HEENT EMERGENCIES CONTINUED Name Cause Signs/Symptoms Battle Sign Trauma Raccoon eyes (periorbital ecchy mosis) and bruising behind the ear (mastoid area) that appears 2-3 days after trauma. Search for clear golden serous discharge from ear or nose. Clear Golden Fluid Discharge from Nose/Ear Basilar skull fracture Clear golden fluid discharge from nose/ear Diagnostics Rule out basilar or temporal bone skull fracture. Test fluid with urine dipstick – positive for glucose (plain mucous or mucopurulent drainage is negative) Treatments Basilar skull fractures can cause intracranial hemorrhage. Refer to ED Refer to ED Severe sore throat with difficulty swallowing, odynophagia (pain on swallowing) and a 30 is very high) Betimol 0.5% - ³ aqueous production (beta/alpha blockers) Latanoprost – topical prostaglandin SE of med: bronchospasm, fatigue, depression, heart failure, bradycardia Contraindicated asthma, COPD, heart failure Most common glaucoma. Blindness due to ischemic damage to retina. 2 nd leading cause of blindness Risk factors: postural hypotension, hx of fungal conjunctivitis, white race Macular degeneration gradual damage to pigment of macula (area of central vision) results in severe visual loss to blindness Asymptomatic in the early stages. Complains of gradual or sudden and painless loss of central vision in one or both eyes. Straight lines become distorted or curved (scotoma). More common in smokers Refer to ophthalmologist. Pt is given Amsler grid to check vision loss daily to weekly Atrophic (dry form) or exudative (wet form) – wet is responsible for 80% Most common cause of vision loss. Leading cause of blindness in elderly Risk factors: age, smoking Sjogren’s Syndrome Chronic autoimmune disorder Decreased function of lacrimal and salivary glands. Persistent daily dry eyes and mouth (xerostomia) for > 3 months. Eyes have sandy or gritty sensation. Uses OTC artificial tears TID OTC tear substitute TID Refer to ophthalmology, dentist and rheumatology HEENT Name Cause Blepharitis Inflammation of eyelids associated with seborrheic dermatitis and rosacea Allergic conjunctivitis IgE mediated response Suppurative conjunctivitis Pseudomonas aeruginosa Allergic rhinitis IgE mediated disease due to genetic and environmental interactions 2 screen for strep Non-severe: mild otalgia < 48hrs. or fever <102.2 in past 24 hours Severe: moderate/severe otalgia, otalgia > 48 hrs. or fever > 102.2 HPI- bacterial Persistent and not improving (>10days); fever Severe > 3-4 days Worsening or double sickening transillumination First line: Remove or avoid allergen. · Intranasal corticosteroids (down regulates inflammatory response) takes 2-7 days · Add Astelin. · Cromolyn sodium TID – mast cell stabilizer · Use decongestants – nasalcongestion · Oral antihistamines (block H1) – itch Direct pressure. Nasal decongestants (Afrin oxymetazoline) – silver nitrate (ouch) Apply triple antibiotic ointment or petroleum jelly in front of nose with cotton swabs for a few days. PCN V 500 BID-TID x 10 days Amoxicillin 500 BID x 10 days PCN allergic : Zpak x 5 days Ibuprofen/Tylenol Salt water gargles, throat lozenges, drink fluids If H. influenza - Augmentin or cephalosporin If M. pneumoniae – macrolide or fluoroquinolone Non-severe – watchful waiting; Treat with amoxicillin 80-90 mg, if recent ab x then Cefdinir followed by Augmentin. (< 2 yrs. 10 days, 2-6= 7 days, >6 = 5-7 days) if pt. has mono do not give Amoxicillin – will have morbilliform rash; tympanic membrane rupture with hearing loss – Refer to ENT Symptomatic tx: Saline nasal irrigation, intranasal corticosteroids, decongestants, mucolytics First line: Augmentin 875/125 or 1000/62.5 or 2000/125 BID 5-7 days : Allergy to PC N/Cephalosporin