NR-511-week-4-midterm-exam
1. Define diagnostic reasoning
Answer: Reflective thinking because the process involves questioning one's thinking to
determine if all possible avenues have been explored & if the conclusions that are being drawn
are based on evidence.
Seen as a kind of critical thinking.
2. What is subjective data?
Answer: Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS
3. What is objective data?
Answer: Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
4. Identify components of HPI
Answer: Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
5. Describe the differences between medical billing & medical coding
Answer: Medical billing: process of submitting & following up on claims made to a payer in
order to receive payment for medical services rendered by a healthcare provider
Medical coding: the use of codes to communicate with payers about which procedures were
performed & why.
6. Compare & contrast the two coding classification systems that are currently used in the US
healthcare system.
Answer: ICD: International classification of disease codes are used to provide payer info on
necessity of visit or procedure performed. Shorth& for pt's dx.
CPT: common procedural terminology codes offer the official procedural coding rules &
guidelines required when reporting medical services & procedures performed by physician &
non-physician providers. Must have corresponding ICD.
7. How do specificity, sensitivity, & predictive value contribute to the usefulness of diagnostic
data?
Answer: Specificity: ability of a test to correctly detect a specific condition. If a pt has a
condition but test is negative, it is a false negative. If pt does NOT have condition but test is
positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to correctly identify a specific
condition when it is present. The higher the sensitivity, the lesser the likelihood of a false
negative.
Predictive value: The likelihood that the pt actually has the condition & is, in part, dependent
upon the prevalence of the condition in the population. If a condition is highly likely, the positive
result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypotheses.
Diagnostic tests may be used to screen for conditions.
Diagnostic tests may be used to monitor the progress in managing a chronic condition.
8. Discuss the elements that need to be considered when developing a plan.
Answer: Pt's preferences & actions
Research evidence
Clinical state/circumstances
Clinical expertise
9. Describe the components of medical decision making in E&M coding.
Answer: Risk, data, diagnosis
The more time & consideration involved in dealing with a pt, the higher the reimbursement from
the payer.
Documentation must reflect MDM
10. Correctly order the E&M office visit codes based on complexity from least to most complex.
Answer: New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204 5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
11. The 5 key components of a comprehensive treatment plan are:
Answer: 1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
12. Define the components of a SOAP note.
Answer: S: subjective (what the pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
Vital signs
General survey
HEENT Etc...
A: assessment
Global assessment of pt including differentials in order from most to least likely
Combination of subjective & objective info
List of dx addressed & billed for at the visit
P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
13. Discuss minimum of three purposes of the written history & physical in relation to the
importance of documentation.
Answer: Important reference document that gives concise info about the pt's hx & exam
findings
Outlines a plan for addressing issues that prompted the visit. Info should be presented in a
logical fashion that prominently features all data relevant to the pt's condition.
Is a means of communicating info to all providers involved in pt's care
Is a medical-legal document
Is essential in order to accurately code & bill for services
14. Why does every procedure code need a corresponding diagnosis code? Diagnosis code
explains the necessity of the procedure code.
Answer: Insurance won't pay if they don't correspond.
15. What are the three components required in determining an outpatient, office visit E&M
code?
Answer: Plan of service
Type of service
Patient status
16. Correctly ID a pt as a new or established given historical info.
Answer: Pt status: whether or not pt is new or established.
New: has not received professional service from provider in same group within past 3 years.
Established: has received professional service from provider in same group in last 3 years.
17. What does a well-rounded clinical experience mean?
Answer: Includes seeing kids from birth through young adult visits for well child & acute visits,
as well as adults for wellness or acute/routine visits.
Seeing a variety of pt's, including 15% of peds & 15% of women's health of total time in the
program.
18. What are the maximum number of hours that time can be spent "rounding" in a facility?
Answer: No more than 25% of total practicum hours in the program
19. What are 9 things that must be documented when inputting data into clinical encounter logs?
Answer: Date of service
Age
Gender & ethnicity
Visit E&M code
CC
Procedures
Tests performed/ordered
Dx
Level of involvement
20. What does the acronym SNAPPS st& for?
Answer: S: summarize (present pt's H&P findings)
N: narrow (based on H&P, narrow down top 2-3 differentials)
A: analyze (compare/contrast H&P findings for each differential & narrow it down to most likely
one)
P: probe (ask preceptor questions of anything you are unsure of)
P: plan (come up with specific management plan)
S: Self-directed learning (opportunity to investigate more about topics you are uncertain of)
21. What is the most common type of pathogen responsible for acute gastroenteritis?
Answer: Viral (can be viral, bacterial, or parasitic), usually norovirus
22. Assessing for prior antibiotic use is a critical part of the history in pt's presenting with
diarrhea.
Answer: True
23. What is the difference between irritable bowel disease (IBD) & irritable bowel syndrome
(IBS)?
Answer: IBS: disorder of bowel function (as opposed to being due to an anatomic abnormality).
Changes in bowel habits (diarrhea, constipation, abd pain, bloating, rectal urgency w/diarrhea).
Symptoms fall into two categories: abd pain/altered bowel habits, & painless diarrhea.
Usually pain is LLQ.
PE: normal except for tenderness in colon.
Labs: CBC, ESR. Most other labs & radiology/scopes are normal.
Dx made on careful H&P.
May be associated with nonintestinal (extra-intestinal) symptoms (sexual function difficulty,
muscle aches/pains, fatigue, fibromyalgia, HAs, back pain, urinary symptoms). Not associate
with serious medical consequences. Not a risk factor for other serious GI dz's.
Does not put extra stress on other organs.
Overall prognosis is excellent.
Major problem: changes quality of life.
Treatment: based on symptom pattern. May include diet, education, pharm (for modsevere
pt's)/other supportive interventions. Usually focuses on lifestyle, diet, & stress reduction. NO
PROVEN TREATMENT! Antidiarrheals: use temporarily, reserve for severe. Loperamide
(Imodium) or diphenoxylate (Lomotil) 2.5-5mg q6h usually works. Constipation: high fiber diet,
hydration, exercise, bulking agents. If these don't work, intermittent use of stimulant laxatives
(lactulose or mag hydroxide); don't use long-term! Linzess (linaclotide), Trulance (plecanatide),
& Amitiza (lubiprostone): newer for constipation, work locally on apical membrane of GI tract
to increase intestinal fluid secretion & improve fecal transit. Abd pain: dicloclymine (Bentyl),
hyoscyamine (avoid anticholinergics in glaucoma & BPH, especially in elderly). TCAs & SSRIs
can relieve symptoms in some pt's.
Can be managed by PCP, but if not responsive to tx, refer to GI.
