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Terms in this set (247)

erythromycin
Explanation
Erythromycin ophthalmic ointment, applied 2 - 4 x daily, is a treatment option for non-sexually transmitted bacterial conjunctivitis. If trying to cover all bacterial etiologies of conjunctivitis, then erythromycin can be given in the oral form in order to include good coverage for both gonococcal conjunctivitis and chlamydial conjunctivitis. If the erythromycin ophthalmic ointment were to be prescribed in a patient with a sexually transmitted bacterial conjunctivitis, there may still be a partial or complete resolution of symptoms. Erythromycin, in either the topical or oral form, has a good chance of treating any bacterial cause of conjunctivitis until the culture results confirm the etiologic agent.

Tetracycline 250 mg po 4 x daily for 3 weeks is a good treatment choice for chlamydial conjunctivitis should the cultures reveal this as the cause; however, it would not be a good prophylactic choice while waiting for lab results.

Bacitracin ophthalmic ointment applied 2 - 4 x daily for 5 days is a good treatment option for patients with bacterial conjunctivitis that is not from a sexually transmitted disease. In these cases, the most common etiologic agent is Staphylococcus aureus.

Olopatadine is an antihistamine ophthalmic solution that is used in the treatment of ocular itching associated with allergic conjunctivitis. It would not be of any help in a patient with bacterial conjunctivitis, regardless of the etiology.

Acyclovir is an antiviral that is prescribed 400 mg po 5 x a day for 7 days in cases of herpetic viral conjunctivitis. It would not be of any help in a patient with bacterial conjunctivitis, regardless of the etiology.
Explanation
This patient is clearly suffering from a peritonsillar abscess. This occurs when an active infection penetrates the tonsillar capsule and then involves the surrounding tissue. These patients will have a severe sore throat, odynophagia, trismus, deviation of the soft palate, and an abnormally muffled voice (i.e., a 'hot potato voice').

Oral candidiasis (or thrush) does not present with the symptoms described in the scenario. Typically, oral candidiasis is painful and appears as creamy-white, curd-like patches; overlying erythematous mucosa can be found virtually anywhere in the oral cavity. The white patches can easily be wiped off when attempted.

Laryngitis is lower on the differential diagnosis list because it usually presents with the primary symptom of hoarseness. Laryngitis frequently occurs approximately 1 week after the occurrence of an upper respiratory viral infection that has since resolved.

A dental abscess would cause severe, persistent, throbbing toothache, sensitivity to hot and cold temperatures, sensitivity to biting or chewing, fever, possibly noticeable swelling in the face or cheek, or even lymphadenopathy relating back to the site of the abscess. The symptoms of a dental abscess do not match the clinical scenario presented.

Mononucleosis also presents somewhat differently than the scenario above, making it a less likely diagnosis. Malaise, fever, sore throat (sometimes exudative), lymphadenopathy, palatal petechiae, and even splenomegaly are found in patients with mononucleosis.
Explanation
The correct answer is Kayser-Fleischer rings, which are the result of accumulation of copper in the cornea and the most unique sign of Wilson's disease. Wilson's disease is an inherited disorder of copper toxicity due to a genetic defect in copper transport. Beginning at birth, copper is not secreted into the bile or incorporated into the copper protein ceruloplasmin, resulting in low serum levels of ceruloplasmin. Symptoms and signs develop between 5 - 40 years of age as copper accumulates in the liver, brain, cornea, kidney, and reproductive organs. 50% of patients present with hepatitis; 40% present with neurological manifestations (tremor, speech disorders, dysphagia, incoordination), and 5 - 10% first present with Kayser-Fleischer rings (a brown-yellow ring in the cornea around the iris from copper deposits), amenorrhea, miscarriages, or hematuria. Diagnosis in confirmed by Kayser-Fleischer rings on slit-lamp examination in the presence of a low serum ceruloplasmin. AST and ALT levels are often elevated; serum copper is low; 24-hour urinary copper excretion is elevated. Treatment is lifelong chelation or oral zinc and a low copper diet.

Keratoconus is a bulging of the cornea to form a cone, and the classic sign is Fleischer's rings, which is an iron colored ring surrounding the cone. This progressive bulge is due to a weakness in the cornea and often occurs bilaterally beginning at 10 - 20 years of age. There are frequent changes in visual acuity necessitating repeated prescription changes, and contacts provide better correction than glasses. Corneal transplant may be necessary if corrective lenses are not adequate.

Arcus juvenilis is a gray or white arc around the peripheral cornea similar to arcus senilis in adults. It occurs in younger adults and is often associated with high blood cholesterol.

A metallic foreign body lodged in the cornea can quickly result in a single, small diameter rust ring that requires ophthalmologic intervention with a rust ring drill for removal.

A pinguecula is a raised, yellowish discoloration on the bulbar conjunctiva at the 3 o'clock or 9 o'clock position of the sclera-corneal junction. It is a benign growth; it is due to an accumulation of conjunctival tissue that can be the result of chronic actinic irritation.
Staphylococcus aureus
Explanation Staphylococcus aureus is a gram-positive staining cocci that is catalase positive, coagulase positive, and frequently beta hemolytic on blood agar. It is probably the 2nd most common bacterial isolate of human infections behind Escherichia coli and the most common cause of bacterial endophthalmitis. The organism has been described as an etiologic agent of many infections, including but not limited to, conjunctivitis, endocarditis, septicemia, abscesses, and urinary tract infections. The conjunctivitis caused by Staphylococcus aureusis usually characterized as non-severe where there is little to no lid edema, scant purulent discharge, and normal cornea; however, in some cases the presentation can be severe.
Chlamydia trachomatis is an obligate intracellular parasite with a unique biphasic life cycle. It does not gram stain, and laboratory procedures used for diagnosis include isolation in tissue culture, EIA detection of antigen, immunofluorescent staining, cytologic examination for intracytoplasmic inclusions, and by the demonstration of nucleic acid by direct hybridization or by amplification techniques. It can cause inclusion conjunctivitis and ocular trachoma. The inclusion conjunctivitis presents as an acute follicular conjunctivitis and is usually self-inoculated from an infected genitourinary site. The patient frequently complains of a foreign body presence in the eye. These symptoms are usually unilateral, and in the first 2 weeks, there is a mucoid discharge that becomes purulent.

Pseudomonas aeruginosa is a gram-negative rod, non-lactose fermenting, oxidase-positive motile bacteria. Pathogenesis is due to its minimal nutritional requirements, relative resistance to antibiotics, and a host of other invasive and toxinogenic substances that it produces. It can cause a keratitis that is rapid in its development. The infection is usually the result of a previous injury to the eye, which causes an interruption in the epithelial surface and allows bacterial invasion of the underlying stroma. Scrapings from the floor of the ulcer exhibiting gram-negative rods are strongly indicative of Pseudomonas aeruginosa and should necessitate treatment.

Haemophilus aegyptius is a gram-negative coccobacillus, non-motile, fastidious bacteria requiring the presence of special factors for its growth on agar media. These factors are hemin and nicotinamide adenine dinucleotide, which are present in chocolate agar but not on other isolation media. The organism is indigenous to humans. It is an important cause of a purulent conjunctivitis called "Pink Eye" and can occur in outbreaks because of its contagious nature. The diffuse pink color of the sclera and the presence of a serous or purulent discharge are virtually diagnostic of Haemophilus aegyptius infection. Leukocytosis is absent. The infection is not acute in presentation.

Bacillus cereus is a gram-positive (or gram-variable) rod that is aerobic, spore-forming, and is ubiquitous in nature. Bacillus cereus is an important cause of food poisoning. It has also been recognized as an ocular pathogen. The ocular infection is acute in presentation and requires aggressive intervention to save the eye. The presence of progressive corneal deterioration and ring abscess formation is a complication of panophthalmitis caused by Bacillus cereus. Except for infections with Pseudomonas aeruginosa, this finding is almost pathognomonic of Bacillus cereus. Because of the seriousness of the infection, early diagnosis is important. Patients presenting with ocular infections after trauma or in the setting of drug abuse should arouse suspicion.

