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Midterm Exam Study Guide
Questions
Week 1
1. Define diagnostic reasoning Reflective thinking because the process involves questioning one’s thinking to determining if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. *Seen as a kind of critical thinking. 2. Discuss and identify subjective & objective data
- Subjective: What the pt tells you, complains of, etc. *Chief complaint, HPI, ROS
- Objective: What YOU can see, hear, or feel as part of your exam. *lab, data, dx test results. 3. Discuss and identify the components of the HPI Specifically related to the CC only. Detailed breakdown of CC. OLDCART. 4. Describe the differences between medical billing and medical coding
- Medical coding: The use of codes to communicate with payers about which procedures were performed and why
- Medical billing: Process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider. 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system
- CPT codes: Common procedural terminology. Offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and nonphysician orders.
- ICD codes: International classification of disease. Used to provide payer info on necessity of visit or procedure performed. 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data
- Specificity: The ability of the test to correctly detect a specific condition. If a patient has a condition but test is negative, it is a false negative. If a patient does NOT have a condition but the test is positive , it is a 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 and 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. 7. Discuss the elements that need to be considered when developing a plan Patient’s preferences and actions. Research evidence. Clinical state/circumstances. Clinical expertise.
8. Describe the components of Medical Decision Making in E&M coding Risk – data – diagnosis. The more time and consideration involved in dealing with a pt, the higher the reimbursement from the payer. Documentation must reflect the MDM! 9. Correctly order the E&M office visit codes based on complexity from least to most complex New patient:
- Minimal/RN visit: 99201
- Problem focused: 99202
- Expanded problem focused: 99203
- Detailed: 99204
- Comprehensive: 99205 Established patient:
- Minimal/RN patient: 99211
- Problem focused: 99212
- Expanded problem focused: 99213
- Detailed: 99214
- Comprehensive: 99215 10. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation
- Important reference document that vies concise info about the pt’s hx and 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 patient’s care.
- is a medical legal document
- is essential in order to accurately code and bill for services 11. Accurately document why every procedure code must have a corresponding diagnosis code Diagnosis code explains the necessity of the procedure code. Insurance won’t pay if they do not correspond. 12. Correctly identify a patient as new or established given the historical information New patient: If that patient has never been seen in that clinic or by that group of providers OR if the pt has not been seen in the past 3 years 13. Identify the 3 components required in determining an outpatient, office visit E&M code Place of service, type of service, patient status. 14. Describe the components of Medical Decision Making in E&M coding Risk – data – diagnosis
1. Identify the most common type of pathogen responsible for acute gastroenteritis Bacteria: Staphylococcus Viral: Norovirus (Norwalk virus) in adults and Rotavirus in Peds up to 2 yrs old. 2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients presenting with diarrhea Due to Risk for C Diff infection 3. Describe the difference between Irritable Bowel Disease (IBS) and Inflammatory Bowel Disorder (IBD) IBS (Irritable Bowel Disease) ○ a disorder of bowel function, not from anatomic abnormality; ○ characterized by alternating bowel pattern, constipation and diarrhea; ○ associated symptoms include abdo pain relieved w/defecation, bloating, rectal urgency w/diarrhea; ○ Extra-intestinal symptoms: pain on intercourse or lack of libido, muscles aches&pain, fatigue, fibromyalgia syndrome, headache, back pain, urinary symptoms (urgency, hesitancy, bladder spasm); ○ Not associated with serious medical consequences; tend to live long; ○ Does not put stress on other organs (heart, liver, kidney) ○ Major problem of IBS: the quality of life that people suffer Inflammatory Bowel Disorder (IBD) ● A chronic immunological disease that manifests in intestinal inflammation. ● Characterized by exacerbations and remissions throughout lifetime. ● UC and CD -- most common 4. Discuss two common Inflammatory Bowel Diseases Ulcerative colitis (UC): ● the thinner mucosa of the rectum and sigmoid colon become inflamed, which results in friability, erosions, and bleeding. ● More in male (age 10-40) ● Involved in the rectosigmoid areas, crypt abscess development ● Sx: bleeding, cramping, urge to defecate d/t mucosa destruction ● Tenderness LLQ or across the entire abdomen, often accompanied by guarding and abdo distension; ● Stools --watery diarrhea w/ blood and mucus d/t loss of absorptive surface ○ Fecal leukocytes almost always present ○ Mild form < 4 BM per day, relieved w/defecation, no associated systemic sx ○ Moderate (4-6 BM/day), ↑ blood and mucus, systemic sx (tachy, fever, wt loss)
