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UTA FNP 2 MIDTERM, MODULE 1 ENT & UPPER AIRWAY
WITH 100% VERIFIED!!
Blepharitis, pharm Antibiotic ointments - (BEQ)
o Bacitracin, erythromycin, and quinolone (any -floxacin).
o If infx doesn't respond to topical meds, if you have resistant infections - use oral antibiotics.
· First line - doxycycline 100mg PO twice a day.
· Tetracycline 250 mg 4 times daily can also be given.
Blepharitis, anterior presentation o Staphylococcal blepharitis characterized by scaling, crusting, and erythema of the eyelid margin, more common among women in their 40s. o Eyelid staph infection - Eyelash loss; crusting or matting of eyelashes upon waking; flaking or scaling of eyelid skin.
Blepharitis, posterior presentation o Inflammation and dysfunction of the meibomian gland within eyelid.
o Excess foamy discharge, chalazion (aka meibomian cyst, is a small, firm, painless bump that develops on the eyelid), and ocular rosacea is common.
Conjunctivitis, bacterial, presentation o Sclera of the eye gets red, and sometimes itchy, and sometimes there will be exudates.
§ Typically, if you see the exudates, it is bacterial conjunctivitis.
o The organisms that cause the bacteria are Staph, Strep, H flu, and M catarrhalis – same as upper respiratory infx.
o Pseudomonas is another less likely cause and, of course, gonorrhea can cause it as well.
Conjunctivitis, bacterial, pharm o Pharm - § Azithromycin 1% solution § Erythromycin 0.5% ointment § Gentamicin 0.3% solution § Sulfacetamide 10% (Bleph-10, Isopto Cetamide, or Sodium Sulamyd) § Tobramycin (Tobrex) § Bacitracin/polymyxin B 500 u/g ointment § Ciprofloxacin 0.3% (Ciloxan) § Ofloxacin 0.3% (Ocuflox)
Corneal Abrasion, pharm · Pharm –
o Eye rx – Ciprofloxacin.
§ Want to use broad spectrum.
Cataracts, assessment · Assessment - o Opacification of the lens. o Diminished red reflex and a white reflex. o Blurred vision and see halo around lights. o Diminished night vision, and diminished visual acuity.
Strabismus, different types/patterns · Different types - o Esotropia - where the eye drifts inward. o Exotropia - where it drifts outward. o Hypertropia - where it drifts upward. o Hypotropia - where it drifts downward.
Glaucoma, excessive IOP value
25mmHg
Glaucoma, tonometer use · You take an average of three readings. Normal pressure is 10 to 23. Anything 25 or greater is considered close angled glaucoma.
Glaucoma, categories of meds beta blockers (5), prostaglandin analogs (4), carbonic anhydrase inhibitors (2), alpha adrenergic (2).
Glaucoma, open angle, beta blockers o Five beta blockers – betaxolol, carteolol, levobunolol, metipranolol, and timolol.
§ These medications decrease aqueous humor production. Can have systemic side effects typical of beta blockers if there is enough systemic absorption.
Glaucoma, open angle, prostaglandin analogs o latanoprost, travoprost, bimatoprost, and tafluprost.
§ These medications work by increasing aqueous humor outflow. These can cause brown pigmentation of the iris. The patient needs to be educated about this side effect.
· Miosis · Contraction of the ciliary muscle § Now considered a second-line drug for open-angle glaucoma. § Emergency treatment of acute angle-closure glaucoma
Diabetic retinopathy, assessment Assessment - · Subjective visual changes · Fundoscopic exam - microaneurysms, intra-retinal hemorrhage, macular edema, and lipid deposits. There will also be cotton wool spots, venous beading and dilation, edema, and in some cases, retinal hemorrhage.
diabetic retinopathy, pharm Pharm - · Lisinopril - The only pharmacologic agent found to slow the progression.
macular degeneration, define dry vs wet
- ‘ dry ’ – Is a slow progressive atrophy and degeneration of the retina.