Acanthamoeba is a free-living amebae that can cause granulomatous amebic encephalitis and keratitis. It can not be cultured by routine culture methods. Detection is usually made by observing the free living motile organisms in a wet prep preparation. Acanthamoeba keratitis is a slow-developing corneal infection that occurs in healthy people and is usually associated with contact lens wearers. Symptoms include blurred vision, conjunctivitis, tearing, severe pain to the eye, and photophobia. The keratitis achieves an advanced stage in several days to several months and can exhibit patchy stromal infiltrates and dendriform epithelial involvement without frank corneal ulceration in its early stages.

Candida albicans is a yeast. Yeasts appear on gram stain as large gram-positive organisms, approximately 3-5 times larger than gram-positive cocci, and are nonhemolytic on blood agar. They are aerobic and generally grow well on most non-selective agar media. Endophthalmitis due to yeast is generally a common and serious complication of intravenous drug use. Candida albicans is the most common fungal cause. It is usually of hematogenous origin where the patient has infective endocarditis or some other infective process occurring. The symptoms are blurred vision, decreased vision, white cotton appearing exudative lesions in the choroid and retina with vitreous haziness, and eye pain. A definitive diagnosis is made by obtaining vitreous fluid for gram stain and culture.
Benign Paroxysmal Positional Vertigo
Explanation
Benign Paroxysmal Positional Vertigo (BPPV) is the correct answer; episodes of BPPV are brief in nature and occur with change in position. People often feel off balance even when an episode is not occurring. BPPV does not typically cause hearing loss. The Dix-Hallpike maneuver elicits an episode of vertigo, with nystagmus being noted during the exam. The nystagmus diminishes with each maneuver due to fatiguability.

Labyrinthitis is incorrect; labyrinthitis is usually caused by an infection, which the patient did not have. Labyrinthitis often includes hearing loss and or tinnitus.

Episodes often last days or weeks.

Meniere's disease is incorrect; vertigo with Meniere's disease usually lasts from 20 minutes to 24 hours in duration. Sensorineural hearing loss and tinnitus are also common features. Typical onset is usually between 20 - 40 years old.

Vestibular schwannoma is incorrect; most people with this have hearing loss and or tinnitus. True spinning vertigo is uncommon with this disorder. People do have unsteadiness with walking. Some other symptoms can include paresthesia, hypesthesia, facial paresis, and taste disturbances. Symptoms are slow onset.

Brainstem infarction is incorrect; patients present with sudden onset of symptoms, and the symptoms persist for days to weeks. Nystagmus has central characteristics versus the above patient, which showed peripheral characteristics. This would also have associated neurological signs and symptoms.
Retinoblastoma
Explanation
The most likely diagnosis is retinoblastoma, as it is the most common primary ocular tumor in children below 5 years of age. 90% of cases are diagnosed below 3 - 4 years of age. The index case is a 1.5-year-old boy who has presented with a recent appearance of squint and absence of normal red reflex in the left eye, replaced instead by a white pupillary reflex (leukocoria). This is due to reflection of light from the white-colored tumor and loss of vision in that eye. The diagnosis is further supported by calcification seen in the globe in the X-ray of the skull. Fundoscopy may show the tumor as a white mass, which may be small and flat or may be large and protuberant. Orbital inflammation, hyphema, and irregular pupil are seen in advanced stages of the disease. Retinoblastoma gene is a recessive gene located on the chromosome13 at the 13q 14 regions, and the tumor may arise from any of the nucleated layers of the retina.

Besides direct observation, ultrasonography or CT scan may help to confirm the diagnosis and demonstrate calcification within the mass. As biopsy can lead to the spread of the tumor, histopathological confirmation of the tumor can be made only after removal of the affected eye

Retinal detachment in infants and children more commonly occurs due to trauma, secondary to other abnormalities like myopia, or after cataract surgery. It can also occur in diabetes, sickle cell disease, and retinopathy of prematurity. Presenting signs can be loss of vision, secondary strabismus (squint), nystagmus, and leukocoria (white pupillary reflex). Calcification seen on an X-ray of the skull in retinoblastoma is absent in retinal detachment. Also ultrasonography and neuroimaging may be required to establish the cause of detachment.

Congenital glaucoma (elevated intraocular pressure) usually manifests during the first 3 years of life. The classical triad of symptoms of congenital glaucoma are epiphora (excessive lachrymation), photophobia (sensitivity to light), and blepharospasm (squeezing of the eyelids). These symptoms are due to corneal irritation. As the cornea and sclera are more elastic during early childhood, the elevated intraocular pressure therefore leads to expansion of the eyeball, including the cornea, and development of buphthalmos (ox eye), which means a large eye. This leads to corneal edema and conjunctival congestion. The cornea may become cloudy. There is no white pupillary reflex or calcification in the globe seen on an X-ray of the skull.

A cataract is an opacity in the lens and may cause significant impairment of vision. It may be an isolated defect or may be a part of a generalized disorder. Common causes are intra uterine infections like rubella, cytomegalovirus infection, toxoplasmosis, metabolic disorders like galactosemia, and chromosomal disorders like trisomy 13, 18, and 21. Trauma to the eyeball is a major cause of cataract in children. The red reflex may be absent or may be irregular or there may be a white pupillary reflex. The retina and the blood vessels may not be visualized due to the lenticular opacities. Nystagmus may be present. Poor visual fixation, squint, and poor social smile may be seen later on. Calcification in the globe is not present in cataract.

Persistent hyperplastic primary vitreous (PHPV) is caused by persistence of portions of the fetal hyloid vascular system and the associated fibromuscular tissue. The condition is usually unilateral, and the affected eye is smaller than normal. The anterior chamber is shallow, and the lens is also smaller than normal. Other presenting signs are white pupillary reflex (leukocoria) strabismus and nystagmus. The course is progressive and outcome is poor.

The major complication is spontaneous intraocular hemorrhage, swelling of lens caused by rupture of posterior capsule, and glaucoma. Sometimes the distinction between PHPV and retinoblastoma can be difficult. Ultrasonography and CT scan can be useful diagnostic aids that may show calcification within the mass in the case of retinoblastoma.
Gamma knife radiosurgery
Explanation
Vestibular schwannoma, which also sometimes is referred to as an acoustic neuroma, are one of the most common intracranial tumors encountered in clinical practice. More than likely these occur as unilateral lesions; only rarely can these occur as bilateral masses. Although growth of these lesions is overall slow, the increased size can eventually cause such symptoms as unilateral hearing loss and deterioration of speech discrimination. Tinnitus will also be seen in these patients and as the tumor increases in size more central nervous system components are affected. This will cause loss of balance, coordination, vertigo, facial numbness, facial weakness, or even dysphagia. Typically these lesions are diagnosed via MRI or even a CT scan.

Treatment options usually are initially centered on surgical removal; however, our patient is not a candidate for a surgical procedure at this time. Other options would be radiosurgery, or specifically Gamma Knife radiosurgery is recommended. Gamma Knife radiosurgery is seen as an acceptable alternative for microsurgery for non-surgical candidates with similar tumor control rates to those having the surgical intervention.

Linear accelerator radiation therapy is another type of radiotherapy used to treat cancers; however, this type is not indicated in the treatment of a vestibular schwannomas.

Proton therapy, or proton beam therapy, is yet another type of radiotherapy; however, it is not a type that is specifically used in the treatment of schwannomas.

Observation only would not be appropriate for this patient currently as she is having significant symptoms currently that are interfering with her every day and quality of life.

Chemotherapy is not used for treating schwannomas.
Central Retinal artery occlusion
Explanation
Central retinal artery occlusion (CRAO) interferes with the major supply of blood to the retina, causing vision loss. In 25% of individuals, the macula is supplied by the cilioretinal arteries, sparing some central vision in the event of CRAO. The occlusion is principally caused by thrombus, thromboembolia, cholesterol plaques, calcium, or vasospasm. The patient notes a sudden, painless, monocular vision loss; the physical examination reveals a problem in the visual afferent way, and the funduscopic examination shows the red spot, which is the pigment of the choroid showing through the macula. Treatment consists of decreasing intraocular pressure in order to increase the pressure gradient in the artery and force the embolus to dislodge, restoring vision. Application of digital pressure, carbonic anhydrase inhibitors, beta-blockers, and paracentesis of the anterior chamber are some of the methods used for this purpose.

Retinal vein occlusion should be considered in the differential; it is characterized by preservation of some vision, and it rarely shows a red spot in the retina at the funduscopic examination.

