Family Medicine End of Rotation Exam and Answers.
Allergic Rhinitis pathophysiology correct answers IgE mediated reactivity to airborne allergies
Allergic Rhinitis etiology correct answers Common in people with other atopic disease:
Atopic Triad: allergic rhinitis, asthma, atopic dermatitis (eczema)
Allergic Rhinitis signs and symptoms correct answers Allergic Shiners
Dennie lines
Rhinorrhea
watery/itchy eyes
sneezing
nasal congestion
dry cough
pale, boggy, blue mucosa
horizontal nasal crease (from allergic salute)
Allergic Rhinitis treatment correct answers **Intranasal Glucocorticoid
Oral antihistamines
Cromolyn sodium
Nasal saline
Immunotherapy (last resort)
Acute pharyngitis pathophysiology correct answers sore throat
Commonly viral but need to distinguish from Group A beta hemolytic streptococcus
Viral causes are self limited- supportive treatment
Signs and symptoms of GABHS pharyngitis correct answers Fever >38/100.4
Tender anterior cervical adenopathy
Lack of cough
Pharyngotonsillar exudate
Diagnostic test for GABHS pharyngitis correct answers Rapid Strep Test 90-99 sensitivity
Confirmation with throat culture
Treatment for GABHS pharyngitis correct answers Oral PCN
2nd generation cephalosporin
macrolide (erythromycin) for PCN allergy
PCN IM if concern for patient compliance
*inadequate tx can lead to scarlet fever, glomerulonephritis, and abscess formation
Peritonsillar abscess pathophysiology correct answers penetration of infection through the
tonsillar capsule
Peritonsillar abscess signs and symptoms correct answers **always assess airway**
,sore throat
odynophagia
trismus
deviation of soft palate/uvula
"hot potato" voice
**deviation of and asymmetrical rise of soft palate/uvula are HIGHLY suggestive of abscess
Peritonsillar abscess treatment correct answers aspiration, I&D, abx, tonsillectomy
abx used= IV amoxicillin, amoxicillin-sulbactam, clindamycin, augmentin
Laryngitis etiology correct answers Usually viral (resolves in 1-3 weeks)
Bacterial = M. catarrhalis & H. influenza
Often follows URI
Signs and symptoms of laryngitis correct answers hoarseness*
cough may be present
pain is atypical
Treatment of laryngitis correct answers supportive therapy: voice rest
bacterial= erythromycin, ceftin, augmentin (decreases hoarseness/cough)
Can use PO/IM corticosteroids to hasten recovery for performers but requires vocal cord
evaluation
Aphthous ulcers etiology correct answers unclear. possible involvement of herpes 6 virus
Signs and symptoms of aphthous ulcers correct answers single or multiple painful, round ulcers
with yellow-gray centers and red halos on non-keratinized mucosa. They are usually recurrent.
Treatment of aphthous ulcers correct answers non-specific
topical corticosteroids
1 week oral prednisone taper
cimetidine (anti ulcer & H2 antagonist)
Acute sinusitis pathophysiology correct answers inflammation of osteomeatal complex,
differentiates between allergic or viral
Acute sinusitis risk factors correct answers Cigarette smoke
Nasal foreign body
Trauma
Signs and symptoms of acute sinusitis correct answers purulent nasal discharge
facial pain
facial pressure
nasal obstruction or congestion
fever
,tender to palpation
decreased transillumination
Diagnostics of acute sinusitis correct answers Usually a clinical diagnosis
X-ray used when presentation unclear, treatment failure, or indication of more serious infection
Acute sinusitis treatment correct answers NSAIDs for pain
Saline washes/steam
Oral/nasal decongestants
Intranasal corticosteroids
Antibiotics used if 10-14 days of symptoms present, or more significant symptoms such as fever,
facial pain, or swelling
Retinal detachment pathophysiology correct answers separation of the retina from epithelial
layer most commonly in the superior temporal area. Can happen spontaneously or secondary to
trauma, inflammatory changes, or extreme myopia
Retinal detachment signs and symptoms correct answers painless blurred or loss of vision
occurring over several minutes to hours and progressing to complete or partial monocular
blindness.
"Curtain being drawn over eyes from top to bottom"
Floaters/flashing lights may be initial presenting symptom
Retinal detachment physical exam findings correct answers afferent pupillary defect
fundoscopic exam may reveal ridges of displaced retina flapping in vitreous humor
Retinal detachment treatment correct answers emergency consult with ophthalmologist for
possible laser or cryosurgery. Keep patient supine with head turned to the side of the retinal
detachment.