Doxycycline 100mg BID or Levofloxacin 500mg daily or Moxifloxacin 400mg daily; Cefdinir, Ceftin, Vantin BID 5-7 days Concerns Seborrheic dermatitis – inflammatory Malassezia, respond to antifungals, worse in winter Medications normally sting the eye temporarily Adenovirus is most common cause of viral conjunctivitis Avoid 1st generation antihistamines due to sedation (chlorphenira mine, diphenhydra mine, carbinoxamine, brompheniramine) Posterior nasal bleeds can lead to severe hemorrhage Viral if cough, rhinorrhea, coryza (watery eyes). If not treated can cause rheumatic fever – rash is increased risk Post-strep glomerulonephritis – proteinuria, hematuria, dk urine, RBC cast, HTN edema Bullous myringitis – blisters on red and bulging TM. Conductive hearing loss. Tx same as AOM. Expect sensation of ear fullness up to 8 weeks Watchful waiting: 10 days No macrolides Treatment 5-7 days = efficacy, fewer complications, better compliance HEENT Name Otitis Externa Cause Pseudomonas aeruginosa S. aureus Proteus spp. Enterobacteriaceae Mononucleosis EBV (incubation is 30-50 days) Aphthous stomatitis unknown Geographic tongue Benign physiological variant Leukoplakia Meniere’s disease Signs/Symptoms External ear pain, swelling, discharge, pruritus and hearing loss. Hx of recent activities that involve swimming or getting the ear wet. Ear pain with manipulation of external ear or tragus. Purulent green discharge. Erythematous ear canal Malaise and fatigue, Fever, pharyngitis, lymphadenopathy. Hx of sore throat, enlarged posterior cervical nodes and fatigue for several weeks. May have abdominal pain. Virus is shed through saliva 50% have splenomegaly (normal spleen is 1 x 3 x 5, weighs 7 oz and lies between 9 and 11 ribs) Diagnostics Physical exam, if malignant consider CT, radionucleotide bone scan, gallium scan, MRI Polymyxin B-neomycin-hydrocortisone suspension (Corticosporin Otic) 4 gtts QID x 7 days; Ofloxacin otic or Ciprofloxacin otic ear drops BID x 7 days. Keep water out of ear. (No steroids if eardrum ruptured) CBC: atypical lymphocytes and lymphocytosis; LFT: abnormal for several weeks; Heterophile antibody test: Monospot +; Large cervical nodes; Erythematous pharynx with inflamed, sometimes white exudate; Hepatomegaly and splenomegaly; red maculopapular rash Limit physical activity for 4 weeks. Abd US is splenomegaly/hepatomegaly. Repeat US in 4 to 6 weeks. Avoid amoxicillin. Avoid close contact, kissing, sharing utensils. If airway obstruction, hospitalize with high dose steroids Painful shallow ulcers on soft tissue of mouth that usually heal within 7-10 days Increased pressure within endolymphatic system Concerns Preventative: Domeboro (boric) or alcohol and vinegar Peak ages 15-24 3F ’s and an L Fever, Fatigue, Pharyngitis and Lymp hadenopathy Magic mouthwash – liquid diphenhydramine, viscous lidocaine and glucocorticosteroid Aphthous ulcer – canker sore Poor fitting dentures, chewing tobacco, alcohol abuse Treatments Multiple fissures and irregular smooth areas looking like a topographic map. May have soreness after eating or drinking acidic or hot foods Slow growing white plaque with firm to hard surface, slightly raised on tongue, floor of mouth or inside cheek Precancerous lesion Present with episodes of vertigo with a sensation that the room is whirling about – preceded by decreased hearing, tinnitus and feelings of increased pressure. Characterized by repeat attacks that last minutes to hours and can be related to food and drinks, mental and physical stress and variations in menstrual cycle Largely diagnosis of exclusion. Horizontal nystagmus usually towards the affected ear with rapid correction to midline. Weber lateralizes to unaffected ear. Rinne’s AC>BC; performing