IBD: chronic immunological dz that manifests in intestinal inflammation.
UC & Crohn's are most common.
UC: mucosal surface of colon is inflamed, resulting in friability, erosions, bleeding. Usually
occurs in rectosigmoid area, but can involve entire colon. Ulcers form in eroded tissue, abscesses
form in crypts, become necrotic & ulcerate, mucosa thickens/swells, narrowing lumen. Pt's are at
risk for perforation. Symptoms: bleeding, cramping, urge to defecate. Stools are watery diarrhea
with blood/mucus. Fecal leuks almost always present in active UC. Tenderness usually in LLQ
or across entire abd.
Crohn's: inflammation extends deeper into intestinal wall. Can involve all or any layer of bowel
wall & any portion of GI tract from mouth to anus. Characteristic segmental presentation of dz'd
bowel separated by areas of normal mucosa ("skipped lesions"). With progression, fibrosis
thickens bowel wall, narrowing lumen, leading to obstructions, fistulas, ulcerations. Pt's are at
greater risk for colorectal cancer. Most common symptoms: cramping, fever, anorexia, wt loss,
spasms, flatulance, RLQ pain/mass, bloody/mucus/pus stools. Symptoms increase with stress,
after meals. 50% of pt's have perianal involvement (anal/perianal fissures).
Inflammation can lead to bleeding, fever, increased WBC, diarrhea, cramping.
Abnormalities can be seen on cross-sectional imaging or colons copy.
No single explanation for IBD. Theory: viral, bacterial, or allergic process initially inflames
small or large intestine, results in antibody development which chronically attack intestine,
leading to inflammation. Possible genetic predisposition.
Dx made by H&P correlated with symptoms, must exclude infectious cause for colitis. Primary
dx tools: sigmoidoscopy, colonoscopy, barium enema w/small bowel follow through, CT.
Tx is very complex, managed by GI.
Drugs: 5-aminosalicylic acid agents have been used for >50yrs, but have shown to be of
little value in CD; still used as first attempt for UC. Antidiarrheals w/caution
(constipation). Don't use in acute UC or if toxic megacolon. Corticosteroids used when 5-ASA
not working. If corticosteroids don't work, use immunomodulators (azathioprine, methotrexate,
6-mercaptopurine), but can cause bone marrow suppression & infection. Newer class: anti-TNF
(biologic response modifiers) for mod-severe dz. Remicade (infliximab), Humira (adalimumab),
Entyvio (vedolizumab); can increase risk of infection.
24. What are two common IBD's?
Answer: Ulcerative colitis
Crohn's disease
25. Describe the characteristics of acute diverticulitis.
Answer: Subjective:
S/S of infection (fever, chills, tachycardia)
Localized pain LLQ
Anorexia, n/v
If fistula present, additional s/s will be present associated w/affected organ (dysuria,
pneumaturia, hematachzia, frank rectal bleeding, etc)
Objective:
Tenderness in LLQ
Maybe firm, fixed mass at area of diverticuli
Maybe rebound tenderness w/involuntary guarding/rigidity
Hypoactive bowel sounds initially, then hyperactive if obstructive process present
Rectal tenderness +occult blood
Diagnostics:
Mild-moderate leukocytosis
Possibly decreased hgb/hct r/t rectal bleeding
Bladder fistula: urine will have increased WBC/RBC, culture may be +
If peritonitis, blood culture should be done (for bacteremia)
Abd XR: perforation, peritonitis, ileus, obstruction
CT may be needed to confirm
26. What is the difference between sensorineural & conductive hearing loss?
Answer: Sensorineural: results from deterioration of cochlea due to loss of hair cells from organ
of Corti.
Very common in adults.
Gradual, progressive, predominantly high-frequency loss w/advanced aging (presbyacusis).
Other causes: ototoxic drugs, loud noises, head trauma, autoimmune dz, metabolic dz, acoustic
neuroma.
Genetic makeup can influence.
Not correctable w/medical or surgical therapies, but can stabilize if loss is gradual.
Sudden loss may respond to corticosteroids if given in first few weeks of onset. Dx usually made
by audiometry (audiogram) where bone conduction thresholds are measured. Done by
audiologist.
No proven or recommended treatment/cure. Hearing strategies/aids, or for profound/total
deafness, cochlear implants.
In Weber test: normal ear hears sounds better.
Commonly seen in primary care: tinnitus & Meniere's.
Conductive: result of obstruction between middle & outer ear.
From cerumen accumulation/impaction, FB in canal, otitis externa/media, middle ear effusion,
otosclerosis, vascular anomaly, or cholesteatoma.
Tx depends on accurately identified etiology.
Most types are reversible.
In Weber test: defective ear hears tuning fork louder.
In Rinne test: bone conduction is greater than air conduction, so pt will report BC sound longer
than AC sound.
27. What is the triad of symptoms associated with Meniere's disease?
Answer: Vertigo
Hearing loss
Tinnitus
28. What symptoms are associated with peritonsilar abscess?
Answer: Almost always unilateral, located between tonsil & superior pharyngeal constrictor
muscle
Gradual onset of severe unilateral sore throat
Odynophagia
Fever
Otalgia
Asymmetric cervical adenopathy
Pronounced trismus (hot potato voice)
Toxic appearance (poor/absent eye contact, failure to recognize parents, irritability, inability to
be consoled/distracted, drooling, severe halitosis, tonsillar erythema, exudates)
Swelling above affected tonsil with a discrete bulge, deviation of soft palate/uvula
29. What is the most common cause of viral pharyngitis?
Answer: Adenovirus
Mononucleosis (Epstein-Barr)
HSV-1
RSV
Flu A&B
Coxsackie
Enteroviruses
30. What is the most common cause of acute n/v?
Answer: Acute gastroenteritis
31. What is the importance of obtaining an abdominal XR to rule out perforation or obstruction
even though the diagnosis of diverticulitis can be made clinically?
Answer: To look for free air (indicating perforation), ileus, or obstruction & treat empirically.
Early treatment leads to better outcomes, so don't delay treatment.
32. What are colon cancer screening recommendations relative to certain populations?
Answer: Age 50 or older: initial scope at 50yo, then every 10yrs.
If at increased/high risk of colorectal cancer, start screening earlier (i.e. age 40) & be screened
more often based on findings.
African Americans: Starts screening at age 40-45.
33. Identify at least two disorders that are considered to be disorders related to conductive
hearing loss.
