What do you include in the work-up of a corneal abrasion?
Slit lamp exam with fluorescein,
evert lids to rule out foreign body
What is the treatment for a corneal abrasion in a non-contact lens wearer?
Erythromycin or Polytrim drops,
What is the treatment for a corneal abrasion in a contact lens wearer?
Must cover pseudomonas (tobramycin ointment, fluoroquinolone drop),
When should a corneal abrasion be referred to an ophthalmologist?
If not healed in 24 hours,
abrasion related to contact lens wear,
white corneal infiltrate develops
Focal loss of corneal stroma with overlying epithelial defect
What is the number one risk factor for corneal infection?
Contact lens wear (overnight, swimming)
What is the #2 risk factor for corneal infection?
Trauma, corneal abrasion
What should you do if you suspect infectious keratitis?
Call an ophthalmologist
What is the treatment for infectious keratitis?
Broad spectrum antibiotic drops
What should be included in the workup for central retinal artery occlusion?
ESR for temporal arteritis
What is the treatment for central retinal artery occlusion?
Although no treatment has been proven to improve outcome you can try, lowering IOP with topicals, Diamox, anterior chamber paracentesis
The immediate treatment for angle closure glaucoma is to lower eye pressure, how is this done?
Drops (timolol, dorzolamide, brimonidine),
oral agents (Diamox, isosorbide),
IV agents (mannitol), h
old pilocarpine until seen by an ophthalmologist
What is endophthalmitis?
Inflammation of the tissue inside the eye caused by bacteria (coag neg staph, SA, gram -),
fungi, rarely viruses (Herpes simplex/zoster),
or protozoa (acanth, toxplasafi),
and is usually associated with eye surgery
What are the symptoms of endophthalmitis?
redness (especially after eye surgery),
blurred vision (pretty generic)
What is the treatment of endophthalmitis?
Injection of intravitreal antibiotics or surgery ASAP
What is the most common etiologic agent of viral conjunctivitis?
What is the treatment for viral conjunctivitis?
throw out contact lens/case/solution,
wash hands religiously
For how long is viral conjunctivitis contagious?
Conjunctivitis in an infant, assume what organisms?
Chlamydia and or gonorrhea
Gonococcal conjunctivitis requires __ treatment
Acute, often red, infection of the sebaceous glands at the base of the eyelashes
Chronic, often fibrotic, infection of the sebaceous glands at the base of the eyelashes
Treatment for hordeolum/chalazion
steroids sometimes injected to prevent recurrence
Inflammation along the eyelashes/meibomian glands (gritty burning eyes)
Treatment of blepharitis
Warm compresses, lid scrubs, consider erythromycin ointment or doxycycline
Blepharitis with ulceration or lash loss consider __
What are risk factors for retinal detachment?
Myopia, trauma, family history, cataract surgery, detachment in the other eye
What will happen to the pressure in an eye affected with a retinal detachment?
May be lower
What is significant in the history of a retinal detachment?
Flashes or floaters
What is the treatment for periorbital cellulitis?
PO or IV antibiotics
Elderly man with history of monocular vision loss, jaw pain, and recent weight loss, what are you suspicious for?
Giant cell/temporal arteritis
29 year old woman with multiple sclerosis presents with acute loss of central vision in one eye, and pain with eye movements. What are you suspicious for?
What is a stye
Acute infection of the oil gland at the lash line that appears as a pustule (aka external hordeolum)
Treatment for stye (external hordeolum)
Warm wet compresses 4x day,
erythromycin ointment 2x/day for 7-10 days
Acute or chronic noninfectious inflammation of the eyelid secondary to meibomian gland blockage in the tarsal plate
Chalazion (internal hordeolum)
Why has gentamicin fallen out of favor for the treatment of bacterial conjunctivitis?
High incidence of ocular irritation
Presents as monocular or binocular eyelash matting, mild to moderate mucopurulent discharge, and conjunctival inflammation
Presents as a monocular or binocular watery discharge, chemosis, and conjunctival inflammation
Treatment of viral conjunctivitis
Cool compresses 4x/day, naphazoline/pheniramine drops for conjunctival congestion or itching. Follow up in 7-14 days
Endophthalmos is a true __
How do patients with endophthalmos present?