pneumatic otoscopy in affected ear can elicit symptoms. Romberg + Fukuda marching step test is positive with drift towards affected ear. Dix-Hall Pike is occasionally also positive indicating BPPV refer Antihistamines such as meclizine, antiemetics or benzodiazepines can minimize symptoms, thiazide diuretics can decrease pressure load in ear and prevent but nottreat attacks. Corticosteroids have also been demonstrated to be helpful Prevention: avoid ototoxic drugs, protecting ears from loud noise and limiting sodium intake Risk factors include: use of ototoxic drugs such as aminoglycosides, longterm high dose salicylate use, certain cancer drugs and long-time exposure to loud noise. Can also have Meniere’s symptoms with certain situations but not the disease SKIN/INTEGUMENTARY SYSTEM DERMATOLOGY ASSESSMENT TIP ➢ Assess the entire patient, not simply the skin problem. Consider whether there is transmission/contagion risk. ➢ Where did it start? (face, torso, extremities, genitals) ➢ How long have you had it? ➢ Does it itch? ➢ Is the patient otherwise well? o Disease limited to skin such as rosacea, keratosis pilaris, seborrheic dermatitis. ➢ Is the patient miserable, but not systemically ill? o Itch, burning, pain – scabies or shingles ➢ Is the patient systemically ill with constitutional symptoms (fever, fatigue, loss of appetite, unintended weight loss, malaise)? o Varicella, transepidermal necrosis, Lyme disease, systemic lupus erythematosus ➢ Primary lesions only? Primary and Secondary? o Where is oldest lesion - when did it occur? o Where is newest lesion – when did it occur? o Primary – result from disease process, has not been altered by outside manipulation or tx ▪ Ex: vesicle – fluid filled < 1 cm (varicella, shingles, herpes) o Secondary – lesion altered by tx or progression of disease ▪ Ex: Crust – raised lesion caused by dried serum and blood remnants, develops when vesicle ruptures SMALLPOX ➢ 1cm w/fluid (burn) ➢ Clustered - lesion occurring in a group without pattern (herpes) ➢ Confluent or Coalescent- multiple lesions blending together (psoriasis vulgaris) ➢ Cyst – raised, encapsulated fluid filled lesion (intradermal lesion) ➢ Lichenification – skin thickening usually found over pruritic or friction areas ➢ Linear - lesion distribution in streaks (poison ivy) ➢ Macule – flat non-palpable are of discoloration <1cm (freckle) ➢ Maculopapular – both color and small papules or raised skin lesions ranging from erythematous to bright pink ➢ Nodule – solid lesion > 0.5 – 2 cm (> 2 cm tumor) ➢ Papule – solid elevation <0.5 cm (mole) o Smooth papule dome shaped with central umbilication with white plug (molluscum contagiosum) ➢ Patch – flat, nonpalpable area of skin discoloration larger than macule (vitiligo) ➢ Petechiae – < 1cm (thrombocytopenia) ➢ Plaque – elevated, variable shape >1cm (psoriasis) ➢ Purpura – flat, red-purple discoloration that does not blanch with pressure ➢ Pustule – vesicle like lesion with purulent content (impetigo) ➢ Reticular – netlike cluster ➢ Scale – raised superficial lesions that flake with ease (dandruff) ➢ Scattered – generalized over body without specific pattern (viral exanthem – rubella/roseola) ➢ Vesicle – clear fluid (herpes) ➢ Wheal – circumscribed area of skin edema (urticaria) SKIN CANCER ASSESSMENT A – Asymmetry B – Border irregularity C – Color (brown, black, red, white, blue) D – Diameter >6mm (pencil eraser) E – Evolving/Elevated (most are new) ➢ > 2 features ABCDE 100% sensitive, 98% specific ➢ Melanoma: dark colored moles with uneven textures – may be pruritic ➢ Acral lentiginous melanoma: most common in AA/Asian. Nailbeds, palms/feet ➢ Subungual hematoma: direct trauma to nailbed causing bleeding between bed and finger – trephination – draining the nailbed ➢ PRESSURE ULCER Stage I: nonblanchable erythema on intact skin ➢ Stage 2: presence of epidermal or dermal skin loss; can appear as intact blister ➢ Stage 3: full-thickness skin loss with exposure of some amount of fat, ulcer has crater-like appearance ➢ Stage 4: full-thickness skin and tissue loss; would exposes muscle, bone and tendons SKIN/INTEGUMENTARY SYSTEM • • • • • • • • • • Potency class 7 (low) to 1 (high) Non-folded trunk and extremities o Triamcinolone 0.1% o Face and body folds – Desonide or hydrocortisone o Palms/soles –fluocinolone or clobetasol Lotions < creams < gels < ointments Creams absorb well and lack greasy texture (sting if open wound) Ointments contain emollient (pounding form of absorption) Lotions water based and spread easily (most gentle) Face greatest rate of absorption, then axilla and genitals 2gm hands, head, face, anogenital 3gm arm, anterior or posterior trunk 30-60gm of topical cream for entire body ➢ 1st degree – reddened easily blanched with gentle pressure ➢ 2nd degree (partial thickness) – red, moist with peeling borders and scattered bulla (Silvadene or polysporin) ➢ 3rd degree (full thickness) – thickened, hypopigmented tissue ➢ Refer o Face, hands, feet, genitals, major joints o Electrical burns, lightning burns o Partial thickness > 10% BSA o 3rd degree any age o Circumferential ➢ P. aeruginosa, E. coli, K. pneumoniae SKIN/INTEGUMENTARY SYSTEM o o o o o o o o o o o o o o o o SKIN FINDINGS WOUNDS Fifth disease – maculopapular rash in lace-like pattern Varicella, zoster, herpes simplex – maculopapular rashes with papules, vesicles and crust (vesicular rash on erythematous base) Pityriasis rosea – maculopapular rashes that are oval shaped with a herald patch (Christmas tree) Seborrheic Keratosis – soft, wart-like growth on trunk ranging from light brown-black; pasted on appearance Xanthelasmas – raised, yellowish plaques under brow or lids. Sign of high lipids Melasma – pregnancy mask. On upper cheeks and forehead Vitiligo – hypopigmented patches of skin w/ irregular shapes Cherry angioma – benign small papules bright cherry red in color, always blanch with pressure Lipoma – fatty cystic tumors of subcutaneous layer on neck, trunk, legs, arms Nevi (moles) – round macules/papules varying in color and size – benign Xerosis – inherited extremely dry skin of mouth and eye Acanthosis Nigrans – velvety thickening of skin behind neck/axilla; associated with DM, metabolic syndrome, obesity, and GI cancer tract Acrochordon – skin tags. Painless pedunculated outgrowths of skin are the same color. Candida – bright-red with satellite lesions Intertrigo – bright-red diffused rash due to bacterial infection Acral – on extremities ➢ Factors that impair wound healing o Older age, poor nutrition, impaired immune system, impaired mobility, stress, diabetes, medications (impair clot formation and steroids), pressure loading, smoking, secondary bacterial infection ➢ Primary healing – wound closed within 24 hours by suturing, tissue glue or butterfly strips ➢ Secondary healing – would is left open and heals from bottom up ➢ Tertiary intervention – wounds with heavy contamination or poor vascularity (crush injuries) are best left open to heal by secondary intention. ➢ Referral – infected wounds, closed-fist injury, facial wounds with risk of cosmetic damage, foreign body or embedded object, injury to joint capsule, electrical injuries, paint-gun or high-pressure wounds, chemical wounds, child abuse ➢ Do not suture wounds > 24 hours - ± infection risk > 12 hrs. ➢ Tdap if last tetanus was > 5 yrs. ➢ Suture removal o Face: 5-7 days o Scalp: 7-10 days o Upper extremities: 7-10 days o Lower extremities: 10-14 days RANDOM FACTS