- ‘ wet ’ – Age related, new blood vessels develop under the retina in the macula and cause sudden distortion or loss of central vision. These patients need to be referred out
macular degeneration, assessment
Assessment –
· If the vision is less than 20/20 – do a pinhole test. If vision corrects with the pinhole this implies uncorrected refractive error.
· With refractive error, fundoscopic exam is usually normal. Yellow spots or drusen spots may be indicative of early macular degeneration. These are in clumps of pigment and irregularly interspaced.
Acute otitis media, which patients absolutely need abx? · Patients who need ABX - o Child <6mo, w/ severe s/s o Child w/ severe AOM o Child <24mo w/ bilat AOM o Any child w/ whom f/u cannot be ensured.
AOM, AAP update guidelines? · AAP update guidelines - o Severe AOM guidelines as - § Prescribe ABX for AOM in children 6mo or older w/ severe s/s § Moderate or severe otalgia for at least 48hr or temp 102.2F (39C)
AOM, what are 1st and 2nd line tx? o Amoxicillin – first line
· AOM and <2yo - 10 days · >2yo - 5-7 days, if severe 7 days.
AOM, Rx for peds w/ tymp tubes Children w/ OM and tympanostomy tubes - · Patients can also utilize topical medications - o Ofloxacin (floxin otic) - 0.3% solution § 6mo to 10yo - 5 drops daily x7 days. o Ciprofloxacin (Ciprodex) - § >6mo - 4 drops daily x7 days.
AOM, complications Complications from OM - · Perforation of TM. · Tympanosclerosis - May lead to conductive hearing loss. · Mastoiditis - Patients with acute mastoiditis present with fever, ear pain, and a protruding auricle. · Meningitis.
OE, abx ear meds Antibiotic ear drops · Ciprofloxacin + hydrocortisone (Cipro HC Otic): >1yo, 3 drops BID x7 days. · Ciprofloxacin 0.3% and dexamethasone 0.1% (Ciprodex Otic): >6mo, 4 drops BID x days.
· Neomycin sulfate3.5 mg, polymyxin b sulfate 10000 units and hydrocortisone 10 mg/mL (Cortisporin Otic): >2yo, 3-4 drops TID or QID x7 days (max of 10 days) · Dexamethasone + tobramycin (TobraDex): >2yo, 1-2 drops q 4-6 hr · Gentamicin ophthalmic (Garamycin, Gentak): >1mo, 1-2 drops q 4 hr · Hydrocortisone and acetic acid (VoSol HC): >3yo, 3-5 drops q 4-6 hr for 24hr, then 3- drops q 6-8 hr · Ofloxacin solution (Floxin Otic): >6mo-13yo, 5 drops once daily x7 days; >13yo, 10 drops once daily x7 days. · Auralgan (benzocaine + antipyrine) is an effective analgesic. · Oral or parenteral antibiotics may be needed for severe cases.
Vertigo, most common cause One of the most common causes of vertigo is benign paroxysmal positional vertigo (BPPV). · BPPV is caused by sediment, such as calcium carbonate crystals, that have become free floating within the inner ear.
vertigo - another common cause ___ Another common cause of vertigo is vestibular neuronitis or labyrinthitis.
· It is thought to be caused by inflammation, secondary to a viral infection, of the vestibular portion of the eighth cranial nerve or of the inner ear balance organs (vestibular labyrinth).
· The patient will usually awaken with room-spinning vertigo that will gradually become less intense over 24 – 48 hours.
· Salt restriction and thiazide diuretics are frequently used as first-line agents.
Allergic Rhinitis, treatment guidelines, mild symptoms Guidelines –
· Mild, intermittent symptoms –
o >12yo, first line treatment is 2nd generation oral antihistamine (OAH) or intranasal antihistamine (INAH).