Pain and visual loss
What is the initial empiric treatment for endophthalmos?
Vancomycin and ceftazidime
Periorbital cellulitis (preseptal cellulitis)
A superficial infection of the eyelids that does not extend past the orbital septum. The eyelids become warm indurated and erythematous but he eye itself is not involved
Orbital cellulitis (postseptal cellulitis)
A potentially sight and life threatening ocular infection deep to the orbital septum, typically as a result of spread from the ethmoid sinuses
How should superficial conjunctival abrasions be treated?
Erythromycin ointment 2x/day for 2-3 days,
ocular foreign body should be excluded
What is the preferred topical ocular anesthetic used when assessing a corneal abrasion?
How will a corneal abrasion appear during fluorescein stain when using cobalt blue light on slit lamp?
It will fluoresce green
What is the treatment for a simple corneal abrasion?
A cycloplegic (cyclopentolate, homatropine) for the pain,
and a topical antibiotic (tobramycin, erythromycin, bacitracin/polymyxin)
What is the antibiotic treatment for a corneal abrasion for a person with contact lenses?
Should include coverage for pseudomonas (ofloxacin or ciprofloxacin)
How are superficial corneal foreign bodies removed?
Under slit lamp microscopy with a fine needle, eye spud, or ophthalmic burr. Proparacaine is used (also instilled in the unaffected eye to depress reflex blinking)
Who should remove a corneal foreign body deep within the corneal stroma, or in the central visual axis?
What do you do for a high risk lid laceration if an ophthalmologist is not immediately available to evaluate and treat?
As long as all sight-threatening lesions have been excluded prescribe oral and topical antibiotics and gentle cold compresses with referral to an ophthalmologist in 24 hours
A hyphema should be dilated with __ to prevent pupillary movement from tearing damaged blood vessels
What orbital walls do blowout fractures commonly involve?
Inferior and medial
Which muscle is usually entrapped in a blowout fracture, and what does it cause?
Inferior rectus muscle.
May cause restricted movement, resulting in diplopia on upward gaze
What must be avoided once a globe injury is suspected?
Any further manipulation or examination of the eye
Severe subconjunctival hemorrhage, shallow or deep anterior chamber, hyphema, teardrop-shaped pupil, limited extraocular motility, extrusion of globe contents, reduction in visual acuity can all mean what?
A bright green streaming appearance to fluorescein instilled into the tear layer (Seidel test) is pathognomonic for what?
Penetrating trauma or ruptured globe
Treatment for ruptured globe
Call ophthalmologist immediately.
Metallic eye shield,
first gen cephalosporin,
antiemetic (prevent Valsalva),
CT to look for foreign body.
How long after the first 2L of irrigation fluid should you wait to check the ph in an eye that has suffered a chemical burn?
What should you do for an eye that has been chemically burned and continues to have an abnormal ph despite being irrigated with 8-10 L of fluid?
The fornices should be inspected thoroughly and re-swept with a moistened tip applicator
What ocular condition classically presents with eye pain or headache, cloudy vision, colored halos around lights, conjunctival injection, a fixed mid-dilated pupil and increased IOP of 40-70 mmhg?
Acute angle closure glaucoma
What is a normal range for IOP?
10-20 mm Hg
What can precipitate an attack of acute angle closure glaucoma in a patient with narrow anterior chamber angles?
ill-advised use of dilatory agents or inhaled anticholinergics
What are some treatments used to reduce IOP?
prednisolone acetate drops
What can you use to decrease pressure if the IOP is greater than 50 mmhg?
What can you use to decrease IOP if it does not do so with first line agents after 1 hour?
Give 1-2g/kg mannitol IV
Once IOP is below 40 mmhg in acute angle closure glaucoma, what can be given as long as the patient has an intact lens in place?
Presents with acute vision loss with a particular reduction in color vision (red desaturation test), often painful especially with eoms
What can often be detected in Optic Neuritis?
Afferent pupillary defect
Presents as a sudden painless, severe monocular loss of vision, often associated with a history of amaurosis fugax
Central retinal artery occlusion
Causes acute, painless monocular vision loss. Examination shows optic disc edema, cotton wool spots, and retinal hemorrhages in all quadrants (blood and thunder fundus)
Central retinal vein occlusion
A systemic vasculitis that can cause a painless ischemic optic neuropathy?