○ Severe -- (6-10/day), abdo tenderness, symptoms of anemia, hypovolemia, and impaired nutrition, --risk for perf colon Crohn’s disease (CD): ● An inflammatory process that begins in the submucosa of the intestine and gradually spreads to involve the mucosa and serosa. ● Can involve all or any layer of the bowel wall and portion of GI tract from mouth to anus (about 80% small bowel involvement and 20% of the colon). ● More in female (age 15-25, 50-80) ● Greater risk for colorectal cancer ● Skipped lesions --some haustral segments are affected while others are not. ● cobblestone appearance--inflamed tissue is surrounded by scar tissue. ● Transmural inflammation -- serosal inflammation cause bowel loops to adhere to one another leads to obstruction, fistulas, and shortening of the bowel. ● Tenderness RLQ or mass ● Sx: abdo cramping, fever, anorexia, weight loss, spasm, flatulence, ● Stools contain blood, mucus, and/or pus ● Symptoms tend to increase during stress or after meals consisting of poorly tolerated fatty, spicy, or dairy. ● Steatorrhea- fatty stools d/t insufficient absorption of bile salt ●
5. Discuss the diagnosis of diverticulitis, risk factors, and treatments
- Diagnosis = occurs when a patient’s diverticulosis becomes inflamed and when the projection becomes eroded it can progress to the point of eruption causing left lower quad pain and tenderness, fever, change in bowel habits (usually diarrhea), N/V, mass, rebound tenderness with involuntary guarding and rigidity, occult blood. If there is a fistula, UA may show increased WBC and RBC, urine culture may be positive.
- Risk Factors = low fiber diet, hypertrophy of the segments of the circular muscle of the colon, chronic constipation and straining, irregular and uncoordinated bowel contractions, obesity, and weakness of the bowel muscle brought on by aging. Directly related to the suspected causes of the disease: older than age 40, low-fiber diet, previous diverticulitis, and the number of diverticula present in the colon.
- Treatments = metronidazole 500mg TID x 10-14 days along with Ciprofloxacin 500mg BID or trimethoprim/sulfamethoxazole DS 160/800 BID. Close office follow up should occur upon completion of abx therapy as complications such as abscess and perforation can occur. 6. Identify the significance of Barrett’s esophagus Thought to be caused by chronic GERD. Gastric contents are so irritating, an inflammatory response is established in the esophagus. Erosion occurs due to increased blood flow due to inflammation. As the erosion heals, the body replaces the normal squamous epithelium with metaplastic columnar epithelium (Barrett’s epithelium) containing goblet and columnar cells. These are more resistant to acid and support esophageal healing. Barrett’s epithelium is a premalignant tissue, and presents a 40 fold increased risk for esophageal adenocarcinoma. Fibrosis and scarring occur, leading to esophageal strictures.
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 3-5mg/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
8. Discuss the differential diagnosis of acute abdominal pain, work-up and testing, treatments
Abdominal pain is one of the most common complaints for which people seek medical attention
The mechanism responsible for the abdominal pain is what gives certain characteristics to the
pain.
● Visceral pain ( poorly localized and is described as dull) and is caused by distention or
spasm of a hollow viscus.
○ Distention of an organ capsule, such as Glisson’s capsule around the liver;
vascular compromise; and mucosal irritations cause pain that is visceral in
nature.
● Parietal pain, described as sharp and well localized, is caused by irritation of the
peritoneum.
○ Appendicitis often causes this type of pain as the peritoneum becomes involved.
● Abdominal pain described as colicky, which simply means that it comes and goes
○ may result from gallstones or renal stones.
● Burning pain, caused by irritation of the gastric mucosa by gastric contents
○ associated with peptic ulcers and esophagitis.
Differential Diagnosis Flowchart 11.1 presents selected causes of abdominal pain and their
characteristics. Treatment of abdominal pain depends on the cause. (This flow chart is amazing
and there is no way to copy it in here)
All patients with abdominal pain should undergo rectal, genital, and pelvic evaluations. Blood
found in the stool or intense pain on examination may indicate more serious conditions.