Retinal detachments often cause prodromal symptoms, such as flashing lights, floating 'spider webs', and the sensation of 'having a curtain drawn up or down' over the visual field. The funduscopic exam reveals an undulating, pale, detached retina.

Acute angle-closure glaucoma is characterized by severe ocular pain and blurred vision, rather than loss of vision.
basal cell carcinoma
Explanation
The patient in this clinical case scenario most likely has basal cell carcinoma (BCC). BCC is a common skin cancer that arises from the basal layer of the epidermis. BCC is particularly common in Caucasians and has a 30% higher incidence in men than in women. BCC incidence also increases with age, with persons aged 55-75 having a 100-fold higher incidence than those under 20.

BCC clinically presents in four or so different clinical types, the nodular form being the most common (making up 60% of the BCC cases). Nodular BCC is described as a pin or flesh-colored papule that is pearly or translucent and evidence of a telangiectatic vessel within the papule. Ulceration is common, sometimes referred to as a "rodent ulcer." The other types of BCC include superficial, morpheaform, other subtypes, and even several BCC syndromes.

Squamous cell carcinoma of the skin typically appears as small, red, conical, hard nodules that occasionally will ulcerate. The presence of a pearly appearance helps distinguish BCC from squamous cell, although the two malignancies present in the same patterns.

Malignant melanoma of the skin is described as being a flat or raised pigmented lesion. The mnemonic of the "ABCD" rule is what is used to help screen suspicious lesions: Asymmetry, Border irregularity, Color variegation, and Diameter > 6 cm.

Benign nevi are common, but any skin lesion that has an ulcer and tendency to bleed should be urgently evaluated to rule out the worst-case scenario.

Actinic keratosis is also an incorrect choice. These are generally small (0.2 cm-0.6 cm) macules or papules that could be flesh color, pink, or even slightly hyper pigmented; however, they will feel like sandpaper and are generally tender when palpated. The clinical scenario does not match this description.
Explanation
The correct answer is diazepam (Valium), as this is a benzodiazepine medication that can be given 5-10mg IV in order to treat an acute attack during a severe episode of Ménière's disease. Other medications that are fast-acting and can effectively treat an acute attack are atropine and transdermal scopolamine. A few second-line choices for acute treatment are droperidol, promethazine (Phenergan), and diphenhydramine (Benadryl). With the exception of the transdermal scopolamine, all of the listed medications are given by IV or IV push in a controlled setting.

Hydrochlorothiazide/triamterene (Dyazide/Maxzide) is not the correct answer, as this combination medication is not used for an acute attack but is the first line treatment for maintenance in patients who have had recurrent attacks. The goal of treating patients with Ménière's disease is to prevent the number of disabling spells of vertigo that they experience. Along with a low sodium diet, diuretics are the mainstay of long-term treatment. Patients should be instructed about a low sodium diet and are to restrict their sodium intake to 1500 mg per day. Other lifestyle changes, such as smoking cessation, caffeine restriction, and alcohol restriction, should also be followed when applicable. If the sodium restriction and diuretic are not effective, then patients should be counseled on an even more restrictive diet of 1000mg sodium per day and have their diuretic dose increased (if not contraindicated) before considering another treatment option.

Meclizine (Antivert) is not the correct answer, as this is an antihistamine medication that can be used for maintenance and long-term prevention of recurrent attacks.

Acetazolamide (Diamox) is not the correct answer, as this is another diuretic medication choice that can be used for maintenance and long-term prevention of recurrent attacks.

Dimenhydrinate (Dramamine) is not the correct answer, as this is another antihistamine medication that can be used for maintenance and long-term prevention of recurrent attacks.
retinoblastoma
Explanation
Retinoblastoma is the most common primary malignant intraocular tumor of childhood. It usually appears quite early in the first 5 years. Leukocoria, a white or Cat's eye reflex in the pupil is the most frequent finding. There may also be strabismus due to vision impairment. Ocular inflammation, intraocular hemorrhage, glaucoma or heterochromia iridis may be seen. On fundoscopic exam, the tumor may appear as a small to large white mass depending on its stage. Primary treatment includes enucleation, though smaller tumors diagnosed at an earlier stage may be amenable to newer alternative treatments such as cryotherapy and photocoagulation.

Though leukocoria may be seen in retrolental fibroplasia or advanced stage of retinopathy of prematurity it is predominantly a disorder in preterm, low birthweight infants who received supplemental oxygen in the newborn period. These infants are susceptible due to the immaturity and subsequent damage of developing retinal vasculature. If the retina goes through various stages to ischemia and neovascularization, leukocoria may be seen representing retinal detachment and a subsequent membrane formation.

Phakomata are retinal findings hallmarking hamartomatous disorders such as tuberous sclerosis. The distinctive ocular lesion is a yellowish multinodular cystic lesion arising from the retina or disc. Similar lesions can occur in neurofibromatosis.

Retinitis pigmentosa is a progressive degeneration of the retina. It is characterized by pigmentary changes, arteriolar attenuation, some degree of optic atrophy and progressively deteriorating visual impairment. Granularity or mottling of the retinal pigment pattern or distinctive focal pigment aggregates can be seen fundoscopically.

Retinoschisis is a congenital disorder involving splitting of the retina into an inner and outer layer. Usually good vision is maintained. An elevation of the inner layer of the retina can be seen.
Explanation
Thumb-like projection superior to the larynx is the correct answer, as this is the description that is often used for an edematous epiglottis seen with epiglottitis. The epiglottis is a flap of tissue at the entrance of the larynx that points upwards while a person is breathing and folds down while swallowing. This mechanism prevents food from entering the trachea rather than the esophagus while eating. Epiglottitis can be life threatening and is an infection of the epiglottis that can lead to obstruction of the airway. It is commonly caused by H. influenza type B, group A Streptococcus, pneumococcus, or staphylococci. The classic thumb sign is usually seen on a lateral neck radiograph, which is essentially a swollen epiglottis seen on X-ray.

Narrowing of the trachea is not the correct answer, as this is not typically seen on the neck radiograph of a patient with epiglottitis. A patient with croup (an upper respiratory viral illness characterized by a barking cough, stridor, and fever) can have narrowing of the trachea on a lateral neck radiograph.

Foreign body in the trachea is not the correct answer. A lateral neck radiograph would show a foreign body in the trachea if one was lodged there, and this would not be associated with epiglottitis.

Soft tissue mass in the nasal cavity is not the correct answer. The epiglottitis is soft tissue, but is not located in or near the nasal cavity. A patient with a nasal polyp may have a soft tissue mass in their nasal cavity on lateral neck radiograph.

Narrowing of the esophagus is not the correct answer. Narrowing of the esophagus can occur with an esophageal stricture, but is more commonly diagnosed with a barium swallow or endoscopy. Narrowing of the esophagus can be seen on a neck radiograph in a patient with esophageal cancer, as well.
Bilateral laser peripheral iridotomy
Explanation The correct answer is bilateral laser peripheral iridotomy. This is a procedure during which a puncture-like opening is made near the base of the iris in order to decrease intraocular pressure in patients with angle-closure glaucoma. While there are various medications used to treat acute episodes, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. If this occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally.

Left laser peripheral iridotomy is not the correct answer. While there are various medications used to treat acute episodes of angle-closure glaucoma, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. Narrow anterior chambers always occur bilaterally. If acute angle-closure glaucoma occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally as opposed to being done in JUST the affected eye.

IV acetazolamide is not the correct answer. This medication is given in episodes of acute angle-closure glaucoma in order to decrease the intraocular pressure. It is typically given in a single 500mg IV dose followed by 250mg orally 4 times daily. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient's underlying issue is narrow anterior chambers.

Oral glycerol is not the correct answer. This medication is an osmotic diuretic that can be given 1-2 g/kg in order to decrease a patient's intraocular pressure during an acute episode of angle-closure glaucoma. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient's underlying issue is narrow anterior chambers.

Topical timolol 0.25% is not the correct answer. This medication is a topical β-adrenergic blocking agent used twice daily chronically in patients who have chronic glaucoma. The disorder does not require the acute lowering of intraocular pressure such as angle-closure glaucoma. Topical timolol would not be effective in lowering intraocular pressure in patients with angle-closure glaucoma.
Oral amoxicillin for otitis media
Explanation
The correct response is oral amoxicillin.

