HEENT and Procedures

Eyes

100

What is the most common cause of this condition and what is the treatment.

What is viral conjunctivitis (adenovirus). Viral conjunctivitis is self-limited; it typically lasts 1 to 3 weeks and requires supportive therapy only, such as cool compresses, and diligent hand hygiene to minimize the risk of spread. It is most contagious when discharge is present; patients should stay away from work, school, and daycare during that time.

200

A mother who had no prenatal care brings her 3-day-old infant to the ED secondary to eye drainage. On exam, the child has marked swelling and redness of the eyelids, severe chemosis, and purulent discharge bilaterally. Which of the following organisms is the most likely diagnosis?

What is N. gonorrhea conjunctivitis. This is an extremely aggressive form of conjunctivitis that can ulcerate and perforate an intact cornea within hours or days. It is considered an ocular emergency and is most commonly seen in newborns (ophthalmia neonatorum), typically within the first 3-5 days of life. It is also seen occasionally in sexually active adults. The discharge is characteristically purulent. Treatment includes parenteral and topical antibiotics. A Gram stain and culture should also be obtained.

300

A 31-year-old woman presents to the ED complaining of a fever, headache, and blurry vision. She states that one week ago she developed a furuncle on her midface that she tried to “pop” by squeezing it. On examination, you note mild proptosis, periorbital edema, and chemosis of the right eye. Extraoculomotor testing reveals a lateral gaze palsy of the right eye. Vital signs are T 39.2°C, BP 128/88, P 105, RR 18. Which of the following is the most likely diagnosis?

What is cavernous sinus thrombosis. This is a life-threatening condition that is usually a late complication of an infection of the central face or paranasal sinuses. The complex network of facial veins with multiple anastomoses allows spread of infection from the face to the cavernous sinus. Staphylococcus aureus is the most common associated organism. Patients initially recall having a sinusitis or midface infection during the preceding five to ten days. Subsequently, the patient develops a headache, periorbital edema, and cranial nerve signs (related to structures within the cavernous sinus). Cranial nerve VI is most commonly affected, presenting as a lateral gaze palsy because it lies freely within the sinus. Periorbital edema may be the earliest finding and chemosis and proptosis results from occlusion of the ophthalmic veins. The diagnosis is clinical but is often aided by CT scan or MRI with IV contrast that reveals a filling defect within the cavernous sinus.

400

What condition is shown in this image of a patient presenting with eye pain and vision loss?

What is Endophthalmitis. an infection involving the anterior, posterior and vitreous chambers of the eye. It results from trauma (blunt globe rupture, penetrating injury, foreign bodies) and also iatrogenically after ocular surgery like cataract repair. Patients complain of severe pain in the eye and visual impairment or loss. Examination of the eye reveals decreased visual acuity, injected conjunctiva, chemosis and haziness of the infected chambers. Infections are treated with both systemic and intraocular antibiotics.

500

What are the four types of HSV keratitis?

What are Although the most common form of HSV keratitis is epithelial keratitis manifesting with the classic dendrites, other forms, including disciform, stromal, and keratouveitis are all manifestations of HSV keratitis. Disciform keratitis is a deeper, disc-shaped, localized area of corneal edema. Patients might have pain and decreased vision. In most patients, there is a history of orolabial or genital herpes infections. The slit lamp examination is useful for separately examining the layers of the eye to determine the source of the vision defect. Treatment usually consists of antiviral eye drops and topical steroids.

Ears

100

Tinnitus, hearing loss and vertigo suggest what cause of peripheral vertigo?

What is Idiopathic endolymphatic hydrops, commonly known as Meniere disease, is a type of peripheral vertigo. Associated tinnitus and hearing loss are hallmarks of the presentation.

200

What is the most common cause of tympanic membrane perforation?

What is infection

300

What is the most common causative organism in acute malignant otitis externa?

What is The causative agent is typically Pseudomonas aeruginosa. Signs and symptoms of necrotizing otitis externa include persistent, excruciating pain that interferes with sleep and continues despite topical treatment. Additional signs and symptoms include fever, erythema of the periauricular tissues, and facial or vagal nerve palsy. Diagnosis of necrotizing otitis externa is by CT of the temporal bone. The key to management is with systemic antibiotics. Antipseudomonal double-coverage is preferred with a penicillin-based antipseudomonal and an aminoglycoside.

500

What three pieces of equipment do you need for a pediatric needle cricothyrotomy?

5 mL syringe, 3.0 mm ETT adapter, and 14G over-the-needle catheter To perform a needle cricothyrotomy place a towel under the shoulders extending the neck and forcing the trachea anteriorly and palpate for the cricothyroid membrane. This may be difficult to find in small children and you may need to cannulate the proximal trachea instead. Place a finger and thumb on either side to stabilize the trachea and cannulate it at a 30° angle directed caudally with a 14G over-the-needle catheter. Aspirate air into a 3- or 5-mL syringe to ensure entry into the trachea. Without firm cartilaginous rings the trachea collapses easily making it difficult not to penetrate the back wall of the trachea. Once you aspirate air, gently slide the catheter off the needle and attach the 3.0 mm ETT adapter to which you can attach a bag-valve mask.

Neck/Mouth

100

What is the most common source of bleeding for anterior and posterior epistaxis?

What are Kiesselbach plexus and sphenopalatine artery. Posterior epistaxis is less common than anterior epistaxis and is most commonly due to bleeding from the sphenopalatine artery, located at the posterior aspect of the middle nasal turbinate. Patients with posterior epistaxis typically complain of bleeding from both nostrils.

200

The most important treatment in postextraction alveolar osteitis is...

