OSCE Possibilities (1) PDF

OSCE Possibilities Summarized Nose ➔ Rhinosinusitis ◆ Maxillary tooth discomfort, ◆ Purulent rhinorrhea ◆ Facial pain and pressure ◆ hyposomnia , headache, cough, sneezing +/- fever ◆ Acute bacterial rhinosinusitis ● Strep. Pneumoniae, h.influenza (R-) ● >10 days ● Sx ○ Nasal congest...

OSCE Possibilities Summarized Nose ➔ Rhinosinusitis ◆ Maxillary tooth discomfort, ◆ Purulent rhinorrhea ◆ Facial pain and pressure ◆ hyposomnia , headache, cough, sneezing +/- fever ◆ Acute bacterial rhinosinusitis ● Strep. Pneumoniae, h.influenza (R-) ● >10 days ● Sx ○ Nasal congestion ○ Rhinorrhea (nasal discharge) ○ Maxillary tooth pain ○ Facial pain/pressure ○ Headache ○ Coughing/sneezing ○ >10 days, double worsening ● Tx ○ adults→Augmentin 5-7 days (alt. doxycycline) ◆ TOPICAL OXYMETAZOLINE (afrin) ○ Children→10-14 days ○ Saline lavage ○ Pseudoephedrine 10-14 days ○ No antihistamine ◆ Chronic bacterial rhinosinusitis ● >12 weeks ● Risk factor: ○ Smoking and frequent URI, obstruction ● Sx ○ Chronic unproductive cough ○ Sore throat ● Dx ○ CT of the sinuses with IV contrast ● ○ cx Tx: Topical or oral glucocorticoids (triamcinolone) + antibiotics (3-4 weeks and culture directed), + nasal irrigation— 3 steps ➔ Allergic rhinitis ◆ IgE ◆ Risk factors ● Family hx ● Mom smoked ● Allergens ● Asthma, polyps, ◆ Sx ● Sneezing ● Itching ● Post nasal drip ● Congestion ● Headache ● Red teary eyes ● Can be systemic ◆ Physical exam ● Injected conjunctiva ● tearing and allergic “shiners” (dark circles under eyes) ● Pale, boggy, blue nasal mucosa ◆ Tx ● Avoid trigger ● Nasal steroids (Mometasone, fluticasone) ○ Educate that it needs to be taken daily and it takes a couple days of use before improvement Eyes ➔ Conjunctivitis ◆ Viral conjunctivitis ● Adenovirus ● HSV→ nerve pain ● Went to a swimming pool ● Overuse of abx drops ● Sx ● ● ● ○ ○ ○ ○ ○ ○ Potential prodrome Watery Burning, sandy, gritty 2nd eye after 24-48 hours Injected conjunctiva Tears ○ ○ Red conjunctiva +/- injection Fluorescent changes ○ ○ Check visual acuity Chlamydia in newborn? ○ ○ ○ Self limiting Gets worse before better Common cold in eye PE: Dx Tx ◆ Bacterial conjunctivitis→ “pink eye” ● Children ● Sx ○ One eye/ unilateral ○ Stuck shut in morning ○ Yellow and purulent Discharge ○ Conjunctival Injection ● Dx: ○ Cx→ haemophilus for children ◆ Adults→ staph. Aureus ● Tx ○ children → Erythromycin drops ○ Ofloxacin + ciprofloxacin or fluoroquinolones (need g (-) if contacts ○ No steroid drops ◆ Allergic conjunctivitis ● 20 y/o ● Seasonal hay fever ● Sx ● ○ ○ ○ ○ ○ Both eyes/bilateral Red, itch, watery Chemosis Eyelid edema No threat to vision ○ ○ ○ Cool Compress Antihistamine/vasoconstrictor drops→ <2 wks or can cause dry eye PO antihistamine→ Olopatadine (pataday), azelastine, cetirizine, ketotifen (zaditor) Tx ➔ Scleritis ◆ Painful and unilateral ◆ A/w systemic disease ◆ Can have blindness ◆ Need high dose topical corticosteroids →prednisone acetate or difluprednate + NSAIDs ● Needs 1 month taper ◆ Workup: ● Labs: ○ CBC, CMP, U/A ○ CRP and ESR →inflammation (Acute Phase Reactants ) ● Serological assay: HLA-B27, ANCA, ANA RF, RF, Lyme, ACE, RPR ● Imaging ○ Orbital US, CTI, MRI, ○ CXR r/o sarcoidosis, TB, Vasculitis ◆ DDX: ● Uveitis ○ CBc, CMP, U/aA, ESR and CRP ○ HLA-B27 → recurrent anterior uveitis ○ Serology for syphilis ○ CXR→ R/O sarcoidosis and TB ○ synechiae → iris adhesions ○ Slit lamp