Answer: Cerumen accumulation/impaction
FB in ear canal
Otitis externa
Chronic otitis media
Middle ear effusion
Tosclerosis
Vascular anomaly
Cholesteatoma
34. What is the most common cause of bacterial pharyngitis?
Answer: Group A Beta Hemolytic Streptococcus (GABHS)
35. What are the clinical findings associated with mononucleosis?
Answer: Gradual onset of fever
Marked malaise
Severe sore throat
Maybe exudative tonsillitis (50% of cases)
Palatal petechiae/rash
Anterior/posterior cervical lymphadenopathy
Splenic enlargement
36. How is the diagnosis of streptococcal pharyngitis made clinically based on the Center
criteria?
Answer: Fever > 38C (100.5F)
Tender anterior cervical lymphadenopathy
No cough
Pharyngotonsillar exudate
Presence of all 4 strongly suggest GABHS infection.
3 or more present: empirically dx & treat w/out further testing
37. What is one intervention for a pt with gastroenteritis?
Answer: Fluid repletion (PO if possible, pedialyte; IVF for more severe dehydration)
Nutrition
38. When are stool studies warranted?
Answer: In pts with severe or prolonged diarrhea, fever >38.5C, bloody stools, stools
+leukocytes/occult blood
39. What is an appropriate treatment for prophylaxis or treatment of traveler's diarrhea?
Answer: Trimethoprim-sulfamethoxazole (Bactrim DS) 1 tab BID x3days
Cipro 500mg
Norfloxacin (Noroxin) 400mg
Ofloxacin (Floxin) 300mg
40. Describe the component of the H&P that should be done for a pt with abd pain.
Answer: OLDCARTS
Upper abd pain: ask about chronic/recurring & related symptoms (bloating, fullness, heartburn,
n/v)
Lower abd pain: if acute, is pain sharp, intermittent continuous? If chronic, is there a change in
bowel habits (alternating diarrhea/constipation)?
Radiation?
41. What is at least one effective treatment for IBS?
Answer: Diet (avoid lactose, caffeine, legumes, artificial sweeteners; eat low-fat diet with
increased protein, high fiber, bulk-producing agents, 64oz water daily)
Lifestyle modification
Exercise
Stress reduction
Pharm (for moderate-severe symptoms only): antidiarrheals (imodium, lomotil), laxatives
(lactulose, mag hydroxide), antispasmodics (dicyclomine, hyoscyamine), tricyclic
antidepressants; avoid anticholinergics with glaucoma & BPH pts.
42. What is at least one prescription med used to treat chronic constipation?
Answer: Linzess (linaclotide)
Trulance (plecanatide)
Amitiza (lubiprostone)
Lactulose
Mag hydroxide
43. What is at least one treatment for Meniere's disease?
Answer: Bedrest with eyes closed, protection from falling
Maintenance therapy: chlorothiazide (Diurel) 500mg/day
Meclizine
Promethazine
Dimenhydrinate
Diphenhydramine
Metoclopramide
44. The majority of dyspnea complaints are due to cardiac or pulmonary decompensation.
Answer: True
45. What are the differences between intrathorax & extrathorax flow disorders?
Answer: Intra: obstruction of distal/smaller airway (asthma, bronchiolitis, vascular ring, solid
FB aspiration, lymph node enlargement pressure). Take place in the supraglottic, glottis, &
infraglottic regions. Supraglottic = space above larynx & epiglottis. Glottis = area of opening in
vocal cords. Infraglottic = starts at bottom of vocal cords & ends at top of trachea.
Extra: Obstruction of proximal/larger airway (rhinitis with nasal obstruction, nasal polyp, craniofacial malformation, OSA, tonsil/adenoid hypertrophy, laryngotracheomalacia, larynx papilloma,
diphtheria, croup, epiglottitis, thymus hypertrophy)
Difference is location of obstruction.
46. What are at least 3 examples of flow & volume disorders (intra &/or extra thorax)?
Answer: Intra Flow:
Asthma
Bronchiolitis
Vascular ring
Solid FB aspiration
Lymph node enlargement pressure
Extra flow:
Rhinitis w/nasal obstruction/nasal polyp
Cranio-facial malformation
Obstructive sleep apnea
Tonsil-adenoid hypertrophy
Laryngo-tracheo-malacia
Larynx papilloma
Diphtheria
Croup
Epiglottitis
Thymus hypertrophy
Intra Volume:
PNA
Atelectasis
Pulmonary edema
Near drowning
Extra Volume:
Pneumothorax
Pneumomediastinum
Cardiomegaly
Heart failure
Pleural effusion
Hernia diaphragmatica
Diaphragmatica eventration
Intra-thorax mass
Chest trauma
Thorax deformity
Neuromuscular disorders
Gastritis
PUD
Extreme obesity
Peritonitis
Appendicitis
Acute abdomen
Aerophagia
Meteorismus
Ascites
Hepato-splenomegaly
Abdominal solid tumor
Anemia
Metabolic acidosis
CNS infections
Encephalopathy
Psychologic
Poisoning
Trauma capitis
CNS disease sequelae
47. Differentiate between rubeola, rubella, varicella, roseola, 5ths disease, pityriasis rosea,
h&/foot/mouth, & molluscum contagiosum.
Answer: Rubeola: "the Measles"
From morbillivirus
Highly contagious spread through respiratory drops
No cure
Vaccine since 1963
Pt appears very sick: high fever, red mucosal membranes, conjunctivitis, nasal congestion,
reddish/purple generalized macular & papular rash. Lesions start on head, esp. face or behind
ears, spread down body within 1-2 days.
Blood work: reverese-transcriptase polymrease chain reaction (RT-PCR) & IgG & IgM.
All positive cases must be reported to CDC.
Possible complications: PNA, bronchitis, myocarditis, encephalitis.
Pregnant: possible miscarriage.
Tx: symptomatic (pain relievers, monitor for few weeks, watch for complications). Infectious 4
days before onset of rash up to 4 days after onset. Able to return to work/school after rash gone.
Rubella: German measles or 3-day measles.
Caused by rubella virus.
Rash may start 2wks after exposure, spread from respiratory droplets.
Low-grade fever, HA, sore throat, rhinorrhea, malaise, eye pain, myalgia 2-5 days before rash
(may last weeks after outbreak).
Skin rash: rose-pink macules & papules, first on head, travel down body. Fades in 1-2 days in
same order they appeared.
Clinical diagnosis.
Tx: symptomatic (apap, NSAIDs, rest).
Rubella vaccination.
Infectious 4-7 days before rash, can return to work/school after rash gone.
Varicella: chicken pox.
Highly contagious.
Caused by varicella zoster virus (VZV).
Malaise, fever, chills, HA, arthralgia, then 1-2 days later urticarial erythematous macules &
papules appear, quickly turning into vesicles & pustules. Rash starts on face/chest, spreads
quickly over entire body. Blisters can be in ear canal or mouth. Dry up in 1wk.