o o o o Bed bugs: do not infect the patient Squamous cell carcinoma: sun exposed areas, lower lip common in smokers • Presents as papule, plaque, nodules, smooth, hyperkeratotic or ulcerative lesion • May bleed easily • Definitive diagnosis is biopsy or excision of specimen – moles procedure? ▪ N - nodular ▪ O - opaque ▪ S – sun-exposed ▪ U - ulcerating ▪ N – nondistinctive borders Irritant contact dermatitis – contaminated water, soaps and detergents, fiberglass, particulate dust, food products, cleaning agents, lubricants, oils, coolants, solvents, plastics, resins, petroleum products Allergic contact dermatitis – poison ivy, rubber, nickel, fragrances LICHEN PLANUS ➢ Small, flat red to purple bums with white scales ➢ Itch – common on wrist, forearms, ankles ➢ Common causes include Hepatitis C – self-limiting ODE TO MRSA ➢ ABCD o o o o MRSA Bactrim Clindamycin Doxycycline SKIN/INTEGUMENTARY SYSTEM Name Rocky Mountain Spotted Fever Cause Dog/Wood Tick bite Rickettsia rickettsii Signs/Symptoms high fever, chills, severe headache, n/v, photophobia, myalgia, conjunctival injection, arthralgia; 2-5 days after onset - rash (petechiae) starts on han ds/feet to trunk (palmar rash) Diagnostics Treatments Concerns Antibody titers to rickettsia Punch biopsy CBC, LFT, CSF Doxycycline 100mg BID for 7-14 days – can be fatal if not started on treatment within 8 days. Remo ve tick by grasping closest to skin and apply steady up ward pressure. Can be fatal (3-9%) Highest in southeastern/south central regions of US Most common Apr - Sept Fever, chills, nausea and vomiting. Red, white and blue sign; central blistering with surrounding gray to purple discoloration at bite surrounded by blanched skin surrounded by large areas of redness Brown recluse spider bite Erythema Migrans (Lyme disease) Borrelia burgdorferi (tick) Expanded red rash with central clearing (bullseye), feels hot to touch and rough texture; common areas belt line, axilla, popliteal, groin FLU-LIKE symptoms Rash appears 7-14 days after deer tick bite Spontaneously resolves Enzyme immunoassay (EIA) Indirect immunofluorescence assay (IFA) Meningococcemia Neisseria Meningitides Gm – diplococci Spread via respiratory sudden onset of sore throat, cough, fever, headache, stiff neck, photophobia, and changes in LOC abrupt onset of petechial to hemorrhagic rashes Lumbar puncture: CSF Blood/throat cultures CT or MRI of brain Varicella / Zoster Herpes-zoster (Chickenpox or Shingles) – spread by direct contact or inhalation Malignant Melanoma Basal Cell Carcinoma Most common skin cancer A – Asymmetry B – Border irregularity C – Color (brown, black, red, white, blue) D – Diameter >6mm (pencil eraser) E – Evolving/Elevated (most are new) May be pruritic Waxy, pearly domed nodule, usually distinct borders with or without telangiectasia; white, light pink, brown or flesh colored. Papule, nodule with or without central erosion PUT ON (Pearly papule, Ulcerating, Telangiectasia, On the face, scalp, pinnae, Nodules, slow growing Slow-growing; Scaling, dry, round, flesh-colored lesions on skin that do not heal; usually sunexposed areas; sizes range from microscopic to several centimeters Actinic Keratosis Erythema Multiforme (Stevens-Johnson syndrome) Chickenpox: Fever, pharyngitis, malaise Pruritic vesicular lesions beginning at head expanding to trunk (vesicles and crust) – most common on thorax Shingles: lesions at various stages along dermatome Contagious 1-2 days before rash until cru sted Rare reaction to medications (NSAIDs, Sulfa, antiepileptic), infection (herpes or Mycoplasma pneumoniae) and malignancies Lesions like 60 Tzanck smear confirms shingles Varicella: Acyclovir within 24-48 hrs. of eruption (avoid ASA and NSAI Ds) Acyclovir or Valacyclovir x 10d for initial outbreak and then x 7 days for flare-ups Post herpetic neuralgia: TCA, anticonvulsant, gabapentin, lidocaine or capsaicin cream to intact skin Herpes zoster ophthalmicus (corneal blindness) CN V photophobia, eye pain, blurred vision Needs biopsy by derm. Refer to Dermatology Acral Lentiginous Melanoma – African American and Asians, located on nail beds, palmar and plantar surfaces Risk factors, family hx of melanoma, sun exposure, tanning beds, lots of nevus, light skin/eyes Risk factors: light-colored skin, Australian decent, sunexposed area Clinical diagnosis Metastatic risk low, significant tissue destruction risk without treatment. Slow growing – common in fair skin types Excisional biopsy fluorouracil cream (5FU cream); 5% imiquimod cream, topical diclofenac gel Liquid nitrogen, laser resurfacing or chemical peel Gold standard: refer to derm for biopsy Pre-cancerous Precursor to squamous cell carcinoma Toxic Epidermal Necrolysis (TEN) (>30% of skin) allopurinol, anticonvulsants, sulfa, NSAIDs SKIN/INTEGUMENTARY SYSTEM Name Cause Psoriasis Inherited; excessive mitotic grown of epithelial cells Tinea Versicolor Yeast - Pityrosporum orbiculare or Pityrosporum ovale. Atopic Dermatitis (Eczema) Acute cellulitis Cutaneous abscess, furuncle, carbuncle Inherited pruritic rash Signs/Symptoms Erythematous papules and plaques 5yrs **Good follow-up; 48 hrs. after initial tx. I & D and warm soaks Bactrim, Doxycycline or clindamycin MSSA: Dicloxacillin or Cephalexin Formation of fissures and risk of infection Triad – allergies, eczema, asthma Refer if s/s don’t resolve, cellulitis not responding to tx, spreading quickly, DM, immunocompromised Osteomyelitis, sepsis Bactroban for folliculitis Non-purulent: Keflex or dicloxacillin Hospitalization for infants, immunocompromised Sudden onset one hot, indurated, erythema with clear demarcation. Usually on lower legs or cheeks Human bite dirtiest of all Cats higher risk of infection than dogs Rabies: skunks, raccoons, foxes, coyotes: Immune glob ulin and vaccine Quarantine domestic animals for up to 10d Wound C&S Augmen tin 875mg x 10d (PC N allergic: doxycycline or Bactrim + Flagyl or clindamycin) Clean, no sutures, tetanus Follo w-up 24-48 hours Watch for closed-fist injury (infection of the joints) 80% cat bites become infected Acute onset painful, large, red nodules and papules under one or both axilla that become abscessed C & S of drainage Mild: Chlorhexidin e; Clindamycin 1% for 12 weeks; Tetracycline 500 BID; doxycycline or minocycline BID for 7-10 days Recurrences and scars Nonbullous – erythematous macule evolves into pustule ruptures leavin g honey crusted exudate . Bullous – clear, yello w fluid ruptures within 1-3 days leaving a rim of red with moist base (scalded appearance) - deep ulcerated=ecthyma Contagious and pruritic: worse in warm weather C & S of crusts/wounds Nonbullous - mupirocin ointment 2% X 10d (treats select gram + organisms) Cephalexin or dicloxacillin QID x 10d Azithro mycin if PCN allergic 250 x 5d or clindamycin X 10d No school until 48-72 hours after treatment initiation SKIN/INTEGUMENTARY SYSTEM Name Cause Herpetic whitlow HSV 1 or 2 Painful blistering on side of finger or cuticle Direct contact with cold sore or genital herpes Analgesic or NSAIDs Acyclovir for severe infections Avoid sharing personal items, gloves, towels. Cover skin lesion until healed Pityriasis Rosea Unknown may be viral Oval plaque with central salmon-colored area and dark red peripheral zone on anterior trunk. Fine scales following skin lines: 5 cysts Small acne-like papules and pustules around nose, mouth and chin. Patient blushes easily and ocular symptoms (dry eyes) Patient usually blonde, blue eyes