Giant cell arteritis
Who is the typical patient with giant cell arteritis?
Women older than 50 years, often with a history of polymyalgia rheumatica
What are associated symptoms of giant cell arteritis?
scalp or temporal artery tenderness,
What is may be seen on funduscopic exam with giant cell arteritis?
What labs should be ordered when giant cell arteritis is suspected?
What should be done if there is a strong suspicion of giant cell arteritis?
The patient should be admitted for methylprednisolone 250 mg IV every 6 hours
What may be done if there is a low suspicion for giant cell arteritis?
The patient may be discharged with prednisone with close follow up
Assume open globe;
poss CT (if suspect blow out fx);
poss US to r/o vitreous hemo or retinal detach;
SPE (pts w/SCD)
What is the most life threatening gynecologic cause of acute abdomen in the female patient?
Amylase is elevated in __
Pronounced: acute pancreatitis;
moderate: small bowel obstruction, salivary gland infxn/inflam, mumps, panc ca, perf'd peptic ulcer
ALT/AST is elevated in __
Bilirubin/Alk Phosphatase is elevated in __
Common bile duct obstruction
Never place __ above an obstruction
Indications for barium studies
Volvulus, colon cancer, mucosal detail
Barium studies are not only useless for evaluation of __ they are dangerous
For what disease process are the five F’s used for
Five F’s of acute cholecystis
Murphy’s sign is used to help diagnose __
Periumbilical pain that migrates to RLQ, anorexia is a possible history of __
Obturator sign/psoas sign is used to help diagnose __
__ hours after acute appendicitis symptom onset there is a >95% perforation rate
What is the rule of 2’s for Meckel’s diverticulitis?
2% of the pop,
2 feet proximal to the ileocecal valve,
2 types of mucosa,
2 years of age,
2:1 M:F ratio
What is the treatment for Meckel’s diverticulitis?
Severe epigastric pain radiating to the back, often associated with ETOH, usually elevated amylase/lipase
Distended abdomen, surgical scars, high pitched bowel sounds, tympanic to percussion, nausea w/ bilious vomiting, constipation, often severely dehydrated
Small bowel obstruction
Non-operative treatment for small bowel obstruction
Most common causes of large bowel obstruction
LLQ pain, fever
Sudden onset of sharp ab pain, N/V, diarrhea, GI bleeding, pain out of proportion to physical exam, may have history of angina, atherosclerosis, smoking
Midline ab pain with tearing sensation to the back, patients often present in shock, exam reveals pulsatile mass
>__ cm AAA has an increased risk of rupture 20-30% within 5 years
Patients with __ pain tend to lie still
Patients with __ pain tend to move about
__ should be considered in any patient older than 50 with ab pain out of proportion to physical findings
CT is the preferred imaging modality for what emergencies
Pancreatitis, biliary obstruction, aortic aneurysm, appendicitis, and urolithiasis
__ in appropriate doses may decrease guarding and improve localization of abdominal pain
Antiemetics such as __ increase patients comfort and facilitate assessment of S/S
What is the most reliable symptom of appendicitis?
Palpation of the LLQ quadrant with pain referred to the RLQ is referred to as the __ and is indicative of __
Rovsing’s sign, acute appendicitis
The diagnosis of acute appendicitis is generally __
The most significant predictors of acute appendicitis in the elderly are __
Tenderness, rigidity, pain at diagnosis, fever, and previous abdominal surgery
What are the main features of intestinal obstruction?
Crampy, intermittent, progressive ab pain
What causes the pseudoobstruction that commonly occurs in the low colonic region?
Depression of intestinal motility from medications such as anticholinergic agents, or tricyclic antidepressants
In the case of pseudoobstruction what is diagnostic as well as therapeutic
Predominant means of diagnosis for hernias
Should you attempt hernia reduction if there is a question about the duration of the incarceration?
__ hernias in children are common
When should a child with an umbilical hernia be referred for surgical evaluation?
