated orchitis Sialadenitis is a bacterial infection of a salivary gland (S. aureus) usually caused by sialolithiasis (obstructing stone) in the salivary gland. Acute swelling of the cheek, which worsens with meals. Diagnose with CT, ultrasonography, or MRI.
- Thyroid neoplastic disease (blueprint endocrinology): papillary is the most common type
- Oral Cancer: Most often squamous cell carcinoma (blueprint dermatology): the use of tobacco and alcohol account for up to 80 percent of cases of squamous cell carcinoma of the head and neck
- Branchial Cleft Cyst: cyst appearing after URI anterior to sternocleidomastoid, most common lateral neck mass
- Thyroglossal duct cyst: Hyoid or sub-hyoid soft mass which rise with tongue protrusion, most common midline neck mass
- Lymphadenopathy: Unilateral, painless, persistent cervical think lymphoma (blueprint hematology)
- Leukoplakia: white oral lesion that is painless and cannot be rubbed or scraped off. Lesions are often linked with tobacco, alcohol, or denture use, 5% are dysplastic or squamous cell carcinomas