Tests : A complete blood count, serum chemistries, liver function tests, urinalysis, pregnancy test, and abdominal films will help determine the acuity of the problem (Dunphy 505-509)
- Discuss the difference between sensorineural and conductive hearing loss Conductive hearing loss : often reversible occurs when a change, obstruction, lesion in the outer or middle ear that impairs sound from the outer to the inner ear. Interference in air conduction. Can be caused by occlusion from cerumen, FB, tumors of CA in the middle or external ear (typically neuro changes), or ET tube dysfunction, OM, cholesteatoma (abnormal non cancerous skin growth), tympanosclerosis or otosclerosis (abnormal immobility of the stapes footplate from sclerotic bone; occurs in young adults 20-40), temporal bone fractures from trauma. S/S: diminished hearing, soft voice, py hears better in a noisy environment (paracusia willisiana) (McCance & Huether, 2013)
Colon Cancer Screening Recommended by the American Cancer Society Risk Screening Recommendations Average risk Annual fecal occult blood (FOB) test Flexible sigmoidoscopy every 5 years beginning at age 50 or colonoscopy every 10 years High risk (general) Annual FOB testing Double-contrast barium enema OR Colonoscopy every 3–5 years starting at age 40 Specific High- Risk Groups Prior colorectal cancer Colonoscopy 1 year postfinding, then every 3 years Hereditary nonpolyposis colorectal cancers Colonoscopy screening must begin 10 years before the age at onset of the earliest affected family member OR Colonoscopy every 1–2 years beginning at age 20–25 and continuing until age 35 and then yearly Inflammatory bowel disease Annual colonoscopy beginning 8 years after onset of disease First-degree family history Colonoscopy every 3–5 years beginning 5 years before the age at onset of the youngest affected relative (Dunphy, p. 590)
16. Identify at least two disorders that are considered to be disorders related to conductive hearing loss
Cerumen impaction,chronic otitis externa, middle ear effusion, AOM (acute otitis media), tympanic membrane rupture or perf
17. Identify the most common bacterial cause of pharyngitis : Group A Beta Hemolytic Streptococcus (GABHS)
Identify treatment options for Group A B-hemolytic streptococcal pharyngitis
o PCN is treatment of choice for GAS pharyngitis b/c of its efficacy, safety,
narrow spectrum, and low cost.
PCN is only abx that has been studied and 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.
18. Identify the clinical findings associated with mononucleosis: Gradual onset of fever, MARKED MALAISE (The child doesn’t even want to get out of bed!). Severe sore throat, may have extensive tonsillitis, palatal petechiae/rash, anterior/posterior cervical adenopathy( FOR OUR BOARD EXAM REMEMBER THAT POSTERIOR CERVICAL NODE ENLARGEMENT IS CLASSIC). Splenic enlargement (NO CONTACT SPORTS). 19. Identify common characteristics in a rash caused be Group A Strep
These turn into a fine pink-red rash that looks like sunburn. The
skin feels rough when touched, like sandpaper. The rash spreads to
the ears, neck, elbows, inner thighs and groin, chest, and other
parts of the body (google, 2018 ;)).
20. Discuss that the diagnosis of streptococcal pharyngitis can be made clinically based on the Centor criteria: Fever greater than 38 Celsius, NO COUGH, tender anterior cervical lymphadenopathy, pharyngotonsillar exudate. The presence of FOUR strongly suggest GABHS infection. THREE or MORE present: Should empirically diagnose and treat without further testing. RAPID STREP TESTS ARE NOT CHEAP!! The treatment for GABHS is PCN V 500 mg BID-TID for 10 days. Alternatives if PCN allergic are Macrolides, Clinda, and 1st gen cephalosporins. 21. Describe an intervention for a patient with gastroenteritis
- Avoid dehydration with fluid and electrolyte management (particularly with children, older adults, and immunocompromised patients). (From powerpoint lecture).
- Oral rehydration: fluids with sodium content of 45-75 mEq/L (Pedialyte or Gatorade), broths, soups, fruit juices. IV rehydration: severe dehydration or patients with chronic diseases and are hypotensive. (from page 535-536).