Clinical diagnosis.
Tx: symptomatic (oral antihistamines, NSAIDs, cool compresses, oatmeal baths).
Varicella vaccination.
Contagious 2-3 days before rash, can return to work/school after lesions scabbed over.
Roseola: 6th disease
Caused by human herpes virus types 6 & 7.
Virus usually mild, common in children under age 2.
Spread through saliva.
Short-lived, 3-5 days.
High fever, irritability, diarrhea, cough, cervical lymphadenopathy.
Rash: light pink, erythematous macules & papules on face, neck, extremities. Usually resolves in
1-3 days.
Dx based on clinical presentation & history.
Tx: symptomatic.
Contagious 1-2 days before fever, can return to work/school when fever, fatigue, cough, diarrhea
gone.
Fifth's dz: erythema infectiosum, human parvovirus.
Spread through respiratory drops, blood products.
3 stages: HA, fever/chills, possible cough, classic slapped cheek rash, bright red bilat cheeks (not
forehead, nasal bridge, perioral area); pink lacy (reticulated) erythematous macules on all
extremities & trunk (not palms, sole surfaces), may be itchy; 2-3wks of body rash
Dx can be made via blood test, but results not detected for 3wks after rash, so not valuable.
Tx: symptomatic. Avoid heat (exacerbates rash).
Contagious few days before rash, can return to work/school after initial s/s of HA, fever, chills
are gone, even if rash still present.
Pityriasis rosea: viral, but difficult to confirm. Majority 10-35yo, more females than males.
Common breakouts in spring.
Solitary 2-4 patch/plaque on trunk ("herald patch"), starts 2-3wks before general rash.
Rash is pink, erythematous, round to oval plaques/papules w/possible scaly borders.
Resembles shape of a Christmas tree on the trunk. Usually not on face, palmar, sole surfaces.
Can be itchy. Pt may have low-grade fever, HA, fatigue. Can last 1-2mo or longer.
Dx made by H&P.
Tx: antihistamines, sun (could help rash). Acyclovir for 1wk (may reduce severity). Contagious
7-14 days prior to rash. Returning to activities depend on symptoms, but by the time rash
appears, pt is not contagious.
H&, foot, mouth dz: mostly occurring in young children.
Caused by coxsackievirus A16 & enterovirus 71.
Low-grade fever, fatigue, sore throat 1-2 days, then rash.
Rash: vesicles on h&s/feet w/mouth sores. Mouth sores are in almost 90% of cases, usually first
sign. H& vesicles appear with erythematous halos & appear mostly on soles/palms. Might
appear on legs, butt, face. Usually resolve in 7 days.
Dx made by H&P.
Tx: symptomatic. Reassure parents that there will be no scarring.
Contagious 4-6days prior to outbreak, can return to school when lesions are scabbed.
Molluscum contagiosum: from family of Poxviridae.
Virus is encased in protective sac that prevents immune system from being triggered. Tiny
pustules 2-5mm, some have slight depression in center of flesh-colored dome.
Single or multiple lesions.
Spread by contact, scratching, autoinocculation, shaving.
Most common places in kids are thighs/arms.
Most common places in adults are genital region.
Never soles/palms.
Sometimes erythematous papules/scaling from itching.
Can last 8mo or longer.
Dx by H&P, often misdiagnosed as genital warts.
Tx: non-Rx OTC Zymaderm. Rx topical retinoids. PO Cimetidine (Tagamet) 40mg/kg/day
x2mo. Cryosurgery w/liquid nitrogen (may be scarring or hypopigmentation).
No single treatment better than another.
Exclude from activities/sports until symptom-free or lesions are covered.
48. What are common characteristics in a rash caused by Group A strep?
Answer: Reds & paper rash (feels like it too)
Fever
Bright red sore throat
Lymphadenopathy
Bright red skin in skin folds (underarms, elbows, groin)
49. What are treatment options for Group A B-hemolytic strep pharyngitis?
Answer: PCN is treatment of choice for GAS pharyngitis b/c of its efficacy, safety, narrow
spectrum, & low cost.
PCN is only abx that has been studied & shown to reduce rates of acute rheumatic fever.
For most adult pts: Pen V 500mg BID-TID x10 days.
For most kids: Pen V or amox.
Alternatives for those with PCN allergies: 1st gen cephs, erythromycin, clinda, clarithromycin,
azithromycin.
50. Differentiate between tinea pedis, cruris, corporis, & unguium. What are the appropriate
treatments for each?
Answer: Tinea pedis: aka athlete's foot.
Erythematous, scaly, possible inflammation/itching.
Tx: antifungal cream, vinegar soak/Burrow solution to decrease itch. Ketoconozole is topical
treatment of choice, used for at least 4wks if not longer to resolve. OTC antifungal spray for all
shoes during/after treatment. Terbanifine sometimes for prolonged/severe cases.
Tinea cruris: aka jock itch.
Rash presents on inner thighs, butt, groin. Well-demarcated erythematous/tan plaques with raised
scaly borders.
Tx: topical antifungal; if repetitive infections, OTC zeabsorb powder can help prevent breakout.
Tinea corporis: aka ringworm
On the extremities or trunk
Erythematous annular lesion with scaly macules & papules, well-defined edges.
May be itchy.
Edge of lesion is raised, center of lesion is flattened. Can be small or cover large body surface
area.
Tx: antifungal topical cream or PO antifungal (Terbanafine) if widespread. Follow-up 3-4wks.
Tinea unguium: aka anychomycosis.
Fingernails or toenails.
Very common.
Nail appearance may vary: yellow, green, black or white ridging w/possible cracking of nails.
Tx: determined by severity & pt's age. Topical Ciclopirox nail laquer 8% applied daily for
months at base of nail. PO Terbanafine 250mg daily x2wks has high cure rate but pt has to have
healthy liver (do CMP prior to inititation).
Cure is VERY slow (4-6mo for fingernails, 8-10mo for toenails).
51. What is the virus that causes warts?
Answer: HPV (human papilloma virus)
52. Differentiate between atopic & contact dermatitis. Give examples of each.
Answer: Contact: allergic reaction to substance that produces immune reaction in skin resulting
in pruritic & erythemic rash.
Common causes: nickel, abx creams, cosmetics, soaps, fragrances, jewelry, plants (poison ivy).
Usually occurs in same area that was directly exposed to reaction within minutes to hours of
exposure.
Not contagious, cannot be spread from one area of body to another by touching. Tx: removal of
substance causing reaction; mostly symptomatic; topical antihistamines; steroid creams; PO
antihistamines to combat itching; mores severe cases or if reaction is on face, esp around eyes:
taper dose of PO steroids. Can lead to secondary infection if area is repeatedly scratched.