Good prognosis *80% recover without recurrence
Macular degeneration causes correct answers age related (>50)
secondary to toxic effects of drugs
signs and symptoms of macular degeneration correct answers Insidious onset
Gradual irreversible central vision loss (central scotoma)
Metamorphopsia; measured with Amsler grid
physical exam findings of macular degeneration correct answers mottling of retina
serous leaks on retina
hemorrhages on retina
scarring of macula (end-stage disease)
Drusen deposits (white/yellow deposits)
Macular degeneration treatment correct answers No effective treatment
, Laser therapy or intravitreal injection of monoclonal antibody drugs may slow progression if
detected early
Vitamins, antioxidants, zinc, copper, omega3 fatty acids may also slow progression.
Central retinal artery occlusion causes correct answers OPHTHALMIC EMERGENCY
Emboli, thrombotic phenomenon, vasculitides (vessel destruction; both arteries and veins)
Must differentiate from giant cell arteritis (fever, HA, scalp tenderness, jaw claudication, and
visual loss)
Signs and symptoms of central retinal artery occlusion causes correct answers OPHTHALMIC
EMERGENCY
Sudden painless, and marked unilateral vision loss
Vision is "black as night" (complete vision loss)
Physical exam finding of central retinal artery occlusion correct answers OPHTHALMIC
EMERGENCY
funduscopy reveals pallor of retina, arteriolar narrowing, separation of arterial flow, retinal
edema, and perifovealatrophy (cherry red spot)
Ganglionic cell death leads to optic atrophy and pale retina (blindness)
Treatment of central retinal artery occlusion correct answers OPHTHALMIC EMERGENCY
Emergent ophthalmology referral for vessel dilation and paracentesis in attempt to save the eye.
Recumbent position and gentle ocular massage may help reduce the extent of the damage.
**workup for artherosclerotic disease or arrhythmia is warranted to reduce the risk of recurrence
Cause of central retinal vein occlusion correct answers Usually secondary to a thrombotic event.
Risk factors include diabetes, HLD, glaucoma, and hyperviscosity states such as anemia or
leukemia
Symptoms of central retinal vein occlusion correct answers variable vision loss, painless, and
unilateral
Physical exam findings of central retinal vein occlusion correct answers Afferent pupillary defect
Optic disc swelling
"Blood and thunder" retina (dilated veins, hemorrhages, edema, and exudates)
Treatment of central retinal vein occlusion correct answers Typically resolves with time
Referral
Can treat with ASA
Causes of retinopathy correct answers Hypertension (greatest risk) and diabetes
Physical exam findings of hypertensive retinopathy correct answers AV nicking
Copper/silver wiring
Diffuse arteriolar narrowing
Allergic Rhinitis pathophysiology correct answers IgE mediated reactivity to airborne allergies
Allergic Rhinitis etiology correct answers Common in people with other atopic disease:
Atopic Triad: allergic rhinitis, asthma, atopic dermatitis (eczema)
Allergic Rhinitis signs and symptoms correct answers Allergic Shiners
Dennie lines
Rhinorrhea
watery/itchy eyes
sneezing
nasal congestion
dry cough
pale, boggy, blue mucosa
horizontal nasal crease (from allergic salute)
Allergic Rhinitis treatment correct answers **Intranasal Glucocorticoid
Oral antihistamines
Cromolyn sodium
Nasal saline
Immunotherapy (last resort)
Acute pharyngitis pathophysiology correct answers sore throat
Commonly viral but need to distinguish from Group A beta hemolytic streptococcus
Viral causes are self limited- supportive treatment
Signs and symptoms of GABHS pharyngitis correct answers Fever >38/100.4
Tender anterior cervical adenopathy
Lack of cough
Pharyngotonsillar exudate
Diagnostic test for GABHS pharyngitis correct answers Rapid Strep Test 90-99 sensitivity
Confirmation with throat culture
Treatment for GABHS pharyngitis correct answers Oral PCN
2nd generation cephalosporin
macrolide (erythromycin) for PCN allergy
PCN IM if concern for patient compliance
*inadequate tx can lead to scarlet fever, glomerulonephritis, and abscess formation
Peritonsillar abscess pathophysiology correct answers penetration of infection through the
tonsillar capsule
Peritonsillar abscess signs and symptoms correct answers **always assess airway**
,sore throat
odynophagia
trismus
deviation of soft palate/uvula
"hot potato" voice
**deviation of and asymmetrical rise of soft palate/uvula are HIGHLY suggestive of abscess
Peritonsillar abscess treatment correct answers aspiration, I&D, abx, tonsillectomy
abx used= IV amoxicillin, amoxicillin-sulbactam, clindamycin, augmentin
Laryngitis etiology correct answers Usually viral (resolves in 1-3 weeks)
Bacterial = M. catarrhalis & H. influenza
Often follows URI
Signs and symptoms of laryngitis correct answers hoarseness*
cough may be present
pain is atypical
Treatment of laryngitis correct answers supportive therapy: voice rest
bacterial= erythromycin, ceftin, augmentin (decreases hoarseness/cough)
Can use PO/IM corticosteroids to hasten recovery for performers but requires vocal cord
evaluation
Aphthous ulcers etiology correct answers unclear. possible involvement of herpes 6 virus
Signs and symptoms of aphthous ulcers correct answers single or multiple painful, round ulcers
with yellow-gray centers and red halos on non-keratinized mucosa. They are usually recurrent.