Week 3
1. Discuss that the majority of dyspnea complaints are due to cardiac or pulmonary decompensation- The most common subjective dyspnea complaints are SOB, DIB, “can’t get enough air”, suffocation or smothering, air hunger and winded. The most common causes of cardiopulmonary decompensations are asthma, COPD, malignancy, Heart Failure, Interstitial Lung Disease, Pneumonia, Valve disorder, Intracardiac shunts, MI, Cardiomyopathies. 2. Explain the differences between intra-thorax and extra-thorax flow disorders Classifications of dyspnea disorders can be classified as Flow or Volume, either intra-thrax or extra-thorax. Flow/Intra-thorax- Obstruction of the distal airway. Flow/Extra-thorax- Obstruction of the proximal/larger airway. Volume/Intra-Thorax- Lung parenchyma disorders. Volume/Extra- thorax- Lung compliance disorders, respiratory center disorders. 3. Identify at least three examples of flow and volume disorders (intra and/or extra thorax) Flow/Intra-thorax- asthma, bronchiolitis, lymph node enlargement, solid foreign body aspiration- Causes expiratory effort in infants and children less than 5. Flow/Extra- thorax- rhinitis with nasal obstruction, cranial-facial malformation, sleep apnea, tonsil-adenoid hypertrophy, diphtheria, croup and epiglottitis- Causes inspiratory stridor in infants and children 5 and under. Volume/Intra-thorax (pulmonary) - pneumonia, atelectasis, pulmonary edema, near-drowning, sepsis- causes inspiratory effort. Volume/Extra-thorax (lung compliance)- neuromuscular disease, obesity, gastritis/peptic ulcer, ascites- causes inspiratory constraint. Volume/ Extra-thorax (pulmonary) - pneumothorax, cardiomegaly, heart failure, chest trauma such as rib fracture or lung contusion, thorax deformity such as pectus excavation or scoliosis- Causes inspiratory effort. Volume/Extra-thorax (Respiratory Center Disorders) - anemia, metabolic acidosis, meningitis, poisoning or salicylate or alcohol ingestion- Causes deep, rapid breathing. **4. Discuss diagnosis, risk factors and treatments for asthma-****needs completed******
Describe the classes of asthma and treatments for each category
Diagnosis-
Essential elements to consider-
HX- cough (especially nocturnal), recurrent wheeze, recurrent episodic dyspnea, recurrent chest
tightness
Symptoms worsen in relation to specific factors- changes in weather, exercise, environmental
allergens, GERD, Beta blockers, sensitivity to ASA, strong emotional expression
To establish the diagnosis of asthma, episodic symptoms of airflow obstruction must be present,
airflow obstruction must be at least partially reversible, and must rule out other diagnoses.
Spirometry measurements are helpful in diagnosis & in evaluation of management
The diagnosis is made by demonstrating the reversibility of the airway obstruction from the pre-
and post- PFTs.
Reversibility is defined as a 15% or greater increase in the FEV1 after 2 puffs of a beta-
adrenergic agonist have been inhaled.
When spirometry is non-diagnostic, bronchial provocation testing maybe useful with histamine,
methacholine, or exercise.
Risk Factors
Family or personal history- allergic rhinitis, eczema/atopic diseases
Residing in urban area
Exposure to smoke or air pollution
Cockroaches and dust
Viral respiratory
infections Cold air
intolerance obesity
Classifications of Asthma Severity
Mild Intermittent Symptoms < 2 days per week OR < 2 nights per month.
Exacerbations brief
anemia or infection. Peak Expiratory Flow Test- determine degree of air flow in COPD and asthma. EKG- look at cardiac activity. Spirometry- Determine obstructive, reactive or mixed.
6. Discuss clinical findings and PFTs for asthma, chronic bronchitis, emphysema, and COPD chronic bronchitis. 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 and have dyspnea with or whitout sheezing. 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 asthma. Chronic, inflammatory, obstructive disease in airways. May occur at any age and presents with wheezing (airway spasms), chest tightness, dyspnea, cough. Reversible hyperreactivity of bronchi and 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 COPD. Progressive disease characterized by presence of airflow obstruction due to chronic bronchitis or emphysema. 3rd leading COD in US. Dz of lung parenchyma and 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 <30% Emphysema 7. Differentiate between the following common rashes: rubeola, rubella, varicella, roseola, 5ths disease, pityriasis rosea, hand, foot and mouth disease and molluscum contagiosum. Rubeola-(measles, 9 day measles, 1st disease) Acute highly contagious viral characterized by fever, cough, coryza & conjunctivitis followed by maculopapular rash starts in face and spreads cephalocaudally (head) & centrifugally (trunk).Transmitted direct contact with droplets.Caused by Morbillivirus. RF: Children <5 & adults>20yrs, pregnant women, immunocompromised
persons, malnutrition, Vit A deficiency,international travelers. Incubation 7- days from exposure.