What is irrigation of the socket with chlorhexidine 0.12% oral rinse or warmed normal saline. - Patients often need analgesia, either with an NSAID or an opiates, or regional anesthesia. If there are signs of infection, antibiotics are warranted, either penicillin VK or clindamycin for penicillin-allergic patients. All patients should be referred back to the dentist who performed the procedure for follow-up.

300

What five features suggest malignancy in a neck mass found in a neonate?

The five features are associated skin ulcer, onset when the patient is a neonate, fixation of the mass to skin or fascia, progressive enlargement, and size greater than 3 cm with a hard consistency.

400

How can you tell whether a coin is in the esophagus or the trachea on X ray as shown below.

. Flat objects (coins) will be oriented in the coronal plane if it is located in the esophagus. An AP or PA radiograph will reveal the flat surface of the coin (as seen in the above radiograph). If it is in the trachea, the coin will be oriented in the sagittal plane (reflecting the angle of the coin required to pass through the vocal cords). The AP or PA radiograph will reveal the coin on edge. The esophageal epithelium can rapidly necrose and perforate with a lodged foreign body; therefore, endoscopy is necessary to remove a foreign body. The patient also is noted to be drooling, which is indicative of partial or complete obstruction.

500

What are the modified centor criteria?

The patients are judged on four criteria, with one point added for each positive criterion:[1] Absence of cough Tonsillar exudates History of fever Tender anterior cervical adenopathy The modified Centor criteria add the patient's age to the criteria:[2] Age under 15 add 1 point Age over 44 subtract 1 point

Procedures

100

How long after first placement of a G tube would you consider replacing it in the ED if the G tube fell out?

What is Most gastrostomy tube (G-tube) tracts mature after 2 to 3 weeks, so dislodgement of the G-tube puts the patient at risk for intestinal content leakage and peritonitis. Imaging, antibiotics, and surgical consultation are typically recommended. Attempting to replace a G-tube or Foley catheter into the tract before the tract matures can create a false lumen or even worsen intraperitoneal leakage. On the other hand, if the G-tube had been in place long enough for the tract to mature (2 to 3 weeks), emergent replacement with another G-tube is indicated (within hours) to maintain tract patency. Maintaining temporary patency with a Foley catheter (16F or 18F, typically) is an acceptable alternative.

200

Which pole of the tonsil is most commonly affected by a peritonsillar abscess and what structure is most commonly injured in the procedure.

What is the superior pole (followed by middle and inferior) and the internal carotid artery.

300

Why is transcutaneous pacing not recommended in severe hypothermia with bradycardia?

Because it can precipitate V fib. These patients should be actively rewarmed and resuscitated.

400

Name the 5 P's of compartment syndrome and the compartment pressure that would be diagnostic for the condition.

The physical examination findings consist of compartment tension and pain with palpation, in addition to pain with passive extension, paresthesias, paresis/paralysis, pallor, and pulselessness (the “five Ps”). pressure >30

500

What size and type of ETT should be used to intubate a premature neonate and a newborn weighing 1.5 to 3 kg or more?

For a premature newborn, a 2.5 ETT is recommended because this is the smallest size available. For a baby weighing 1.6 kg to 3 kg or more, a 3.0 ETT is appropriate.

Signs and Symptoms

100

Name 3 characteristics of nystagmus seen in BPPV that distinguishes it from nystagmus from a central etiology.

the nystagmus has a long latency, transient duration, and is fatigable with provocative testing (the Dix-Hallpike maneuver) also can say unidirectional and not vertical. Furthermore, it is not associated with any other neurologic deficits. This is distinct from central vertigo, such as that caused by strokes and tumors, which tends to have nystagmus with a short latency, a sustained duration, is not fatigable, and tends to be accompanied by other cranial and peripheral nerve deficits.

200

What are the PERC Criteria (name all 6)

Age <50yr Pulse ox >94% (room air) HR <100 No prior PE or DVT No recent surgery or trauma (within prior 4wk) No hemoptysis No estrogen use No unilateral leg swelling

300

Describe the "toddler's" fracture and appropriate management.

Toddler fracture is a very common injury in children who have recently began to walk (toddlers). Emergency department treatment is largely supportive, usually placement of a long-leg splint. The mechanism of injury described by the father is consistent with findings on the xray, so there is no specific reason to suspect child abuse. This type of fracture, considered to be a subset of childhood accidental spiral tibia (CAST) fractures, occurs in young children from those just beginning to walk to those older than 7 years. The mean age for it is 50 months, just over 4 years. It is a fracture of the tibia diaphysis and usually occurs in the distal third but can extend into the midshaft. Spiral fractures of the proximal third of the tibia or of the femur are less likely to be accidental and should prompt consideration of abuse.

400

What does the Coombs test detect in the evaluation of a neonate with jaundice?

A Coombs test can detect maternal IgG antibodies on the baby’s RBCs; it should be included in the evaluation of this patient, as should testing for hemoglobin, liver function, a total and fractionated bilirubin, and possibly blood typing for the patient and mother if this information is unknown.

500

Name the 2 major and at least 4 minor criteria in the DUKE criteria.

What is the two most definitive tests for this disease are blood cultures (from at least two different venipuncture sites) and echocardiography. These are the two major Duke criteria and, if results of both tests are positive, indicate a definitive diagnosis of infective endocarditis. The minor Duke criteria are a predisposing factor (such as intravenous drug use), fever above 38°C (100.4F), evidence of septic emboli (such as Janeway lesions, Osler nodes, or, as in this case, splinter hemorrhages), and a single positive blood culture.