§ Cetirizine- Only one that causes drowsiness more than placebo. § Fexofenadine § Loratadine § Levocitirizine – most expensive § Desoloratadine
Allergic Rhinitis, treatment guidelines, moderate-severe symptoms · Moderate/severe symptoms - o Initially w/ 2nd generation OAH/INAH as needed, adding intranasal corticosteroid (INCS) to the INAH. § INCS - most effective drug class for allergic rhinitis symptoms, daily dosing. · Budesonide · Fluticasone · Triamcinolone · Ciclesonide · Use after showering and direct spray away from septum to improve deposition on mucosal surface. · Leukotriene receptor antagonists (Montelukast, zafirlukast) are not recommended for initial treatment of allergic rhinitis. Corticosteroid injections are no longer recommended given their side effect profile.
· Sublingual or subcutaneous immunotherapy should be offered to patients who do not respond to pharmacologic therapy.
Sinusitis, major / minor symptoms · Patients may exhibit several of the major symptoms –
o Facial pressure/pain
o Facial congestion/fullness
o Purulent nasal discharge
o Nasal obstruction
· Minor symptoms –
o Headache
o Fever
o Fatigue
o Cough
o Toothache
o Cefdinir 600 mg/day or cefpodoxime 200 mg two times daily or cefuroxime 500 mg two times daily
· Anaphylaxis to PCN – Levofloxacin 750 mg once daily or moxifloxacin 400 mg once daily or doxycycline 100 mg two times daily
Sinusitis, pharm, which ABX typically have resistance? · These medications typically have resistance - o Azithromycin, clarithromycin, TMP/SMX (Bactrim).
Sinusitis, pharm, treatment failure after 3-5 days...what meds do you give? · If treatment failure after 3-5 days –
o Mild or moderate disease:
§ Amoxicillin-clavulanate 2000 mg/125 mg two times daily.
§ or 2nd/3rd generation cephalosporin
- Cefdinir 600 mg/day or cefpodoxime 200 mg two times daily or cefuroxime 500 mg two times daily.
o Severe disease:
§ Levofloxacin 750 mg once daily.
§ or moxifloxacin 400 mg once daily.
sinusitis, when should a patient be referred? · They have three to four infections per year. · An infection that does not respond to two to three-week courses of antibiotics. · Nasal polyps on exam, or any complications of sinusitis.
throat swab, sensitivity and specificity? throat swab testing is sensitive for 90 - 95%, and has a specificity of 90 - 99%.
abx for pharyngitis will reduce incidence of what complications? Antibiotics also reduce the incidence of acute rheumatic fever, peritonsillar and retropharyngeal abscesses.
The Modified Centor Criteria · History of fever: 1 point
· Tonsillar exudates: 1 point
· Tender anterior cervical adenopathy: 1 point
GABHS/strep throat, pharm, first line - Pharm – 1st line are all PCNs
· PCN V – will have narrow spectrum of efficacy, this will decrease possible abx resistance.
o Adult – 500mg PO BID x10 days.
o Children – 250mg PO TID x10 days.
· Amoxicillin – can be option for children d/t ease of administration, as it tastes better. But guidelines still emphasize PCN due to narrow spectrum.
o Adult – 500mg PO BID x10 days.
o Children – 10mg/kg PO TID x10 days.
· Penicillin G (Bicillin L-A) –
o Adult – 1.2 million units IM once.
o Children – <27kg – 600,000 units IM once.
§ >27kg – 1.2 million units IM once.
GABHS/strep throat, pharm, 2nd line - Pharm – 2nd line –
· Cephalexin (Keflex)
· Cefadroxil (Duricef)
If allergic to PCN – macrolides!
· Clindamycin (Cleocin)
· Azithromycin (Zithromax)
· Clarithromycin (Biaxin)
What is the frequency of pharyngitis that would require tonsillectomy? · Seven or more infections in one year (7-1) · Five per year for two years (5-2) · or three per year for three years (3-1-3)
Epiglottitis, degree of swelling, by grade - Degree of swelling of tonsils can be graded 1-4 - · Grade 1 - very mild swelling.