Children older than 4 or with hernias greater than 2cm in diameter
Ecchymosis across lower abd 2/2 seat belt, assoc L-spine fx
Grey Turner sx
Ecchymosis over flanks,
usu dev after 12 hrs = retroperitoneal hemo
Ecchymosis over umbilicus,
usu dev after 12 hrs = retroperitoneal hemo
Mesenteric ischemia: cause
Embolus to SMA 2/2 intracardiac thrombus 2/2 A-fib
dec breath sounds if pleural effusion;
abd distension if ileus;
Cullen & Gray Turner sxs if hemo
Supportive: IVF 2/2 n/v;
NPO, poss NG tube;
NGT for bowel decompression;
IVF 2/2 n/v;
broad abx (Flagyl, amp/ gent)
Colicky abd pain in waves, n/v, obstipation;
no peritoneal sxs;
early: Distended tympanitic;
later: tinkling BS
Tx for diarrhea 2/2 Shigella, Yersinia, ETEC, V cholerae
Infxs diarrhea: no abx for:
Ranson's criteria predict M&M for:
What is the suspensory ligament of the duodenum?
Ligament of Treitz
What is the most common cause of lower GI bleeding?
Common, painless and can be massive, caused from an erosion into penetrating artery from the diverticulum
What is the most common cause of upper GI bleed?
Peptic ulcer disease
Cause of esophageal and gastric varices
Longitudinal mucosal tear in the cardioesophageal region, caused by repeated retching
Common cause of lower GI bleeding, seen in people with hypertension and aortic stenosis
Spider angiomata, palmer erythema, jaundice, and gynecomastia are seen in __
Petechiae and purpura seen in __
Why would you do a careful ENT exam on a patient suspected of GI bleed?
Rule out causes that can mimic GI bleed such as epistaxis
Can be diagnostic and therapeutic but requires a brisk bleed at .5-2ml/min
Can only be diagnostic but are more sensitive than angiography and require a bleeding rate of only .1ml/min
Is diagnostic and therapeutic and more accurate than bleeding scans and angiography
Class __ bleed replace volume with crystalloid
I and II
Class __ bleed replace volume with crystalloid and blood
III and IV
Hemorrhaging is broken down into how many categories by the ACS
Class __ hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary
Class _ hemorrhage involves 15-30% of total blood volume. A patient is often tachy, narrowed pulse pressure. Peripheral vasoconstriction, pale cool skin, slight changes in behavior, volume resuscitation with crystalloids
Class __ hemorrhage involves loss of 30-40% of blood volume; pt’s BP drops, HR increases, peripheral perfusion decreases (prolonged cap refill), mental status worsens; crystalloid & blood transfusions usually necessary
Class __ hemorrhage involves loss of >40% of blood volume; limit of body’s compensation is reached and aggressive resuscitation is required to prevent death
__ ulcers do not extend through the muscularis mucosa
Only __ % of patients who are infected with H. Pylori will develop ulcers
Inhibits bicarbonate ion production and increases gastric emptying
Main complaint of gastric ulcer
Gnawing, aching or burning epigastric pain
Physical exam of uncomplicated PUD, there may be a finding of __
Inhibit gastric acid secretion, equally as effective as antacids with better compliance due to decreased frequency of doses
Inhibits gastric acid secretions, heals ulcers faster than H2-antagonists and antacids
Locally binds to the base of the ulcer and therefore protects it from acid
Prostaglandin E1 analogue which acts as natural prostaglandin in the body
Vomiting and diarrhea is most often __
Which is more common: upper or lower GI bleeding?
What is the most common cause of acute lower GI bleeding?
Hemorrhoids, followed by diverticular disease
What is the most important lab test for a patient with a significant GI bleed?
Type and crossmatch
When is surgical treatment for hemorrhoids indicated?
Severe, intractable pain, continued bleeding, incarceration, or strangulation
Treatment of choice for patients with pseudomembranous colitis
Metronidazole for mild to moderate disease in patients who do not respond to supportive measures
__ should be reserved for patients with pseudomembranous colitis who have not responded to or are intolerant of metronidazole and for children and pregnant patients
For patients with pseudomembranous colitis __ may prolong or worsen symptoms and should be avoided
Sx of esophageal perf: vomiting, chest pain, subq emphysema
Output <400 cc/day (or 0.5-1.0 cc/kg/hr)
Pre-renal ARF: ineffective circulating volumes; may be due to:
3rd space sequestration (pancreatitis, peritonitis, ischemic bowel)