Emergency Medicine Q & A, 2009, Pg

Emergency Medicine Q & A, 2009, Pg


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proven that restoration of vision is minimal
beyond 90 minutes. Nonetheless, all attempts should be made within the \ufb01rst 24 hours.
17. A 62-year-old woman complains of sudden, painless, vision loss in her right eye. Your funduscopic
examination shows a diffuse retinal hemorrhage, including marked tortuosity and dilatation of all the retinal
veins. You tell your ophthalmologist consultant that you suspect:
a. Acute angle-closure glaucoma.
b. Acute central retinal artery occlusion.
c. Nonischemic central retinal vein occlusion.
d. Ischemic central retinal vein occlusion.
e. Macular degeneration.
The answer is d. This is a classic presentation of retinal vein occlusion. Fundus examination is essential to
differentiate artery occlusion from vein occlusion. Ischemic and nonischemic types present with visual loss; fundus
examination shows dilatation and tortuosity of all retinal branch veins. Nonischemic forms have a few scattered
retinal hemorrhages in the posterior pole; ischemic forms have diffuse retinal hemorrhages extending from the optic
disc to the periphery of the fundus. Acute central retinal artery occlusion typically results in a pale retina and a
small reddish dot near the fovea (Tintinalli et al., 2003:1461).
... CHAPTER 7 Head, Eye, Ear, Nose, and Throat Emergencies 105
18. A 56-year-old woman complains of nausea, headache, and a painful, red right eye. Her visual acuity is
20/200 in the right eye, 20/20 in the left eye. Her right pupil is 6 mm and does not react to light. Her left
pupil is 3 mm and reactive. The right cornea looks cloudy. You should now:
a. Order emergent head MRI.
b. Order emergent head CT.
c. Dilate the pupils for funduscopic examination.
d. Obtain intraocular pressures.
e. Begin high-dose steroid therapy for optic neuritis.
The answer is d. The patient must be evaluated for evidence of acute narrow-angle glaucoma; this is vision
threatening. Glaucoma commonly presents with systemic signs of nausea, vomiting, or headache and must be
considered in the differential of all patients with these complaints. Tonometry is essential in making the diagnosis.
Signs include a middilated, poorly reactive pupil with corneal edema and a shallow anterior chamber. An
in\ufb02ammatory reaction is often present. These classic \ufb01ndings may not always be present early in the clinical course.
19. A 38-year-old man without past medical history woke up this morning and noted a collection of blood in his
left eye. His visual acuity is 20/20 in each eye. The blood is super\ufb01cial and does not cross the limbus. He
requires:
a. Blood coagulation studies.
b. Emergent ophthalmology consult.
c. Reassurance\u2014send home without treatment.
d. Drainage of the blood.
e. Fluorescein angiography to determine vascular anomalies.
The answer is c. This patient has a subconjunctival hemorrhage. These usually develop spontaneously or from
trauma. Most patients can be sent home without further treatment. The hemorrhage should resolve within 2\u20133
weeks. More complicated cases may result from a large collection of blood (which prevents lid closure) or from an
associated conjunctivitis.
20. A 35-year-old man was struck in the left eye with a softball. He complains of blurred vision, vertical double
vision, numbness of his cheek, and eye pain. The most important evaluation is:
a. Visual acuity and pupil evaluation.
b. Orbital x-ray.
c. Slit lamp evaluation.
d. Orbital CT scan with 3-D reconstructions.
e. Muscle balance evaluation.
The answer is a. Traumatic optic neuropathy, ruptured globe, or an intraocular injury must be ruled out before any
consideration should be given to an orbital \ufb02oor fracture. Loss of vision and/or an afferent pupil must be
investigated \ufb01rst.