Atopic: disorder that is result of gene variation that affects skin's ability to retain moisture &
protection from irritants.
Often associated in people with asthma or hay fever.
Patches of itchy, dry skin; red to brownish-gray; may have small raised vesicles that leak when
scratched.
Usually starts before age 5, persists into adulthood.
Tx: symptomatic, much like contact derm. Topical steroid creams, PO antihistamines. Moisturize
skin at least BID. Avoid triggers that worsen rash.
53. What is a normal response to TB skin tests & what does it mean?
Answer: Standard recommended TB test (Mantoux test) is administered by injecting 0.1mL
containing 5 TU of PPD into intradermal layer of forearm. Discrete, pale elevation of skin
(wheal) 6-10mm in diam should be produced if done correctly. Wheal is usually quickly
absorbed.
Test should be read 72hrs after administration: looking/feeling for induration (measured
transversely to the long axis of the forearm, in mm).
54. What are some common reasons for decreased responsiveness to TB skin testing?
Answer: HIV-infected pts
People with weakened immune systems
Severe TB disease
Some viral dz's (measles, mumps, chicken pox, etc.)
Some bacterial dz's (typhoid, etc.)
Pts infected with m. tuberculosis in the past 8wks
Pts injected with a live virus vax
Pts with brucellosis, typhus, leprosy, pertussis
Pts with fungal infections
Renal failure
Severe protein depletion or afibrinogenemia
Hodgkin's, lymphoma, chron. leukemia, sarcoidosis
Medical steroids, TNF alpha blockers
Newborns
Elderly with immature or waning immunity
Surgery, burns, mental illness, graft-vs-host reactions
55. What are some common meds used to treat TB?
Answer: Isoniazid
Rifampin
Pyrazinamide Ethambutol
56. What is the MOA & common SE's of Isoniazid?
Answer: MOA:
Isoniazid is a prodrug & must be activated by M. tuberculosis catalase-peroxidase enzyme KatG.
Activation produces oxygen-derived free radicals (super oxide, hydrogen peroxide,
peroxynitrite) & organic free radicals that inhibit formation of mycolic acids of bacterial cell
wall, causing DNA damage, & death of bacillus.
Most common mechanism of resistance consists of KatG mutations, which decrease activity of
isoniazid & prevent prodrug from being converted into its active metabolite.
SE:
N/V
Epigastric pain
Transitory & asymptomatic increase in hepatic enzyme levels
Arthralgia
Changes in behavior: HA, insomnia, euphoria, agitation, anxiety, somnolence
Acne
Cutaneous pruritis or fever
What is the MOA & common SE's of Rifampin?
MOA:
Inhibits gene transcription of mycobacteria by blocking DNA-dependent RNA polymerase,
which prevents bacillus from synthesizing messenger RNA & protein, causing cell death.
SE:
Nausea
Anorexia
Abd pain
Orange colored tears/sweat/urine
Pruritis with or without erythema (6% of pts)
Flulike syndrome
Fatigue
Dizziness
HA
Dyspnea
Ataxia
57. What is the MOA & common SE's of Pyrazinamide?
Answer: MOA:
Prodrug that needs to be converted to active form, pyrazinoic acid, by bacterial enzymes.
MOA not fully understood
Possibly enters bacillus passively, converts to pyrazinoic acid by pyrazinamidase, reaches high
concentrations in bacterial cytoplasm due to inefficient efflux system. Accumulation of
pyrazinoic acid decreases intracellular pH to levels that cause inactivation of enzymes.
SE:
N/V
Anorexia
Hyperuricemia
Arthralgia
Exanthema
Pruritis
Dermatitis (photosensitivity)
58. What is the MOA & common SE's of Ethambutol?
Answer: MOA:
Interferes with biosynthesis with arabinogalactan enzyme, which mediates polymerization of
arabinose into arabinogalactan.
SE:
Retrobulbar neuritis (usually reversible, depending on dose & length of therapy)
N/V
Abd pain
Hepatotoxicity
Eosinophilia
Neutropenia
Thrombocytopenia
Myocarditis
Pericarditis
HA
Dizziness
Confusion
Hyperuricemia/gout
Skin rash
Arthralgia
Fever
Occasionally pulmonary infiltrates
59. What are the different strengths of tretinoin & when is each appropriate?
Answer: Gel:
0.025% & 0.01%
Cream:
0.1%, 0.05%, & 0.025%
Caps:
10mg
Topical used for acne
Oral used for induction of remission in acute promyelocytic leukemia
60. Identify various types of lesions based on their characteristics:
Answer: Rubeola:
Pt looks ill
High fever
Red mucus membranes
Conjunctivitis
Nasal congestion
Reddish/purple generalized macular/papular rash
Lesions start on head (face/behind ears), spread over rest of body in 1-2 days
Rubella:
Low-grade fever
HA
Sore throat Rhinorrhea
Malaise
Eye pain
Myalgia 2-5 days before rash
Rose-pink macules/papules
Lesions start on head, travel down body
Rash disappears in 1-2 days in same order it appeared
Varicella:
Malaise
Fever
Chills
HA
Arthralgia
1-2 days later, urticarial erythematous macules/papules appear, quickly turning to
vesicles/pustules
Rash starts on face/chest, spreads quickly over entire body, dry up in 1 week
Roseola:
High fever
Irritability
Diarrhea
Cough
Cervical lymphadenopathy
Light pink erythematous macules/papules on face, neck, extremities, resolves in 1-3 days
Fifth's Disease:
Starts with HA, fever, chills, maybe cough
Stage 1: "Slapped cheek" rash
Stage 2: Pink lacy erythematous macules on extremities/trunk, spares palms & soles.
May be itchy.