The diagnosis in this case is acute otitis media (inflammation of the middle ear), which is a common childhood infection. Infants and children are at highest risk for otitis media; incidence rates are 15 - 20%, with peaks occurring from 6 - 36 months and 4 - 6 years of age. Children who develop otitis media in the 1st year of life have an increased risk of recurrent acute infection or chronic disease.

In the usual course, a child suffering an upper respiratory infection for several days suddenly develops otalgia, fever, and hearing loss. The characteristic features include a bulging, opaque, erythematous tympanic membrane with impaired mobility. Purulent otorrhea may be present, but earache and fever are not always present. Any child with a 'fever of undetermined origin' must also be evaluated for a middle ear infection.

Bacteria are the primary agents of otitis media. The most common causes in all age groups are Streptococcus pneumoniae (25 - 40% of cases), followed by Haemophilus influenzae (15 - 25% of cases). In addition, Gram-negative bacilli cause about 20% of otitis media in neonates; however, these bacteria are rarely found in older children with otitis media. Less common causes include group A Streptococci and Branhamella catarrhalis. Staphylococcus is a less common cause of chronic otitis media.

Normally, children will improve clinically within 48 hours after antimicrobial therapy. If there is no improvement, the possibility of a resistant organism must be suspected; trimethoprim-sulfamethoxazole, or erythromycin and sulfonamides may be given. The antibiotic of choice is amoxicillin orally; it is effective for both S. pneumoniae and H. influenzae.

There is no added advantage of intramuscular injection over oral amoxicillin. An increasing percentage of H. influenzae and Moraxella catarrhalis strains have now become beta-lactamase producing and, therefore, ampicillin-resistant. Some resistant cases may benefit from a change of antibiotics to erythromycin or sulfonamides.

Needle aspiration of the middle ear is only rarely necessary, as in the case of a critically ill child or a child who fails to respond to standard antimicrobial therapy.
H Influenzae
Explanation Streptococcus pyogenes is a gram-positive coccus, catalase negative, beta hemolytic on blood agar, appearing as chains on gram stain. Definitive identification to distinguish it from other beta hemolytic streptococci is the detection of its specific "A" antigen by latex agglutination techniques. It is associated with streptococcal pharyngitis, scarlet fever, streptococcal pyoderma, necrotizing fascitis, and streptococcal toxic shock syndrome. Bacteremia is uncommon. They are universally sensitive to penicillin.
Streptococcus pneumoniae is a gram-positive lancet-shaped coccus that is catalase negative and occurs in pairs. It is a common cause of otitis media in children. It is also a major cause of meningitis in elderly people and especially those that have underlying conditions, are malnourished, or are alcoholics. The organism is alpha hemolytic on blood agar.

Staphylococcus aureus is a gram-positive coccus, catalase positive, and coagulase positive, predominantly beta hemolytic on blood agar, appearing in characteristic grape clusters on gram stain. Staphylococcus aureus can cause a variety of infections. In children with reactive tonsils, this can be a source of infection, leading to severe tonsillitis. A semisynthetic penicillin is the treatment of choice.

Haemophilus influenza is a gram-negative coccobacillus. It is also a major cause of meningitis. It occurs mostly in young infants and children where it can also cause a severe epiglottitis that can necessitate intubation. When it occurs in adults, it is usually due to an underlying condition, such as paranasal sinusitis, remote head trauma, or otitis. The organism will not grow on blood agar and requires the presence of growth factors (hemin and NAD) for growth.

Candida albicans is a yeast. Yeast appears on gram stain as large gram-positive organisms approximately 3-5 times larger than gram-positive cocci. They are aerobic and generally grow well on most nonselective agar media. The organism is a major cause of throat infections in the immunocompromised, such as patients with HIV. When causing an infection in the throat, it is called "thrush."
Daily cleaning with a damp cotton applicator and baby shampoo
Explanation
The scenario presented above depicts a patient with anterior blepharitis, which is a common disorder seen in primary care; it typically consists of a recurrent bilateral inflammation of the lid margins that involves the eyelid skin, eyelashes, and associated glands. Commonly, the underlying cause is seborrhea, which usually originates in the scalp, eyebrows, or ears. Sometimes, anterior blepharitis can be ulcerative, and the origin in the presented case is staphylococci. Anterior blepharitis can typically be resolved and controlled by cleaning the affected areas daily using a damp cotton applicator, warm water, and a baby shampoo mixture. The object of the daily cleaning is to remove the visible scales as efficiently as possible. None of the other listed options are an appropriate treatment plan for anterior blepharitis.

Patients can also be diagnosed with what is known as posterior blepharitis, which is an inflammation of the meibomian glands of the eyes. It is usually staphylococcal in origin, and it typically presents with significantly worse signs and symptoms, such as hyperemic lids, the presence of telangiectasias, inflammation of the gland or their orifices, or even abnormal secretions; tears may be described as being frothy or greasy. More significant cases of posterior blepharitis can lead to conjunctivitis, hordeola, chalazions, eyelash trichiasis, or even corneal vascularization and thinning. Treatments for posterior blepharitis may consist of long-term oral antibiotic therapy, short-term topical steroids, or short-term topical antibiotics eye drops; if significant complications are evident, an ophthalmologist referral is indicated.
heredity
Explanation
The correct response is heredity.

The child most likely has inherited retinoblastoma. Retinoblastoma is a rapidly developing cancer that generally affects children under the age of 6. It is most commonly diagnosed in children aged 1 - 2 years. Genetic counseling is especially important when more than 1 family member has had the disease or if the retinoblastoma occurs in both eyes.

Leukocoria is seen as a whitish color behind the pupil, which is usually black. It is a sensitive test best done by looking at the "red reflex." Normally, red reflection often occurs in people's eyes when taking flash photographs. Dimming the room lights and using a flashlight to shine light directly into the child's eyes can also elicit the red reflex. With leukocoria, also known as "cat's eye," red reflex is absent. This abnormality is present in approximately 60% of all children with retinoblastoma. Keeping in mind that retinoblastoma is the third most common cancer overall affecting children, red reflex is a useful screening tool. It is a sign and not a risk factor for the disease.

Although smoking can affect pregnancy and a child, in this particular case, heredity is probably the main risk factor.

Heterochromia iridis is a relatively late symptom caused by the tumor invasion and/or neovascularization. It is a symptom, not a risk factor.

Crossed eyes, or strabismus, which occurs as a result of visual loss, is a common sign of retinoblastoma. That is the reason funduscopic examination through a well-dilated pupil must be performed in all cases of childhood strabismus. Strabismus is usually secondary to macular involvement. It is also a sign and not a risk factor for the disease.
Haemophilus Influenzae

Explanation
This patient presents with a classic acute bacterial rhinosinusitis (sinus infection). The most common causative organisms are Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis. Viruses and anaerobes can also be implicated as causes. Haemophilus influenzae is a Gram-negative bacterium. It is important for clinicians to understand the basic underlying etiology of common infections in order to select appropriate empiric antibiotic therapy. Because of difficulty in obtaining sinus cultures without nasal contamination, culture and identification of sinusitis-causing organisms is rarely done in clinical settings.

Candida albicans is a common fungal organism. It is typically responsible for vaginal yeast infections and thrush. It does not usually cause sinusitis.

Clostridium difficile is a Gram-positive, anaerobic bacillus. It can be a causative organism in diarrheal illnesses and colitis, and it is often considered a nosocomial (hospital-acquired) infection. It is not linked with sinusitis.

Escherichia coli is a Gram-negative bacterium commonly found in the gastrointestinal tract. It is part of the normal GI flora, but can contribute to infection in other systems, such as the urinary tract. It is not usually found in the sinuses.

Francisella tularensis is a Gram-negative bacterium that causes tularemia (also known as "rabbit fever"). It is carried by various vectors (ticks, rabbits, and rodents). Tularemia can cause various systemic symptoms, such as fever, malaise, fatigue, aches, and swollen lymph nodes.