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
and papules, first on head, travel down body.
Fades in 1-2 days in same order they appeared.Tx: symptomatic (apap,
NSAIDs, rest). Rubella vaccination.Infectious 4-7 days before rash, can return
to work/school after rash gone.
Varicella: chicken pox.Very contagious.Caused by varicella zoster virus (VZV).
Malaise, fever, chills, HA, arthralgia, then 1-2 days later urticarial
erythematous macules and papules appear, quickly turning into vesicles and
pustules. Rash starts on face/chest, spreads quickly over entire body.
Blisters can be in ear canal or mouth. Dry up in 1wk.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 and 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 and papules on
face, neck, extremities. Usually resolves in 1-3 days.Dx based on clinical
presentation and history.Tx: symptomatic.Contagious 1-2 days before fever,
can return to work/school when fever, fatigue, cough, diarrhea gone.
5ths Disease: 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 and trunk (not palms, sole surfaces), may be itchy; 2-3wks of
body rashDx 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.
Pityruasis rosea: viral,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
Tinea corporis (ringworm). Affects all age group. On the extremities or trunk.
erythematous annular lesion with scaly macules and papules, well-defined
edges.Pt/gaurdian reports lesion size increasing..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
Itraconazole/Terbanafine (if severe).
Tinea unguium: (onychomycosis).Fingernails or toenails.Very common in
adults & elderly.Nail appearance may vary: yellow, green, black or white
ridging w/possible cracking of nails.Diagnosed by fungal culture/potassium
hydroxide (POH) exam.Tx: determined by severity and pt's age. Topical
Ciclopirox nail laquer 8% applied daily for months at base of nail. PO
Terbanafine 250mg daily x6wks (fingernails) X 12 wks (toenails,has high cure
rate but pt has to have healthy liver (do CMP prior to initiation).Cure is VERY
slow.
9. Identify the virus that causes warts Human papillomavirus (HPV). 10. Differentiate between atopic and contact dermatitis and give examples of each Contact: allergic reaction to substance that produces immune reaction in skin resulting in pruritic and 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 and 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. 11. Identify common characteristics associated with blepharitis, chalazion and hordeolum 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.
12. Differentiate between viral, allergic, bacterial, toxic and HSV conjunctivitis (CH. & lecture) Viral- Benign, watery discharge, visual acuity is normal, itching present, mod/diffuse conjunctival abnormalities (bumps on the conjunctiva “follicles” hallmark sign ), no pupillary involvement, mild photophobia (lecture), no photophobia (book),often has bilateral involvement, highly contagious, IOP normal, Preauricular nodes palpable, a URI usually present (adenovirus mainly), resolves on its own (few days-weeks), no firm guidelines when to return to work/school, AAO recommends when redness and tearing gone, treatment- no scratching, artificial tears, OTC anti-allergy drops may help, systemic antihistamines not helpful. HSV- HSV 1(above the waist) & 2 (below the waist), cause by direct contact with a person with visible lesions or shredding of lesions (predromal stage, before lesions appear), skin vesicles present, conjunctivitis, corneal infection w/ hallmark “dendrite” appearance (look at lecture for pic), referral to ophthalmology is necessary. Allergic- stringy/mucoid discharge, visual acuity normal, itching/burning present, mild/diffuse conjunctival abnormalities, no pupillary involvement, no photophobia, usually has bilateral involvement, IOP normal, preauricular nodes not palpable, other symptoms- rhinorrhea, sneezing, tearing, occurs in fall or spring. Bacterial- Contagious (24hrs w/ antibiotics before returning to work/school), purulent/thick discharge, crusted lids in the a.m, visual acuity normal, pain described as sandiness, Mod to heavy/diffuse conjunctival abnormalities, no pupillary abnormalities, no photophobia, begins unilateral, but may spread bilaterally, IOP normal, preauricular nodes not palpable, occurs in fall and winter, mainly caused by direct contact with infected person or one’s own bacteria. - May resolve w/o tx, but antibiotic drops can shorten duration(4x/day, 4- days). All antibiotic drops are pretty effective-choice depends on allergies, cost, and availability - Gonococcal infection- involves the cornea, hyper purulent discharge-send to ER Toxic- Caused by overuse of topical ocular meds (visine, antibiotics-longer than necessary), clear/watery discharge,red conjunctiva, TX- stop using offending agent 13. Discuss which chemical injury is associated with the most damage and highest risk to vision loss -