Stage 3: 2-3 weeks of body rash
Pytiriasis rosea:
2-4 patches or plaques on trunk that starts 2-3wks before general rash, aka "herald patch"
Rash pink to erythematous, round to oval plaques & papules with possibly scaly borders
Rash resembles shape of Christmas tree
Rash can be itchy
Low-grade fever
HA
Fatigue
Can last 1-2mo or longer
H&, foot, & mouth:
Mouth sores usually first to appear
H& vesicles are erythematous halos, mostly soles & palms
Sometimes are on legs, butt, face Usually resolve in 7 days
Molluscum contagiosum:
Tiny pustules 2-5mm
Flesh-colored dome, some have slightly depressed center
Single or multiple lesions
Kids: thighs & arms
Adults: genital region from sexual contact
Soles & palms always spared
Sometimes erythematous & scaly Can last 8mo or longer
Folliculitis:
Little pustules or erythema around base of hair follicle
Abscesses:
Sac or pore filled with pus
Erythematous, tender nodule that can be fluctuant
Furuncle:
infection that involves hair follicle & extends into surrounding tissue
Mostly on axillae, neck, buttock
Carbuncle:
Cluster of abscesses that connect subcutaneously to form mass
Group A strep:
Red s&paper rash
Fever
Bright red sore throat
Lymphadenopathy Bright red skin in skin folds
Tinea pedis:
Erythematous, scaly, possibly inflammation or itching on feet
Tinea Cruris:
Jock itch
Rash present on inner thighs, butt, groin
Well-demarcated erythematous or tan plaques with raised scaly borders
Tinea corporis:
Ringworm
On extremities or trunk
Erythematous annular lesion w/scaly macules/papules, well-defined edge
May be itchy
Edge is raised & center is inflamed
Tinea unguium:
Onychomycosis
Fingernails or toenails
Appearance varies: yellow, green, black, white ridging, cracking of nails
Warts:
HPV causes
Skin colored rough papule, sometimes grayish surface
Single lesions or clusters
Sometimes tiny black or red dots in lesions
Scabies:
Intense itching worse at night
Light pink curved or linear burrows, occasionally w/black dot on one end Commonly in between
fingers & toes
Aktinic keratosis:
Result of cumulative sun exposure & aging
Rough textured skin, maybe flesh or pink colored
Sometimes thick & scaly, can evolve into plaque
Sometimes stinging sensation when rub area
Lesion never goes away, no matter how much moisturizer used
Vitiligo:
Michael Jackson disease
Depigmented areas of skin
Well-demarcated
Macules or papules surrounded by normal skin
Contact dermatitis:
Allergic reaction to substance
Pruritic & erythemic rash
Occurs on area that was directly exposed to reaction
Atopic dermatitis:
Patches of itchy, dry skin
Can be red to brownish-gray
May have small raised vesicles that leak when scratched
61. What are common characteristics associated with blepharitis, chalzion, & hordeolum.
Answer: Blepharitis: irritation, burning, itching, scales, redness.
If lice is cause: reddish brown crust in lashes (not white or clear as typically seen).
Chalzion: mass in mid-portion of upper lid away from margin. Usually not painful or tender.
Slightly red, swollen.
Hordeolum: usually on outside of lid, abscess on lid margin. Redness, swelling, painful.
62. Differentiate between viral, allergic, bacterial, toxic, & HSV conjunctivitis.
Answer: Bacterial: aka pink eye.
Direct h&-to-eye contact w/infected person.
Spread of one's own nasal/sinus bacteria during illness.
Purulent discharge (HALLMARK)
Reddened conjunctiva
Eyelid swelling
Can start unilat, but can spread bilat.
May resolve without treatment, but abx drops can shorten duration.
Very contagious (stay home until 24hrs of abx treatment or when clinical improvement noted).
Viral: usually caused from adenovirus, but can be HSV, HZV, molluscum contagiosum.
Irritation, mild light sensitivity, swollen lids, mild FB sensation.
Mild conjunctival hyperemia to insense hyperemia. Watery/mucousy drainage, not purulent.
Enlarged tender preauricular lymph nodes on affected side.
Red throat, nasal drainage, ear infection, etc.
Self-limiting, resolve on their own from few days to few weeks.
Highly contagious
Current recommendation is stay home until redness/tearing resolved.
Allergic: usually caused by environmental allergen (pollen, grass, trees, etc.). Can be seasonal &
can be isolated to eyes or include upper resp allergy symptoms such as rhinitis.
Hallmark characteristic: itching
Diffuse, milky, conjunctival hyperemia
Swollen conjunctiva
Tearing
Almost always bilat
Uniquely identifying bumps on conjunctiva ("follicles")
Tx: symptomatic. Artificial tears, anti-allergy drops.
Toxic: due to overuse of topical ocular meds (Visine), but abx drops most common (usually from
using abx drops for longer than prescribed or for viral infections).
Clear, watery discharge & red conjunctiva
Dx usually from history
Tx: stop the drops
HSV: spread by contact w/persons who have visible, infected lesions & w/persons
symptomatically shedding the virus.
Pt may be experiencing prodrome of ill-related symptoms (malaise, low grade fever,
pain/tingling near site of lesions but lesions not yet visible).
Skin vesicles
Conjunctivitis (same as viral)
Corneal infection w/hallmark dendrite appearance
63. Which chemical injury is associated with the most damage & highest risk to vision loss?
Answer: Moderate to severe alkali (ammonia, drain cleaners, cement, plaster/mortar, airbag
rupture, fireworks; all contain ammonia, lye, lime, sodium, mag hydroxide).
64. Which cardiac or pulmonary disorders contribute to the majority of dyspnea complaints due
to decompensation?
Answer: asthma;
chronic obstructive lung disease;
malignancy;
heart failure;
interstitial lung disease;
pneumonia;
valvular heart disease;
intracardiac shunt;
arrhythmias;
cardiomyopathies;
myocardial ischemia.
65. What are appropriate tests in the work-up for dyspnea?
Answer: CXR to rule out tumors, TB, PNA, other major pulmonary disorders.
CBC w/diff to rule out anemia, infection
Peak expiratory flow test (in office) to determine degree of expiratory airflow obstruction in pt's
with asthma, COPD
EKG
Echo
Spirometry to determine obstructive, restrictive, mixed lung dz
Sleep apnea or sleep hypoxia testing
66. Describe classes of asthma.
Answer: Mild intermittent:
Less than once weekly
Brief exacerbations lasting few hrs to few days
Nighttime symptoms 80% predicted
PFT variability >20%
Mild persistent:
Symptoms >2/wk but 80%
PFT variability 20-30%
Moderate persistent:
Daily but not continual
Nighttime, but not every night
More than once weekly
Exacerbations affect activity/sleep
Daily use of short-acting beta-2 agonist
PEFR or FEV1 60-80%
PFT variability >30%
Severe persistent: Continuous daily
Frequent nighttime
Frequent exacerbations
Physical activity limited
PEFR or FEV1 30%
67. What are the different treatments for the asthma classes?
Answer: Mild intermittent:
No daily meds
PRN inhaled short acting beta-2 agonist or cromolyn before exercise or allergen exposure
Mild persistent:
One daily controller med (inhaled corticosteroid), cromolyn/nedocromil, leukotriene modifiers
Inhaled beta-2 agonist PRN
Moderate persistent:
Daily meds: combo inhaled medium dose corticosteroid & long-acting bronchodilator:
cromolyn-nedocromil, leukotriene modifiers
Severe persistent:
Inhaled beta-2 agonist PRN
Multiple daily controller meds: high dose inhaled corticosteroid, long-acting bronchodilator,
cromolyn/nedocromil, leukotriene modifiers.