Pseudomonas aeruginosa is a Gram-negative bacterium that can be found in infections throughout several body systems. It can cause pneumonia, skin infections, as well as gastrointestinal and urinary tract infections. However, it is typically associated with some type of inoculation or immunocompromising condition (e.g., burns, post-catheter, puncture wounds, neutropenia, ventilator use, etc.). This patient history does not suggest any unusual etiology for his sinusitis. Pseudomonas aeruginosa is an unusual and rare cause of sinus infection.
5 Right ear conductive hearing loss, possibly due to cerumen impaction

Explanation
Hearing loss can be recognized at the bedside as either sensorineural or conductive through the Rinne and Weber tests. In this case, the Rinne test bone conduction (BC) lasts longer than air conduction (AC) in the right ear ( affected ear) and the Weber test lateralizes to the right ear (affected ear). Normally AC lasts longer than BC because of the amplifying effects of the eardrum and middle ear. If BC is longer than AC, the patient is likely to have conductive deafness. Both tests in this patient indicate a conductive hearing loss in the right ear, probably produced by cerumen impaction; there is no apparent evidence of middle-ear disease. In sensorineural hearing loss, both AC and BC are equally diminished.

Right ear sensorineural hearing loss due to Meniere's disease is incorrect. The patients Rinne and Weber test results indicate conductive hearing loss confined to the right ear not sensorineural hearing loss. There is no evidence of Meniere's disease.

Left ear sensorineural hearing loss due to Meniere's disease is incorrect. This patient's hearing tests indicate a conductive hearing loss in the right ear. In sensorineural hearing loss both AC and BC are equally diminished. Symptoms of Meniere's disease are not present.

Left ear conductive hearing loss due to middle-ear disease is incorrect. The patient's hearing tests indicate a conductive hearing loss in the right ear not the left.

Right ear sensorineural hearing loss due to acoustic neuroma is incorrect. There is no evidence of sensorineural hearing loss or acoustic neuroma in this patient.
Site-specific recombination of DNA must occur
Explanation
The correct response is site-specific recombination of DNA must occur.

Allergy shots are given to individuals who have an allergic reaction to common allergens (e.g., mold or pollen from grasses, ragweed, and trees). A small amount of the allergen is injected into the patient and the body starts making antibodies to the allergen; this allows the body to fight the allergen, and relieve the symptoms of the allergic reaction. The mature antibody molecule is composed of 4 polypeptide chains, 2 heavy chains, and 2 light chains. Generation of the mature antibody molecule, specific to a given antigen, requires rearrangement of immunoglobulin genes in the B cells. There is a 'pool' of gene segments that eventually must be brought together to synthesize the mature antibody molecule. During B cell development, a complete coding sequence for the 2 Ig chains is assembled from the pool of gene fragments by a process called site-specific genetic recombination. Site-specific recombination alters the relative position of gene sequences in the chromosome and requires specific enzymes. Site-specific recombination events primarily occur as a mechanism to change the program of genes expressed at specific stages of development. The most significant site-specific recombination event is the somatic cell gene rearrangement which takes place in the immunoglobulin genes during B-cell differentiation in response to antigen presentation. Extremely diverse potential for antibody production occurs as a result of these gene rearrangements in the immunoglobulin genes.

A typical antibody molecule is composed of both heavy and light chains. The genes for both heavy and light peptide chains undergo somatic cell rearrangement, which yields approximately 3,000 different light chain combinations and approximately 5,000 heavy chain combinations. The gene sequences needed to form the mature antibody chains are brought together. A complete Ig chain can only be synthesized after this genetic recombination occurs.
A 30-year-old woman presents to the emergency room at 7 am with severe pain and swelling of her right eye. She was awakened early the previous evening due to the discomfort and swelling of the surrounding conjunctiva. She found it difficult to sleep due to the discomfort. She planned on going to work, but the swelling had closed her eye shut, and she developed excruciating pain in the eye that radiated internally.

The patient does not recollect any previous trauma or injury to the eye. She uses contact lenses, but they were not in use due to the condition of her eye. The contact lenses were stored in a small pillbox container with some fluid that she later described as tap water. She ran out of sterile cleaning and soaking solution for the contact lenses, so she has been using tap water as a substitute for approximately 5 days. She frequently sleeps with her contacts in.

The patient is afebrile. Pulse is 70/min, and blood pressure is 135/80 mm Hg. Lungs are clear, and there is no evidence of lymphadenopathy. The eye has a profound conjunctivitis that is acute and follicular. Purulent drainage is present. The acute nature of the conjunctivitis requires an ophthalmologist consult.

The ophthalmologist obtains ocular fluid for culture and Gram stain. CBC results are unremarkable. The Gram stain reveals the following results (see image). Prompt and aggressive therapy is initiated. What is the most likely organism causing this acute eye threatening infection?

Answer Choices
1 Chlamydia trachomatis
2 Pseudomonas aeruginosa
3 Haemophilus aegyptius
4 Bacillus cereus
5 Acanthamoeba spp
6 Staphylococcus aureus
7 Candida albicans
Pseudomonas
Explanation
Pseudomonas aeruginosa is a Gram-negative rod; it is a non-lactose fermenting, oxidase-positive motile bacteria. Growth on MacConkey agar is usually characterized by the production of a "grape-like" smell. A blue-green color, due to the production of the diffusible fluorescent pigments pyoverdin and pyocyanin, is characteristic of the colonies growing on MacConkey. Pseudomonas aeruginosa is a very common opportunistic source of human infections, especially in the hospital setting. Pathogenesis is due to its minimal nutritional requirements, relative resistance to antibiotics, and a host of other invasive and toxicogenic substances that it produces. It can cause a keratitis that is rapid in its development. The infection is usually the result of a previous injury to the eye, which causes an interruption in the epithelial surface and allows bacterial invasion of the underlying stroma. It can also be caused by contact lenses. Fever is usually absent, and leukocytosis is absent or minimal. The infection can lead to corneal ulceration, resulting in the rapid loss of ocular function; therefore, these infections need to be approached as a medical emergency. Scrapings from the floor of the ulcer exhibiting Gram-negative rods are strongly indicative of Pseudomonas aeruginosa and should necessitate treatment. Immediate initiation of combined topical and subconjunctival therapy with an aminoglycoside antibiotic such as gentamicin or tobramycin is advised. Topical steroids are sometimes used to reduce ocular inflammation.

Chlamydia trachomatis is an obligate intracellular parasite with a unique biphasic life cycle. It does not Gram stain; laboratory procedures used for diagnosis include isolation in tissue culture, EIA detection of antigen, immunofluorescent staining, cytologic examination for intracytoplasmic inclusions, and by the demonstration of nucleic acid by direct hybridization or by amplification techniques. It can cause inclusion conjunctivitis and ocular trachoma (as well as urethritis, lymphogranuloma venereum, urogenital infections, infertility, salpingitis and endometritis, reactive arthritis, etc.). The inclusion conjunctivitis presents as an acute follicular conjunctivitis and is usually self-inoculated from an infected genitourinary site. The patient frequently notes a foreign body presence in the eye. These symptoms are usually unilateral, and in the first 2 weeks, there is a mucoid discharge that becomes purulent. Usually the inclusion conjunctivitis resolves without complications, but some untreated or improperly treated cases can result in a prolonged infection that can last for months, and it can produce conjunctival and corneal scarring that is similar to mild ocular trachoma. Antibiotics, such as the tetracyclines, macrolides, rifampin, and some of the fluoroquinolones, have activity against chlamydia.

Haemophilus aegyptius is a Gram-negative coccobacillus; it is non-motile, fastidious bacteria requiring the presence of special factors for its growth on agar media. These factors are hemin and nicotinamide adenine dinucleotide, which are present in chocolate agar. The organism is indigenous to humans. It is an important cause of a purulent conjunctivitis called pink eye, and it can occur in outbreaks because of its contagious nature. The diffuse pink color of the sclera and the presence of a serous or purulent discharge are virtually diagnostic of Haemophilus aegyptius infection. Leukocytosis is absent. The infection is not acute in presentation. The treatment of Haemophilus aegyptius is with topical antibiotics. Because of the infectious nature of the infection, instructions should be provided to the patient to help prevent the spread of the infection to others.