test ○ Cilliary flush ○ ➔ Cataracts ◆ Risk factors ● >80 y/o ● ● ● ● Poor nutrition Systemic disease Corticosteroid tx Smoking ● ● ● Painless Bilateral vision change Loss of color ● ● Non dilated fundus Dark red reflex ● Extraction + lens replacement ◆ Sx ◆ PE ◆ Tx ➔ Orbital cellulitis ◆ eye muscles and fat around eye ◆ Pediatric ◆ Hx of surgery ◆ Usually from underlying sinus infxn ◆ sx ● Pain w/movement of eye ● Ptosis ● Double vision (diplopia) ● Fever ◆ Dx ● CT/ MRI w/ contrast if: ○ Labs: ◆ Elevated WBC, ANC ○ Signs and Sxs of CNS involvement ○ No improvement within 24 to 48 hours of initiating appropriate therapy ● cx ◆ Treatment ● Must be refer to ophthalmologist ● IV Vancomycin + IV Ceftriaxone or IV Cefotaxime (2 step) → 2-4wks ● IV Vanco + 3rd gen cephalosporin + metronidazole for anaerobic coverage ● PCN allergic → Vanco + metronidazole (anaerobic coverage) + levofloxacin ➔ Periorbital cellulitis ◆ Pain without moving eye ◆ Unilateral ◆ Treatment: ● Outpatient ○ Amoxicillin-clavulanic acid (Augmentin) ○ Augmentin or 2-3 cephalosporin + bactrim for skin infxn ➔ Vertigo ◆ Older woman ◆ Less severe over time ◆ Sx ● Lightheaded ● Near fainting ● Poor balance ● N/V ◆ Hx ● Alcohol ● Aminoglycosides ● Anticonvulsants ◆ PE ● Orthostatic bp ● Pulse ● Neuro ◆ Dx ● Dix-hallpike ● Head impulse test ● MRI for all inner ear ◆ Tx ● Epley maneuver (maybe curative BPPV) ➔ Glaucoma ◆ Angle-closure glaucoma→ think blockage and blurred vision ● Increased age ● Asian/inuit ● ● ● ● Pupillary dilation Sx ○ Blurred vision ○ Red eye ○ Cupping ○ N/V ○ Headache ○ Painful Dx ○ Dilated pupil that doesn’t react to light ○ Red conjunctiva ○ Ciliary flush→ halos around light ○ Hazy cornea “steamy” ○ High IOP (measure w/ tonometer) Tx ○ Referral to ophthalmology ○ Topical beta blocker (timolol + betaxolol) + carbonic anhydrase inhibitor (acetazolamide) ◆ Open-angle glaucoma ● African american, 60+ ● Sx ○ Asymptomatic ● Dimmed/blurred vision ● PE ○ Cupping ○ Thin cornea ● Tx ○ IOP lowering ○ Prostaglandins (Latanoprost or bimatoprost) drops ○ Topical beta blocker ○ Laser therapy ● ➔ Diabetic retinopathy ◆ Sx ● Floaters ● Blurry vision ● Dark streaks/red film ● Poor night vision ◆ Non proliferative ● Microaneurysms ● Hard exudates ● Retinal/macular edema ● ◆ Proliferative ● Neovascularization– abnormal vessel growth ● Cotton wool spots ● ◆ Tx ● ● Control bp, sugars, lipids VEGF injections ➔ Macular degeneration ◆ >65 white females ◆ Atrophic/dry ● Sx ○ Gradual, Progressive ○ Blurred central vision ● ● Dx: ○ ○ Amsler grid test→ straight lines are wavy Otoscopy→ drusen → refractile glittering particle ○ ○ ○ STOP SMOKING Add mediterranean diet and antioxidants Visual assist devices Tx ● ◆ Neovascular/wet ● accumulation of serous fluid ● ● ● Sx ○ ○ Rapid and Severe Central blind spot ○ Intraocular injection of antagonists to vascular endothelial growth factor (VEGF) ◆ Bevacizumab, Ranibizumab, Aflibercept, or Faricimab ◆ Once a month for 3-6 months Tx ○ Ears hint when in doubt ciprofloxacin or ofloxacin for treatment ➔ Otitis externa (Swimmer’s ear) ◆ PE ● Erythema and edema ● Exudate ● Pain when touching outer ear ● Swollen canal ◆ Tx ● Mild (minor discomfort) ○ Clean canal ○ Petroleum jelly + cotton ball ○ NSAIDS ○ Acetic acid-hydrocortisone drops ● Moderate (partially blocked canal, discomfort) ○ Topical antibiotic (g (-)) + Acidifying agent + Glucocorticoid → 7-14 days ● Severe (Completely blocked canal, fever, red outer ear) ○ Topical antibiotic (g (-)) + Acidifying agent + Glucocorticoid → 7-14 days ● ● Beyond auditory canal → topical + PO fluoroquinolone (cipro or orfloxacin) for 7-10 days Does not improve w/in 48 hrs→ referral to ENT +/- cx of ear canal ➔ Malignant otitis externa ◆ diabetic , elderly HIV ◆ Disproportionate pain (triagus) ◆ Granulation tissue on floor of osseocartilaginous junction ◆ Facial palsy secondary to affected innervation of segments of the facial nerve (V) ◆ CT or technetium Tc 99 bone scanning → osseous erosion ◆ IV ciprofloxacin or PO (select patients) ➔ Acute otitis media ◆ After viral URI ◆ Most common 6-24 months ◆ Sx ● Otalgia ● Decreased hearing ● ● Fever Feeding difficulties and irritability (infants) ◆ PE ● Erythema ● Decreased TM mobility ● TM outward bulging ● Pain relief after otorrhea (ear drainage) ● All children→ Conductive hearing loss ◆ Dx = clinical ● 3 criteria ○ acute onset ○ middle ear effusion (bulging drum, lack of movement on otoscopy, flat tympanogram) ○ inflammation-red TM, pain, and fever ◆ Tx ● Pediatric ○ No decongestant ○ 10 days Amoxicillin 80-90 mg/kg/day in 2 or 3 divided doses for severe cases, immunocompromised ◆ Augmentin if previous abx + purulent → chronic ◆ Cephalosporin if allergic ◆ Azithro if anaphylactic ○ Mild AOM = joint decision making with parents ● Adult ○ First line → Amoxicillin-clavulanate (augmentin) ○ Allergy→ 2nd or 3rd gen cephalosporin ○ severe penicillin allergy→ Doxycycline ➔ Chronic suppurative otitis media ◆ TM perforation ◆ Purulent discharge ◆ Conductive hearing loss ◆ RO AOM or trauma ◆ Treatment ● Topical ABX drops (oflaxacin 0.3% or cipro with dexamethasone) ● Cipro may resolve drainage x 1-6 wks ● Definitive TX- surgical repair ➔ Serous otitis media ◆ Mostly children ◆ If adult: ● Due to ○ URI ○ Barotrauma ○ Allergic rhinitis ◆ Sx ● Hearing difficulties ● Tugging at ear ● Bad balance ● Delayed speech ◆ Dx ● Otoscopy ○ Middle ear fluid w/o bulging ○ TM = dull and hypermobile ● Conductive hearing loss ◆ Tx ● Children ○ Spontaneous resolve ○ Recurring = tympanostomy tubes ● Adults ○ Resolve w/in 12 months ○ Allergic sx relief: ◆ Antihistamines ◆ Decongestant ◆ Nasal corticosteroids ➔ Sensorium→ acoustic neuroma or tinnitus , meiners ◆ ○ ➔ Mouth ➔ Oral candidiasis ◆ Infants and neonates ◆ Patients on abx or steroids ◆ Endocrine disorders ◆ HIV ● Sx ● ● ○ ○ ○ ○ ○ Oral and throat pain Difficulty swallowing Loss of taste Scrape white plaque Erythematous gingiva ○ ○ KOH prep HIV testing ○ Mild ◆ Topical clotrimazole - lozenge 5x/day for 14 days ◆ Miconazole ◆ Nystatin Moderate/severe ◆ Fluconazole - 100 mg daily for two weeks Dx Tx ○ Throat ➔ Bacterial pharyngitis ◆ Risk factors ● Hx of URI ● Smoking ● Exposure to group A strep ◆ Presentation ● Kids 4-7 years ● Sudden onset ◆ Sx ● Centor criteria ○ Fever ○ Absence of cough ○ Swelling of anterior lymph nodes ○ Tonsillar exudates ○ Strawberry tongue ◆ Dx ● Throat culture ◆ Tx– 10 days ● Child ● ◆ DDX ● ● ● ● ● ○ ○ Adult ○ ○ Pen VK 250 mg po bid-tid x 10 days Amoxicillin 50mg/kg q day for 10 days Pen VK 500 mg po bid x 10 days Amoxicillin 500mg BID or 1g daily x 10 days HIV Mono Chlamydia/gonorrhea Diphtheria Flu/COVID Oral Presentation 1. Opening statement 2. History a. HPI b. ROS c. Med, allergies d. PMH e. FH f. SocialH 3. Vitals/physical exam 4. Labs 5. Summary statement 6. Assessment and plan