68. Identify respiratory characteristics of chronic bronchitis.
Answer: Characterized by excessive mucus secretion in bronchial tree
Manifests by chronic or recurrent cough (with or without sputum), present on most days for
minimum of 3mo of the year for at least 2 consecutive years.
Pts usually use accessory muscles with respiration & have dyspnea with or without sneezing.
Pts may have s/s of right HF (edema, cyanosis).
FVC: normal to increased
RV: increased
TLC: normal
EFR: normal to decreased
FEV1/FVC: decreased
69. Identify respiratory characteristics of asthma.
Answer: Chronic, inflammatory, obstructive disease in airways.
May occur at any age & presents with wheezing (airway spasms), chest tightness, dyspnea,
cough.
Reversible hyperreactivity of bronchi & bronchioles to a variety of stimuli.
FVC: normal
RV: normal, increased during attacks
TLC: normal to increased
EFR: normal to decreased
FEV1/FVC: normal to decreased
70. Identify respiratory characteristics of COPD.
Answer: Progressive disease characterized by presence of airflow obstruction due to chronic
bronchitis or emphysema.
3rd leading COD in US.
Dz of lung parenchyma & small airways
Pts may be asymptomatic for 10-20yrs except for frequent colds, persistent morning cough,
URIs.
Pts present with fatigue, SOB, cough, hyperinflation (barrel chest), wheezing, decreased breath
sounds, hyperresonance.
Stage 1 (mild): FEV >80%.
Stage 2 (moderate): FEV 50-79%
Stage 3 (severe): FEV 30-49%
Stage 4 (very severe): FEV 19
R: resp rate >30
B: BP syst 7days
Objective:
Fever,
Discolored nasal drainage
Facial swelling
Bad breath
75. What are subjective & objective findings with allergic rhinitis?
Answer: Subjective:
itchy throat/nose/eyes
Watery eyes
Head/nasal congestion
Fatigue
Ear pressure Sneezing
Objective:
Cobbles toning in back of throat
Post-nasal clear drip
Red eyes
76. What are subjective & objective findings with vasomotor rhinitis?
Answer: Subjective:
Stuffy nose
Congestion
Sneezing
Cough non-productive
Objective:
Clear post-nasal drip
Possible cobblestoning
77. What are subjective & objective findings with influenza? Subjective:
Answer: Cough
Sore throat
HA
Fatigue
Muscle/body aches
Sometimes n/v/d
Chills
Objective:
Fever
Rhinorrhea w/productive phlegm occasionally discolored
Occasionally red eyes
Sometimes tachy
78. What are treatment options for asthma?
Answer: Long acting steroid inhalers to prevent symptoms
Short acting albuterol rescue inhalers prn
Learn triggers & avoid as much as possible
79. What are treatment options for COPD?
Answer: Maintenance steroid inhaler & bronchodilator prn
O2 may be necessary
Quit smoking
Complete pulmonary rehab
Exercise for breathing & muscle strength
80. What are treatment options for sinusitis?
Answer: Short-term ( 3 Centor criteria can be empirically diagnosed with GABHS & treated
without further testing.
Answer: True
114. Empiric treatment of asymptomatic household contacts o patients with acute GABHS
pharyngitis is recommended.
Answer: False
115. Doxycycline is an alternative for patients with GABHS pharyngitis who are allergic to
PCN.
Answer: False
116. Patients with mononucleosis who develop an erythematous, macular rash after taking
amoxicillin for pharyngitis should be identified as having a PCN allergy.
Answer: False
117. Which is (are) a symptom(s) of peritonsillar abscess? (select all that apply)
Severe, unilateral sore throat
Fever
Asymmetric cervical adenopathy
Exudate
Severe, bilateral sore throat
Answer: Severe, unilateral sore throat
Fever
Asymmetric cervical adenopathy
Exudate
118. The most common cause of viral laryngitis is _____.
Answer: H. influenza
119. Fluorosceine staining is a method used to differentiate the types of conjunctivitis.
Answer: False
120. Poison ivy is contagious & can be spread from touching the affected area.
Answer: False
121. Treatment for nonfluctuant abscess should include incision & drainage (I&D).
Answer: False
122. Which is NOT treatment for warts?
Salicylic acid
Liquid nitrogen
Duct tape
Mercurochrome
Answer: Mercurochrome
123. Tinea corporis is found on the:
Answer: Trunk/extremities
124. Tinea unguium is found on the:
Answer: nail
125. Tinea cruris is found on the:
Answer: Groin
126. Tinea pedis is found on the:
Answer: feet
127. Patients should be referred to a dermatologist for treatment of acne with Accutane.
Answer: True
128. Treatment of moderate acne may include the use of topical & oral antibiotic with a retinoid.
Answer: True
129. How is an appropriate differential developed?
Answer: List of possible diagnoses in order of priority.
Consider "skin in:" after complaint is given, clinician begins to consider all possible causes
beginning with skin level & visualizing all structures in that area inward.
130. Clinical characteristics of GERD:
Answer: Heartburn
Regurgitation
Water brash (reflex salivation)
Dysphagia
Sour taste in mouth in the morning
Odynophagia (painful swallowing)
Belching
Coughing
Hoarseness
Wheezing usually at night
Substernal or retrosternal chest pain
Aggravating: reclining after eating, eating large meal, alcohol, chocolate, caffeine, fatty/spicy
food, nicotine, constrictive clothes, heavy lifting, straining, bending over. Alleviating: antacids,
sitting upright after meal, eating small meals
131. Treatment for GERD:
Answer: 1st line: life modification (elevate HOB, smoking cessation, avoid high fat/large meals,
chocolate, ETOH, peppermint, caffeine, onions, garlic, citrus, tomatoes); don't sleep 34hrs after
meal, avoid bedtime snack.
Meds: avoid Ca blockers, beta blockers, alpha adrenergic agonists, theophylline, nitrates, some
sedatives.
Encourage wt loss for overweight/obese pts
If lifestyle mods not working: step-up/down treatment guidelines for GERD. Mild, intermittent
symptoms: trial for 4wks, if symptoms persist, step up:
1. Dietary/lifestyle mods
2. Antacid
3. OTC H2-RA: cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine(Axid)
Trial above for 6wks, if symptoms persist, step up +referral to GI:
1. Continue dietary/life mods
2. H2-RA Rx dosage: cimetidine 800mg TID, ranitidine 150mg TID, nizatidine 150mg TID,
famotidine 20mg TID. OR PPI: omeprazole 20mg, rabeprazole 20mg, lansoprazole 30mg,
esomeprazole 20mg, or pantoprazole 40mg daily.
