Emergency Medicine Q & A, 2009, Pg

Emergency Medicine Q & A, 2009, Pg


DisciplinaMedicina9.770 materiais29.919 seguidores
Pré-visualização50 páginas
created within
the middle ear because the diver could not \u201cequalize\u201d to ambient pressure, leading to pain. If equilibration of
middle ear pressure does not occur, the \ufb02oppy medial third of the Eustachian tube collapses shut, making any
further attempts at equalization futile. Further pressure increases can cause the TM to rupture.
CHAPTER 7
Head, Eye, Ear, Nose,
and Throat Emergencies
Stephanie Barbetta, MD, and
Scott H. Plantz, MD, FAAEM
1. A 78-year-old woman complains of a new rash on the left side of her face. The dermatomal distribution is
consistent with herpes zoster ophthalmicus (HZO). You should:
a. Prescribe the oral antiviral acyclovir 800 mg 5 times/d for 7 days.
b. Prescribe oral antiviral acyclovir 800 mg 5 times/d for 7 days, and desipramine 25 mg, taper up to 75 mg at
bedtime for several weeks.
c. Treat with oral antiviral famciclovir 500 mg tid, valacyclovir 1 g tid, or acyclovir 800 mg 5 times/d for 7 days;
nortriptyline or desipramine 25 mg, taper up to 75 mg at bedtime for several weeks (if needed) to inhibit acute
and prolonged postherpetic neuralgia.
d. Document all external lesions and ocular \ufb01ndings. Proceed with treatment protocol for acute herpes zoster
ophthalmicus. Prescribe oral antiviral (famciclovir 500 mg tid, valacyclovir 1 g tid, or acyclovir 800 mg
5 times/d for 7 days); prescribe tricyclic antidepressant (nortriptyline or desipramine 25 mg, taper up to 75 mg
at bedtime for several weeks if needed) to inhibit acute and prolonged postherpetic neuralgia. Prescribe
additional topical steroids, antibiotics, dilators, antivirals, and glaucoma medications as necessary for keratitis,
iritis, or glaucoma. Advise the patient of disease prognosis, and prepare the patient for the possibility of
postherpetic neuralgia. Consult an ophthalmologist.
e. Document all external lesions and ocular \ufb01ndings. Proceed with treatment protocol for acute herpes zoster
ophthalmicus. Prescribe oral antiviral (famciclovir 500 mg tid, valacyclovir 1 g tid, or acyclovir 800 mg
5 times/d for 7 days); prescribe tricyclic antidepressant (nortriptyline or desipramine 25 mg, taper up to 75 mg
at bedtime for several weeks if needed) to inhibit acute and prolonged postherpetic neuralgia. Prescribe
additional topical steroids, antibiotics, dilators, antivirals, and glaucoma medications as necessary for keratitis,
iritis, or glaucoma. Advise the patient of the disease prognosis, and prepare the patient for the possibility of
postherpetic neuralgia. Set up an appointment with a neurologist.
The answer is d. Prescribe oral antiviral (famciclovir 500 mg tid, valacyclovir 1 g tid, or acyclovir 800 mg 5 times/d
for 7 days); prescribe tricyclic antidepressant (nortriptyline or desipramine 25 mg, taper up to 75 mg at bedtime for
several weeks if needed) to inhibit acute and prolonged postherpetic neuralgia. Prescribe additional topical steroids,
antibiotics, dilators, antivirals, and glaucoma medications as necessary for keratitis, iritis, or glaucoma. Advise the
patient of disease prognosis, and prepare the patient for the possibility of postherpetic neuralgia. Consult an
ophthalmologist.
99
100 Emergency Medicine Q & A: Pearls of Wisdom ...
2. Proper treatment for a hordeolum consists of:
a. Systemic antibiotic therapy.
b. Topical antibiotic ointment.
c. Daily warm compresses.
d. Surgical incision and curettage.
e. Observation.
The answer is c. Frequent use of daily warm compresses is the mainstay in the treatment of this lesion. Warm
compresses also are used in the prevention of new lesions in patients with blepharitis or meibomian gland
dysfunction.