Treatment of aphthous ulcers correct answers non-specific
topical corticosteroids
1 week oral prednisone taper
cimetidine (anti ulcer & H2 antagonist)
Acute sinusitis pathophysiology correct answers inflammation of osteomeatal complex,
differentiates between allergic or viral
Acute sinusitis risk factors correct answers Cigarette smoke
Nasal foreign body
Trauma
Signs and symptoms of acute sinusitis correct answers purulent nasal discharge
facial pain
facial pressure
nasal obstruction or congestion
fever
,tender to palpation
decreased transillumination
Diagnostics of acute sinusitis correct answers Usually a clinical diagnosis
X-ray used when presentation unclear, treatment failure, or indication of more serious infection
Acute sinusitis treatment correct answers NSAIDs for pain
Saline washes/steam
Oral/nasal decongestants
Intranasal corticosteroids
Antibiotics used if 10-14 days of symptoms present, or more significant symptoms such as fever,
facial pain, or swelling
Retinal detachment pathophysiology correct answers separation of the retina from epithelial
layer most commonly in the superior temporal area. Can happen spontaneously or secondary to
trauma, inflammatory changes, or extreme myopia
Retinal detachment signs and symptoms correct answers painless blurred or loss of vision
occurring over several minutes to hours and progressing to complete or partial monocular
blindness.
"Curtain being drawn over eyes from top to bottom"
Floaters/flashing lights may be initial presenting symptom
Retinal detachment physical exam findings correct answers afferent pupillary defect
fundoscopic exam may reveal ridges of displaced retina flapping in vitreous humor
Retinal detachment treatment correct answers emergency consult with ophthalmologist for
possible laser or cryosurgery. Keep patient supine with head turned to the side of the retinal
detachment.
Good prognosis *80% recover without recurrence
Macular degeneration causes correct answers age related (>50)
secondary to toxic effects of drugs
signs and symptoms of macular degeneration correct answers Insidious onset
Gradual irreversible central vision loss (central scotoma)
Metamorphopsia; measured with Amsler grid
physical exam findings of macular degeneration correct answers mottling of retina
serous leaks on retina
hemorrhages on retina
scarring of macula (end-stage disease)
Drusen deposits (white/yellow deposits)
Macular degeneration treatment correct answers No effective treatment
, Laser therapy or intravitreal injection of monoclonal antibody drugs may slow progression if
detected early
Vitamins, antioxidants, zinc, copper, omega3 fatty acids may also slow progression.
Central retinal artery occlusion causes correct answers OPHTHALMIC EMERGENCY
Emboli, thrombotic phenomenon, vasculitides (vessel destruction; both arteries and veins)
Must differentiate from giant cell arteritis (fever, HA, scalp tenderness, jaw claudication, and
visual loss)
Signs and symptoms of central retinal artery occlusion causes correct answers OPHTHALMIC
EMERGENCY
Sudden painless, and marked unilateral vision loss
Vision is "black as night" (complete vision loss)
Physical exam finding of central retinal artery occlusion correct answers OPHTHALMIC
EMERGENCY
funduscopy reveals pallor of retina, arteriolar narrowing, separation of arterial flow, retinal
edema, and perifovealatrophy (cherry red spot)
Ganglionic cell death leads to optic atrophy and pale retina (blindness)
Treatment of central retinal artery occlusion correct answers OPHTHALMIC EMERGENCY
Emergent ophthalmology referral for vessel dilation and paracentesis in attempt to save the eye.
Recumbent position and gentle ocular massage may help reduce the extent of the damage.
**workup for artherosclerotic disease or arrhythmia is warranted to reduce the risk of recurrence
Cause of central retinal vein occlusion correct answers Usually secondary to a thrombotic event.
Risk factors include diabetes, HLD, glaucoma, and hyperviscosity states such as anemia or
leukemia
Symptoms of central retinal vein occlusion correct answers variable vision loss, painless, and
unilateral
Physical exam findings of central retinal vein occlusion correct answers Afferent pupillary defect
Optic disc swelling
"Blood and thunder" retina (dilated veins, hemorrhages, edema, and exudates)
Treatment of central retinal vein occlusion correct answers Typically resolves with time
Referral
Can treat with ASA
Causes of retinopathy correct answers Hypertension (greatest risk) and diabetes
Physical exam findings of hypertensive retinopathy correct answers AV nicking
Copper/silver wiring
Diffuse arteriolar narrowing