Trial above for 8wks, if symptoms persist step up:
1. Diet/lifestyle mods
2. PPI increase to 40mg daily
Trial for 8wks, if symptoms persist, step up:
1. Diet/lifestyle mods
2. Surgical intervention
132. Characteristics of AGE:
Answer: Nausea
Vomiting
Diarrhea
Fever
Abd pain/cramping
Fatigue
Malaise
Anorexia
Tenesmus
Rectal burning d/t frequent diarrhea
Rectal abrasion
Rectal bleeding
Passing stool w/blood & mucus
Severe dehydration
Increased HR Dizziness
133. Treatment for AGE:
Answer: Fluid & diet
PO pts: Pedialyte, gatorade, oral rehydration salts, sports drinks, diluted fruit juices, broths,
soups.
Boiled starches/cereals to facilitate enterocyte renewal
Hosp pts: IV fluid
Diarrhea:
Pepto (can be used to treat acute diarrhea, but not as effective as loperamide; don't use w/abx in
pts with HIV)
Loperamide (Imodium): drug of choice for afebrile, nondysenteric cases of acute diarrhea
Lomotil: Rx only, used in afebrile, nondysentery of acute diarrhea, has central opiate effects.
Antibiotic treatments:
Bacterial:
C-diff (metronidazole/Flagyl 250mg x4 daily x10 days; vanc 125mg x4 daily x10 days). Vibrio
cholerae (tetracycline 500mg PO q5hr x2 days; bactrim DS q12hr x2 days). Yersinia
enterocolitica (tetracyclines 250-500mg q6hr x7-10days; cipro 500mg BID; tobramycin 35mg/kg q8h).
Salmonella (Bactrim DS or quinoline, norfloxin 400mg or ofloxin 400mg x2 daily x7-10 days).
Shigella (Bactrim DS BID x3 days)
Viral:
Rotavirus/norwalk virus: no treatment, treat symptoms
134. Eustachian tube disorder presentation, symptoms, causes:
Answer: Presentation: depends on how it happened. Retracted TM, nasopharyngeal resemble
allergic rhinitis, fusion may be present or not
Symptoms: decreased hearing, muffled hearing, feeling of fullness in ear, inability to pop ear,
disequilibrium, tinnitus, pain
Causes: airplane, scuba diving, any disorder that can cause nasal congestion (allergic rhinitis,
swollen adenoids, sinusitis, etc.)
135. Eustachian tube disorder treatment:
Answer: Treat underlying problem
Otitis media, sinusitis: treat w/abx
Allergic rhinitis: nasal steroids, decongestants (not in kids 50 = greatest risk. No ethnic or gender predispositions. Immunocompromised people at greater
risk (esp of invasive disease). Excess moisture from any cause increases risk. Seborrheic
dermatitis, hearing aids, ear plugs, cotton swabs all increase risk with extended use.
OM: Incidence increases in winter. Most common in very young or elderly. Native
American (esp Navajo) & Native Alaskans = higher prevalence. Men & women = risk. More rare
in adults. Risk factors: allergies, sinusitis, rhinitis, pharyngitis, recent/recurrent URI, perforation
of eardrum, active/passive smoking.
Pathogens:
OE: Pseudomonas aeruginosa (most common cause of diffuse infection). Staph aureus.
Group A strep pyogenes. Bacteroids. Peptostreptococcus. Aspergillus niger.
Pityrosporum. C&ida albicans.
OM: Strep pneumoniae (most frequent cause in adults). H influenzae. Moraxella catarrhalis.
Strep aureus & strep pyogenes far less common causes.
Clinical presentation:
OE Subjective: acute, severe otalgia that may worsen at night. Worsens with pulling pinna or
applying pressure to tragus. Chewing may exacerbate pain in severe cases. Initially ear may feel
full/obstructed with temporary conductive hearing loss. May be pruritic. Systemic symptoms
may be present with infectious etiology. Chronic illness may include dryness & pruritis of ear
canal.
OE Objective: tenderness on traction of pinna, pain w/pressure of tragus. Purulent drainage may
be present w/bacterial infection. Canal may be reddened & edematous. Usually lacks cerumen.
Auditory canal appears edematous/erythematous. Diffuse cases may have localized pustules or
furuncles in canal or external processes. Green exudate w/Pseudomonas. Yellow crusting in
midst of purulent drainage w/Staph. Fungal infections have fluffy white/black malodorus carpet
of growth. Allergic reactions are scaly, cracked, &/or weepy tissue. Usually no
lymphadenopathy. TMJ tenderness may be present in invasive disease.
OME Subjective: Stuffiness, fullness, loss of acuity unilaterally. Pain is rare. Popping, crackling,
gurgling. Rarely causes vertigo.
AOM Subjective: Deep ear pain. Fever. unilateral hearing loss. Recent URI. Dizziness.
Vertigo. Tinnitus. Chronic repeated bouts of AOM.
OME Objective: external ear usually unremarkable. Mucus membranes may be infected or
edematous. TM may be dull but not bulging.
AOM Objective: TM may be amber or yellow-orange. TM may be infected & pinkish gray to
fiery red. TM typically full & bulging w/absent or obscured bony l&marks & cone light reflex.
Discharge present if TM perf'd. Otorrhea may be purulent or mucoid. Chronic OM has perf'd,
draining TM & possibly invasive granulation tissue. Lymphadenopathy or preauricular & post
cervical nodes is common. If OM along with acute mastoiditis, tenderness over mastoid will be
present.
Management:
OE: Localized application of heat or ice for pain. NonRx pain reliever for mild to mod pain. Tyl
#3 for severe pain. Keep ear dry. Gentle cleaning of ear canal. Eval otic discharge & edema of
auditory canal & TM. Select local med appropriate for etiology.
May need I&D of pustules or furuncles. Diffuse infection may be treated empirically. Topical
otic preps. Abx: 1st gen cephs or pcns, 2nd gen cephs, fluroquinolones, ceftazidime.
OM: Uncomplicated is often self-limiting. Treatment recommended for chronic or recurrent OM.
Supportive treatment indicated for acceptance of pt's auditory hearing loss r/t chronic dz. If
symptoms persist >12wks, 10-day abx course is warranted. Abx: amox, augmentin, 2nd/3rd gen
cephs. Steroids not recommended for kids.
137. What are the characteristics of nuclear cataracts?
Answer: Significant nearsightedness
Slow, indolent course
138. What are the characteristics of cortical cataracts?
Answer: Does not significantly impair vision
139. What are the characteristics of posterior cataracts?
Answer: Creates a subcapsular haze & a severe glare in bright light