106 Emergency Medicine Q & A: Pearls of Wisdom ...
21. A 45-year-old man has watery discharge and erythema of his right eye. Visual acuity is normal. A tender,
ipsilateral preauricular lymph node is present on examination. The sclera is diffusely erythematous. The
cornea has small punctate opacities that stain poorly with \ufb02uorescein. His most likely diagnosis is:
a. Allergic conjunctivitis.
b. Herpes zoster conjunctivitis.
c. Blepharitis.
d. Epidemic keratoconjunctivitis.
e. Corneal abrasion.
The answer is d. Erythema and eye irritation are characteristic of both viral and bacterial causes of conjunctivitis. A
purulent discharge is more commonly seen in bacterial conjunctivitis. Empiric therapy for uncomplicated
conjunctivitis includes systemic analgesics and topical antibiotics. Epidemic keratoconjunctivitis, caused by
adenovirus, is a highly contagious eye infection associated with tender preauricular lymph nodes and a mild
keratitis. It is self-limited condition.
22. A 29-year-old man sustained blunt trauma to his right eye from a racquetball. He complains of eye pain only.
Visual acuity is normal. Extraocular muscles are intact. The pupils are equal, the light re\ufb02exes are intact, and
no photophobia is present. Funduscopic examination reveals a small inferior vitreous hemorrhage. The
remainder of the ocular examination is unremarkable. An appropriate action is to:
a. Refer the patient for immediate ophthalmologic evaluation.
b. Instruct the patient to return for reexamination in 24 hours or sooner if he notices blurry vision or eye pain.
c. Advise the patient to use cool compresses as needed and see an ophthalmologist in 5\u20137 days for follow-up.
d. Apply an eye patch, prescribe a topical cycloplegic and topical anesthetic, and instruct the patient to return in
24 hours.
e. Administer a topical cycloplegic and topical steroid and refer the patient for follow-up.
The answer is a. Posttraumatic vitreous hemorrhage suggests the possibility of a retinal tear. Peripheral traumatic
tears may be dif\ufb01cult to visualize. Ultrasonography may be used to search for retinal injury and the need for
operative repair. Treatment of vitreous hemorrhage includes elevating the head of the bed as well as avoiding
platelet-inhibiting drugs and Valsalva maneuver. Vitrectomy is performed for vitreous hemorrhage with an
associated retinal detachment. In the above case, there is no evidence of a traumatic iritis and therefore no
indication for a topical cycloplegic or ophthalmic steroid preparation. Topical ocular anesthetics should never be
prescribed for use by the patient. Other injuries associated with blunt eye trauma include traumatic lens
dislocation, traumatic mydriasis, and orbital wall fractures.
23. The bacterial organism most commonly associated with bullous myringitis is:
a. Staphylococcus pyogenes.
b. Staphylococcus aureus.
c. Chlamydia trachomata.
d. Mycoplasma pneumoniae.
e. Pseudomonas aeruginosa.
... CHAPTER 7 Head, Eye, Ear, Nose, and Throat Emergencies 107
The answer is d. Bullous myringitis is a painful condition of the ear characterized by bulla formation on the
tympanic membrane. The blisters occur between the highly innervated outer epithelium and the inner \ufb01brous layer
of the TM, explaining the severe otalgia. Opioid pain medication is often required. It is believed that most cases are
viral in nature but Mycoplasma still remains the most frequent bacterial organism isolated. Treatment consists of
warm compresses, analgesics, and systemic macrolide antibiotics. In severe cases, the patient should be referred to
an ENT surgeon for therapeutic rupture of the bullae.
24. A 4-year-old boy presents with high fever, anorexia, and drooling. He has mild inspiratory stridor and resists
the nurse\u2019s efforts to assist him into the supine position. You should next:
a. Use a tongue blade to visualize the posterior oropharynx and rule out epiglottitis.
b. Obtain a portable lateral soft tissue x-ray of the neck with the child in his mother\u2019s arms, while arranging airway
management in the operating room.
c. Perform immediate tracheostomy.
d. Begin high-dose steroid therapy and arrange for a croup tent.
e. Sedate