Bacillus cereus is a Gram-positive (or Gram-variable) rod that is aerobic and spore forming; it is ubiquitous in nature. Bacillus cereus is an important cause of food poisoning. It has also been recognized as an ocular pathogen. The ocular infection is acute in presentation and requires aggressive intervention to save the eye. It is many times associated with metal-on-metal projectile injuries, soil and dust contamination as seen in rural farm areas, and drug abuse. The presence of progressive corneal deterioration and ring abscess formation is a complication of panophthalmitis caused by Bacillus cereus. Except for infections with Pseudomonas aeruginosa, this finding is almost pathognomonic of Bacillus cereus. Because of the seriousness of the infection, early diagnosis is important. Patients presenting with ocular infections after trauma or in the setting of drug abuse should arouse suspicion. As with Pseudomonas aeruginosa, it is important for the prompt initiation of therapy before permanent structural changes occur, leading to loss of vision. Clindamycin and gentamicin in combination, administered intravitreally, is the course of therapy favored by ophthalmologists. The prognosis is poor and usually results in the loss of the eye unless an aggressive approach is undertaken; even then, there is assuredly some loss of vision. Topical steroids are sometimes used to reduce ocular inflammation.

Acanthamoeba is a free-living amebae that can cause granulomatous amebic encephalitis and keratitis. Detection is usually made by observing the free-living motile organisms in a wet prep preparation. Acanthamoeba keratitis is a corneal infection that occurs in healthy people and is usually associated with contact lens wearers. To prevent Acanthamoeba keratitis, it is recommended that contact lenses be cleaned and stored with Benzalkonium chloride-preserved saline and solutions containing thimerosal with edetate. Swimming in fresh water (where the organism is naturally found) with contact lenses can predispose the wearer to Acanthamoeba keratitis. The keratitis is slow in developing and is frequently mistaken for herpes, bacterial, or fungal keratitis. Frequently, the average delay to definitive treatment can range from days to months. Symptoms include blurred vision, conjunctivitis, tearing, severe pain to the eye, and photophobia. The keratitis achieves an advanced stage in several days to several months, and it can exhibit patchy stromal infiltrates and dendriform epithelial involvement without frank corneal ulceration in its early stages. A ring corneal infiltrate is characteristic of this keratitis in its late stages. Early diagnosis, aggressive surgical debridement, and medical management can prevent eye damage. High concentrations of topical antimicrobial drugs (1% miconazole, 0.1% propamidine isethionate, and Neosporin) for a minimum of 3 - 4 weeks is part of the antibiotic therapeutic regimen employed in the treatment of Acanthamoeba keratitis.

Staphylococcus aureus is a Gram-positive staining cocci that is catalase positive and coagulase positive. It is probably the 2nd most common bacterial isolate of human infections behind Escherichia coli and the most common cause of bacterial endophthalmitis. Staphylococcus aureus has a host of invasive and toxigenic characteristics that enhance the pathogenesis of the organism in the human host. The organism has been described as an etiologic agent of many infections including, but not limited to, conjunctivitis, endocarditis, septicemia, abscesses, and urinary tract infections. The conjunctivitis caused by Staphylococcus aureus is usually characterized as non-severe where there is little to no lid edema, scant purulent discharge, and normal cornea; however, in some cases the presentation can be severe. Topical agents are usually used to treat this infection such as cephalosporins or semisynthetic penicillins. In suspected cases of resistance, topical vancomycin should be considered.

Candida albicans is a yeast. Yeast appear on Gram stain as large Gram-positive organisms that are approximately 3 - 5 times larger than Gram-positive cocci. They are aerobic and generally grow well on most non-selective agar media. Endophthalmitis due to yeast is generally a common and serious complication of intravenous drug use. Candida albicans is the most common fungal cause. It is usually of hematogenous origin, where the patient has infective endocarditis or some other infective process occurring. The symptoms are blurred vision, decreased vision, white cotton appearing exudative lesions in the choroid and retina with vitreous haziness, and eye pain. A definitive diagnosis is made by obtaining vitreous fluid for Gram stain and culture. The treatment consists of parenteral amphotericin B together with flucytosine. Intraocular amphotericin B administration as therapy is controversial. The incidence of permanent intraocular damage is high.
Hearing Impairment
Explanation
Hearing impairment is the most likely cause for this boy's poor communication and reading ability and his classroom problems. Children with hearing impairment appear to learn more slowly because they miss many important cues and information. They often become frustrated and develop other behavioral disturbances such as classroom disruptiveness. Thus, sensory impairment is an important consideration in the differential diagnosis of any child with symptoms that might suggest MR/ID or learning and communication disabilities.

The 4 most common causes of speech or language delay are developmental language disabilities (i.e., normal cognition (IQ), impaired intelligibility, and delayed emergence of phrases, sentences, and grammatical markers), mental retardation/intellectual disability (MR/ID), hearing impairment, and autistic spectrum disorders.

That being said, research has shown that approximately one third of hearing impaired children will also be found to have at least 1 other disability that affects development of speech and language (e.g., mental retardation, cerebral palsy, craniofacial anomalies).

Any child who shows developmental warning signs of a speech or language problem should have a hearing assessment by an audiologist and an examination by a geneticist as part of a comprehensive evaluation.

Autism is unlikely in this case because the boy is interactive with classmates and his environment.

Reading disorder (or "Developmental Dyslexia") is the most common learning disability. The clinical picture is consistent with a learning disability in that the IQ score is higher than academic performance would suggest (poor speaking and reading ability, failure to follow directions). However, before this boy can be given a diagnosis of a learning disability, hearing impairment must be ruled out with audiometric studies.

Childhood schizophrenia is a rare condition that can cause learning disabilities and is characterized by inattention and disruptive behavior; however, it is unlikely in this case, as there appears to be no impairment in social skills, no preoccupations with internal stimuli, and no aggression or rage behavior.

Seizure disorders (epilepsy) can cause cognitive disturbances, but these should be detectable with IQ testing. The boy in this case has a normal IQ. Although a topic of much discussion and debate, it is well known that chronic epilepsy has an association with neuropsychological impairment.
Acute Sinusitis
Explanation
Acute sinusitis is a common condition that is characterized by nasal congestion, purulent nasal discharge, headache, facial pain, cough, teeth pain, myalgias, and low-grade fever. Other symptoms include halitosis, anosmia, and metallic taste in the mouth. Out of these 11 features, presence of 4 or more is diagnostic for bacterial sinusitis. History regarding previous medications (rhinitis medicamentosa), occupational rhinitis, polyps in the nose, or vasomotor rhinitis needs to be taken. Maxillary sinuses are tender, as in this case, along with congested nasal mucosa. Diagnosis is usually clinical. Radiological confirmation may aid in definitive diagnosis and treatment. Transillumination of maxillary sinuses with a torchlight may reveal loss of normal illumination, but doing so is generally not recommended in practice. Plain radiographs in various sinus views may show opacification or air fluid level. The imaging of choice in recent times has been a limited CT scan of sinuses, which is fairly reasonable price wise and has proven to be quite helpful. It can show opacification, mucosal thickening, abscess formation, bone destruction, tumors, and blockage of the osteomeatal complex. Treatment includes a 2-week course of amoxicillin, amoxicillin-clavulanate, cefuroxime, or quinolones, along with an oral decongestant, nasal decongestant, and anti-inflammatory medications.

Acute rhinitis is usually viral and characterized by serous nasal discharge, rather than purulent, fever, fatigue, sneezing, scratchy throat, and moderate cough. Examination is not very remarkable. It is self-limiting, and it resolves after 4 - 7 days. There is no response to antibiotics. Symptomatic treatment with decongestants and antitussives is indicated.

Migraine headaches are not associated with nasal congestion, fever, cough, or sore throat. Recurrent headaches are common, and patients may get an aura prior to an attack.

Acute pharyngitis is associated with severe sore throat, pain on swallowing, erythematous pharynx with or without exudates, and enlarged tonsils. There may be headache and body ache with fever, especially in streptococcal infections. Throat swab can be sent for culture. Office-based rapid streptococcus tests are also available. Sinus pain and tenderness are absent, and nasal congestion is absent or mild.

Influenza is a viral illness with high fever and chills, severe myalgias, headache, malaise, and fatigue. It can be debilitating and life threatening in the elderly. Dry hacking cough with sore throat may be present. Examination reveals few positive findings. Mild hyperemia of the pharynx and flushed face may be the only findings other than fever. Diagnosis is clinical. Treatment is supportive.
Blepharitis
The symptoms described above are typical for blepharitis, an inflammation of the lid margins. There are 2 types of blepharitis:

Ulcerative blepharitis: it is caused by bacterial infection (mostly staphylococci) of follicles and meibomian glands. Adherent crusts develop that result in bleeding if removed. Pustules form in the lash follicles and turn into small ulcers. Repeated episodes can lead to permanent loss of lashes, scarring of the lids, and sometimes even corneal ulceration. Treatment consists of application of antibiotic ointment for 7 to 10 days.
Seborrheic blepharitis: the cause is not known. Sometimes it is associated with seborrhea of scalp and face. The scales are easily removable. Treatment is usually to just keep the eyelids clean. If it does not clear, antibiotic ointment is needed.
Hordeolum is a localized infection of the Zeis, Moll, or meibomian glands; it is usually caused by staphylococci. It can be associated with blepharitis or follow it.

The internal hordeolum (affecting the meibomian glands) involve pain, redness, and localized edema with an elevated yellow area near the affected gland that turns into an abscess, which rarely ruptures spontaneously.
The external hordeolum (affecting the glands of Zeis or Moll) starts with pain, redness, and tenderness, which turns into an induration with a yellowish spot in the center. The abscess soon ruptures and emits pus.
Acute conjunctivitis is an inflammation of the conjunctiva that can be bacterial, viral, or allergic. The most common pathogens for bacterial infection in adults are Staphylococci, Streptococcus pneumoniae, and Haemophilus influenzae. In children, bacterial conjunctivitis is more common than viral conjunctivitis and is caused by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Symptoms are itching, irritation, foreign body sensation, tearing, and in bacterial infection, mucopurulent discharge. Small bumps with fibrovascular cores on the palpebral conjunctiva that look like a velvety surface are a typical papillary reaction. Bacterial conjunctivitis is usually self-limiting but can also cause corneal or systemic complications (like meningitis in primary meningococcal meningitis) and should therefore be treated with topical antibiotics (e.g., polymyxin-bacitracin, ciprofloxacin, or ofloxacin).

Viral conjunctivitis is more common than bacterial conjunctivitis in adults; it is caused by herpes virus or during the course of systemic or cutaneous infections, such as rubella, measles, cytomegaly, syphilis, or systemic adenovirus infections. Occasionally permanent vision loss can occur, as well as cataract, microphthalmos, retinal involvement, interstitial keratitis, and optic neuritis.

Trachoma is a chronic conjunctivitis caused by chlamydia trachomatis. It is transmitted via contact (hands, towels, etc.), and it is a major cause of blindness in developing countries due to poor hygiene and economic conditions. In the United States, only mild forms are typically seen, usually in immigrants from endemic areas. The disease presents as conjunctivitis with small lymphoid follicles. Cultures are often false negative; therefore, PCR to prove the presence of chlamydial DNA in ocular secretions should be performed. Treatment consists of topical or systemic tetracycline or erythromycin.
Neomycin/polymyxin B/hydrocortisone topical solution
Explanation
Neomycin/polymyxin B/hydrocortisone (Cortisporin) solution is the correct answer. In this case, the patient has the diagnosis of acute left bacterial otitis externa. Initially, removal of any desquamated epithelium and moist cerumen should be performed. Topical solutions are usually adequate to treat the infection and should be chosen based on the most likely causative organism. Bacterial cases of otitis externa are usually caused by Pseudomonas aeruginosa or Staphylococcal species. Cortisporin has broad spectrum coverage, including a steroid to reduce inflammation. It is usually given 3-4 times daily for 7-10 days. This is not the first choice, however, if the patient has a perforation of the tympanic membrane in the infected ear.

Clotrimazole 1% solution is not the correct answer for treatment of bacterial otitis externa. However, it would be adequate for treatment of fungal otitis externa, as clotrimazole is an antifungal rather than an antibacterial medication.

Ciprofloxacin oral suspension is not the correct answer. Topical treatments are usually enough to resolve episodes of acute otitis externa. However, should it become recurrent or if signs of invasive infection (such as fever or cellulitis) are present, then oral antibiotics may be necessary. In those cases, fluoroquinolones are often chosen.

Triamcinolone 0.1% solution is not the correct answer. Some children suffer from eczematous otitis externa, and this should be treated differently from acute bacterial otitis externa. Topical therapy is still effective, but acetic acid 2%, aluminum acetate, or various steroid preparations (such as triamcinolone 0.1% solution) are used.

Amoxicillin oral solution is not the correct answer. Topical treatments are usually enough to resolve episodes of acute otitis externa. However, should it become recurrent or if signs of invasive infection (such as fever or cellulitis) are present, then oral antibiotics may be necessary. Amoxicillin would likely not be chosen over an oral fluoroquinolone and is more likely to be chosen as treatment for acute otitis media.
Ecothiophate
Cholinomimetics are front-line drugs in the treatment of open-angle glaucoma. The cholinomimetics (or cholinergic agonists) include direct-acting choline esters with M3-muscarinic activity such as pilocarpine and carbachol, and indirect-acting cholinesterase inhibitors such as physostigmine and echothiophate (an ultra-long-acting organophosphate). Cholinesterase inhibitors are nonspecific cholinergic agonists that bind available cholinesterase enzymes such as acetylcholinesterase and plasma cholinesterase. Compared to acetylcholine, these drugs are more slowly hydrolyzed from the enzyme. More importantly, cholinesterase is prevented from inactivating acetylcholine while cholinesterase inhibitor molecules are attached. Physostigmine exhibits reversible cholinesterase inhibition whereas anticholinesterases such as the organophosphates, echothiophate and isoflurophate, produce extended action in glaucoma therapy. The prolonged duration of effect of these cholinergic drugs aids in patient compliance in the treatment of glaucoma. The extended effect is due to the irreversible nature of the cholinesterase enzyme inhibition and the time required to synthesize new enzyme to replace that which has been hydrolyzed. (It should be noted that the risk of cataract development is higher with the organophosphate derivatives than with other drugs used in glaucoma therapy.) The cholinomimetics produce miosis and contraction of the ciliary muscle which increases tension on the trabecular meshwork, opens pores, and improves the drainage of aqueous humor into the canal of Schlemm.

Alpha agonists such as epinephrine cause an increased outflow of aqueous humor through the trabecular meshwork at the anterior chamber angle.
Intranasal corticosteroids
Explanation
The scenario above is describing a common presentation of allergic rhinitis, most likely leaning more towards the seasonal rhinitis. Based on this diagnosis, the most appropriate first-line treatment is intranasal corticosteroids (ICS). The use of ICS for treatment of allergic rhinitis has essentially been a revolution; evidence-based reviews have found ICS to be much more effective and much less expensive than oral antihistamines. They are also less sedating. Key components of ICS therapy that must be addressed with all patients when prescribing them include appropriate training on usage as well as educating the patient that it will typically take 2 or more weeks to note any improvement.

Oral antihistamines are a viable alternative for treatment of allergic rhinitis, but they should not be considered first line. If the patient is unable to tolerate ICS or proper usage cannot be executed, oral antihistamines could potentially be initiated.

Oral steroids and oral decongestants are not indicated for the treatment of allergic rhinitis.

Intranasal decongestants should not be prescribed to any patients who are diagnosed with allergic rhinitis, and they should be discouraged in general. These over the counter nasal sprays will lead to a condition known as rhinitis medicamentosa after around 5 - 7 days of treatment; a characteristic of this condition is severe rebound nasal congestion. Increased and longer use of intranasal decongestants will further worsen this condition, creating a viscous and endless cycle.
Beclomethasone (Beconase) nasal spray
xplanation
This patient is demonstrating signs and symptoms consistent with a nasal polyp and contributory allergic rhinitis. They present as yellowish boggy masses of hypertrophic mucosa and are associated with long-standing allergic rhinitis.

Intranasal corticosteroids are the mainstay of treatment of allergic rhinitis. Intranasal corticosteroid sprays have revolutionized the treatment of allergic rhinitis. Evidence-based literature reviews show that these are more effective (and frequently less expensive) than nonsedating antihistamines. Patients should be reminded that there may be a delay in onset of relief of 2 or more weeks. Corticosteroid sprays may also shrink hypertrophic nasal mucosa and nasal polyps, thereby providing an improved nasal airway and osteomeatal complex drainage. Because of this effect, intranasal corticosteroids are critical in treating allergy in patients prone to recurrent acute bacterial rhinosinusitis or chronic rhinosinusitis.

Intranasal anticholinergic agents, such as ipratropium bromide 0.03% or 0.06% sprays (42-84 mcg per nostril 3 times daily), may be helpful adjuncts when rhinorrhea is a major symptom. Ipratropium nasal sprays are not as effective as intranasal corticosteroids for treating allergic rhinitis but are useful for treating vasomotor rhinitis.

In general, first- and second-generation antihistamines have been shown to be effective at relieving the histamine-mediated symptoms associated with allergic rhinitis (e.g., sneezing, pruritus, rhinorrhea, ocular symptoms), but are less effective than intranasal corticosteroids at treating nasal congestion. Antihistamines offer temporary, but immediate, control of many of the most troubling symptoms of allergic rhinitis. Over-the-counter antihistamines include nonsedating loratadine (10 mg orally once daily), fexofenadine (60 mg twice daily or 120 mg once daily), and minimally sedating cetirizine (10 mg orally once daily).

Clindamycin is an antibiotic and not appropriate for non-infections conditions.

Oral and topical decongestants (such as Sudafed) improve the nasal congestion associated with allergic rhinitis by acting on adrenergic receptors, which causes vasoconstriction in the nasal mucosa, resulting in decreased inflammation. The abuse potential for pseudoephedrine should be weighed against its benefits. Common adverse effects that occur with the use of intranasal decongestants are sneezing and nasal dryness. Duration of use for more than 3 to 5 days is not usually recommended, because patients may develop rhinitis medicamentosa or have rebound or recurring congestion. Because oral decongestants may cause headache, elevated blood pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia, patients with underlying cardiovascular conditions, glaucoma, or hyperthyroidism should only use these medications with close monitoring.
Loss of cochlear hair cells

Explanation Hearing loss may be the result of one of two basic problems. Auditory disorders may be related to either conductive disorders, or sensorineural disorders. Conductive disorders are those that result from the mechanical impedance of sound waves from reaching the auditory sensory receptors. Sensorineural disorders are those that result from the loss of the ability to transduce or convey the mechanical signal into the neural signal. Fibrosis of the tympanic membrane, excessive secretion of cerumen in the external auditory meatus or ankylosis (bone deposition) of the stapes at the oval window are all examples of conductive disorders leading to hearing loss.Furthermore, conductive disorders such as these would result in a clinical situation with the loss of sound at all frequencies, rather than only a high frequency or selected frequency. Loss of the cochlear hair cells, particularly at the beginning of the basal turn of the cochlea, typically result in the loss of high frequency sounds. This is due to a sensorineural disorder which results in the loss of a specific frequency due to inability to transduce or convey the mechanical signal to a neural signal. This selective hearing loss of high frequency sounds, such as that of a beeping microwave oven, can be associated with hearing disorders during the process of aging.Loss of neurons from the spiral ganglion would be another example of a sensorineural disorder. The loss of otoconia in the otolithic membrane would probably have little effect on auditory responses.
Herpetic gingivostomatitis
Explanation
Herpetic gingivostomatitis, caused by herpes simplex virus type 1, is the most common cause of stomatitis in children 1 - 3 years of age. Symptoms may appear abruptly, with high fever, drooling, fetid breath, and refusal to eat, as noted in the above vignette. However, the fever may precede the oral lesions by 2 - 3 days and presage to a more insidious onset of the disease. The tongue, cheeks, and gingiva are most commonly affected, but the entire oral cavity may be involved. These areas can present with ulcers that are yellowish-gray in color, and the gingiva may be quite friable. Drooling may be present secondary to the pain associated with chewing and swallowing, and dehydration is a real concern in the management of the patient. Cervical and submaxillary adenitis is common. The acute phase may last up to 1 - 2 weeks. Treatment consists of measures to relieve the pain and facilitate the intake of fluids for adequate hydration.

Oral candidiasis (thrush) typically presents in the infant period and is usually caused by the yeast Candida albicans. This common affliction presents with white curd-like plaques on the oropharyngeal mucosa and tongue. Scraping the plaques may reveal an erythematous base. Treatment is usually accomplished with oral nystatin. It may be seen in older infants and children on antibiotic treatment or with immunodeficiencies.

Herpangina is usually associated with a prodrome of fever, headache, and occasional emesis. Lesions are characteristically 1 - 3 mm in diameter, present as vesicles and ulcers, and are yellow-white in color. Each lesion is surrounded by an erythematous halo up to 10 mm in diameter. The lesions are most always found on the anterior tonsillar pillars, as well as the uvula, soft palate, and tonsils. The anterior mouth is rarely affected. The illness is caused by members of the Enterovirus family and the affected children do not appear as toxic as those that have herpes gingivostomatitis. Treatment is supportive and the acute phase lasts 3 - 6 days.

Nursing bottle caries is relatively common, and it is seen in patients that sleep with a bottle in their mouth. These children present with significant erosion of the enamel of the anterior dentition. Treatment typically consists of extraction of severely affected teeth to prevent pain and spread of infection of contiguous tissues.

Impaction of a foreign body would lead to pain, edema, and erythema of only a localized portion of the gingivae and not the widespread inflammation noted in the vignette. Difficult cases should be referred to a dentist for further treatment.
Hordeolum
Explanation
The clinical picture is suggestive of hordeolum, which is an infection of the lid glands. The most common causative agent is staphylococcus aureus, which may either be acute or subacute. When the Meibomian glands are infected it is referred to as internal hordeolum, wherein the lesion tends to be large and extend to the skin or conjunctival surface. If it affects the glands of Zeis and Moll, it is referred to as an external hordeolum or stye. It is smaller, more superficial, and points to the lid margins. Treatment, like any abscess, is warm compresses and surgical drainage (if needed). Topical antibiotics are also used. If left untreated, it may progress to cellulitis of the lid or orbit, which requires systemic antibiotics. Recurrence is also frequent, and children with recurrent styes should be evaluated for an immunologic problem.

Blepharitis is an inflammation of the lid margins, which is characterized by redness and a scaling or crusting lesion. It is initially manifested by itching, irritation and burning sensation. It is recurrent, chronic, and usually bilateral. In cases of the seborrheic type, the scales are greasy, erythema is less, and ulceration seldom occurs. In cases of the staphylococcal type, ulceration is common; lashes may fall out, and it is often accompanied by conjunctivitis and superficial keratitis. Most of the blepharitis is of mixed type. Application of antistaphylococcal agent or sulfonamides directly to the lids daily is the treatment of choice. Daily cleaning of the lid with moist cotton applicator to remove scales and crusts is very helpful.

Chalazion is an inflammation of the meibomian glands characterized by a firm nodule on the upper eyelid, which is non-tender. It differs from hordeolum because it does not have the presence of inflammatory signs. Excision is recommended if the nodule is large enough to cause astigmatism by exerting pressure on the globe. Some cases subside spontaneously.

Entropion is a condition in which the lid margin is directed inwards. It usually causes discomfort and corneal damage because the eyelashes are also turned inwards. It is most commonly caused by scarring due to inflammation seen in trachoma; it may also result from Steven-Johnson-syndrome. Surgery is effective.

Ectropion is the opposite of entropion, in which the lid margin is turned outwards or everted; it is associated with an overflow of tears, maceration of the lid skin, inflammation of exposed conjunctiva, and/or superficial exposure keratopathy. Scarring from inflammation, burns, trauma, or orbicularis muscle weakness from facial palsy are the common causes. Surgical correction is necessary to protect the cornea.
Intravenous antibiotics and surgical consultation
Explanation
A peritonsillar abscess results from a complication of acute tonsillitis. Usual etiologic agents include group A streptococci, Staphylococcus aureus, Streptococcus pneumoniae, and oral anaerobes. The infections have a rapid onset, and they are accompanied by fever, severe sore throat, trismus, drooling, alterations in speech and dysphagia. The tonsil is unilaterally displaced medially with erythema and edema of the soft palate. Uvular deviation may be deviated to the opposite side. The infection is usually unilateral, but can be seen bilaterally in up to 10% of cases.

Therapy consists of intravenous antibiotics and surgical drainage of the abscess. Some surgeons may opt for serial aspirations of the abscess. