Acute rhinosinusitis (ARS)
inflammation of the mucosal lining of the nasal/paranasal sinuses lasting up to 4 weeks
primarily c/b viruses, can also be c/b bacteria or fungi
Acute bacterial rhinosinusitis
Secondary bacterial infection of the paranasal sinuses, usually following viral URI
Clinical pearls of sinusitis - patho, s/s, diagnostics, common pathogens, treatment, complications
- patho - undrained collection of pus in sinuses
- s/s - headache when bending over
- diagnostics - typically clinical diagnosis, can do CT
- Pathogens - strep pneumonia, consider Pseudomonas in vent patients, H. influenza in smokers
Treatment- Augmentin, if PCN allergy doxycycline (Pregnancy category D)
Complications - orbital cellulitis, osteomyelitis, sinus thrombosis
causative pathogens in ABRS
s. pneumoniae - gram + (most common)
h. influenzae - gram - (recurrent infection, tobacco users)
m. catarrhalis - gram - (uncommon)
initial empiric therapy for ABRS
first-line - amoxicillin-clavulanate (augmentin)
second line - doxycycline (pregnancy category D) levofloxacin, or moxifloxacin
Patients on vent - imipenem or meropenem
risk for MRSA - vancomycin
conjunctivitis etiology/patho
inflammation of the conjunctiva c/b bacteria, viruses, or allergies
no matter the cause there is a high risk of bacterial infection secondary to the fragility of the conjunctiva
- always treat with antibiotics, always remove contacts
conjunctivitis s/s
common symptoms - pruritis, foreign body sensation, “gritty eye”
type of discharge based on infection type
- if a patient presents w/ pain - its not conjunctivitis
conjunctivitis physical exam findings
conjunctiva erythema, injection, ocular discharge
viral conjunctivitis - diagnosis and treatment
- unilateral or bilateral (typically seen first unilaterally, then spread bilaterally)
- treatment - consider abx, artificial tears, topical antihistamine, cold compress
- d/c contact use
bacterial conjunctivitis - diagnosis and treatment
- typically will start unilaterally (maybe spread bilaterally by the patient)
- purulent discharge - gonococcal/chlamydial, eyelid edema, corneal infiltrates/ulcerations
- antibiotics - gentamicin drops, Cipro (ointment or drops), azithromycin drops
- gonococcal or chlamydial - refer to optho, ceftriaxone + azithromycin
- d/c contact use
allergic rhinitis - diagnosis and treatment
- typical during high allergy season
- unilateral, stringy discharge
- decongestants, antihistamines (oral or topical), cold compress
- d/c contact use
common causes of corneal abrasion
scratch, flying debris, dry eyes, iatrogenic
corneal abrasion symptoms
gradual throbbing pain, intensifies over 12-24 hrs, sensation of foreign body
corneal abrasion physical findings
erythema, tearing, interrupted endothelial surface on fluorescein stain
corneal abrasion diagnosis
fluorescein stain
clinical diagnosis
orbital CT or MRI if high-velocity injury or retained foreign body suspected
treatment of corneal abrasion
initial anesthesia of the eye - tetracaine
topical NSAID drops - diclofenac, ketoralac
topical antibiotics - bacitracin, chloramphenicol, cipro
if the patient wears contacts cover for Pseudomonas (cipro)
oral opiates
tetanus - if penetrating injury
refer to optho if no improvement in 48hrs
cause/risk factors of chronic (wide or open-angle) glaucoma
elevated pressure in the trabecular meshwork reduces flow –> gradual rise in pressure
risk factors - age, extreme near sighted ness, diabetes, and ethnicity (AA)
s/s of chronic glaucoma
gradual, painless, loss of peripheral vision
usually asymptomatic and discovered upon routine exam
rarely symptomatic, but may present with ocular discomfort (burning, stinging, soreness), halos, and blurry vision
PH findings for chronic glaucoma
elevated IOP (not as high as acute)
gross PE - may appear normal, abnormalities of specific structures may be visible to optho
chronic glaucoma treatment
ophthalmic medications to reduce pressure by either improving flow or reducing the production of aqueous humor
- prostaglandin analogs (Xlantin) or beta-adrenergic antagonists (1st line)
- systemic abs is v. high
- refer to optho
Acute (narrow or closed-angle) glaucoma cause
variety of anatomic abnormalities (including narrow angle) resulting in reduced flow of aqueous humor
acute blockage of flow produces acute pressure elevations
acute glaucoma s/s
severe ocular pain
sudden vision loss
pain with eye movement
ipsilateral HA
blurry vision
“halos” around objects **
N/V
acute glaucoma physical exam findings
decreased visual acuity
corneal and scleral injection
ciliary flush
edematous and cloudy cornea
mid-dilated nonreactive pupil
firm globe
IOP elevated (normal 10-20)
acute glaucoma treatment
treat as emergency
systemic carbonic anhydrase inhibitors - acetazolamide (diamox)
topical BB (quick to reduce IOP)
laser peripheral iridectomy
refer to optho
- watch for Na+ abnormalities and metabolic acidosis