3. The canilicula are located:
a. In the nose.
b. In the palpebral portion of the eyelid.
c. Lateral to the puncta.
d. Inferior to the puncta.
e. In the super\ufb01cial aspect of the medial eyelid.
The answer is e. The canaliculi are located in the vulnerable medial aspect of the superior and inferior eyelid.
4. A 55-year-old woman complains of painful double vision. Examination shows her right pupil is 7 mm with
sluggish reaction, her left pupil is 4 mm and briskly constricts. There is 3 mm ptosis of the right lid. She
cannot adduct her right eye when asked to do so. You should now:
a. Tell the patient she has Horner syndrome and needs evaluation of her carotid artery.
b. Arrange emergent evaluation for possible aneursymal compression, as she has a pupil-involved third nerve palsy.
c. Place pilocarpine drops in her right eye, as this is probably a pharmacologically dilated pupil.
d. Administer a serotonergic (5HT) triptan, as this is almost certainly a migraine variant.
e. Place a dilating drop in her eyes and perform direct ophthalmoscopy to con\ufb01rm your suspicion of retinal tear
involving the fovea.
The answer is b. A painful, pupil-involved third nerve palsy demands emergent evaluation for possible aneurysmal
compression. Approximately 25% of posterior communicating artery aneurysms produce a third nerve palsy.
Aneurysms may affect the third nerve via enlargement, sentinel leak, or frank subarachnoid hemorrhage, which is a
life-threatening event.
5. A 40-year-old man complains of right facial pain for 24 hours that started shortly after he was elbowed in
the neck while playing football. His right pupil is 4 mm, his left is 5.5 mm, and both are reactive. He has
approximately 1 mm ptosis of the right lid. This patient has:
a. Partial third nerve palsy which may represent uncal herniation; he requires an emergent CT scan.
b. Partial third nerve palsy which may represent aneurysmal compression; he requires emergent angiography.
c. Horner syndrome which likely represents carotid dissection; he requires emergent angiography.
d. Physiologic anisocoria and requires no further workup.
e. Traumatic iritis; he needs a careful slit lamp examination.
... CHAPTER 7 Head, Eye, Ear, Nose, and Throat Emergencies 101
The answer is c. Painful Horner syndrome demands consideration for carotid dissection. Sympathetic \ufb01bers travel
up the carotid to enter the orbit after traversing the cavernous sinus. The \ufb01bers are vulnerable to carotid disease
within the neck. Dissections commonly produce ipsilateral neck, face, or periorbital pain. The clinical scenario of
anisocoria greater in dark with normally reactive pupils only can result from physiologic anisocoria or Horner
syndrome.
6. The most common cause of branch retinal artery occlusion in patients older than 60 years is:
a. Vasculitis.
b. Idiopathic.
c. Embolism.
d. Vasospasm.
e. Blood dyscrasia.
The answer is c. Embolic causes are the most common cause of branch retinal artery occlusion. In many cases, the
emboli are visible on funduscopic examination.
7. When confronted with a patient who suffered a chemical burn to the eye, your \ufb01rst step in evaluation or
treatment is to:
a. Assess visual acuity (the \u201cvital sign\u201d of the eye).
b. Determine how long ago the injury occurred.
c. Determine how the patient treated the injury prior to visit.
d. Copiously irrigate the affected eye.
e. Perform \ufb02uorescein staining of the cornea to check for the presence of a corneal abrasion.
The answer is d. Time is of the essence when dealing with chemical injuries, and the top priority should be to
irrigate the eye, even if the patient says that the eye has been washed out. The eye should be irrigated again, and the
pH must be determined to be neutral before continuing with the examination.
8. A 22-year-old college student presents at 3 AM approximately 1 week after he was struck in the face with a \ufb01st
during a \ufb01ght with a fellow student. He complains of double vision in dim light. His visual acuity is 20/25 in
the right eye, 20/20 in the left eye. You note resolving periorbital ecchymosis on the right. His globes are
intact and intraocular pressure is 14 mmHg in both. There is no afferent pupillary defect, and his
extraocular movements are normal. His corneas are clear, and anterior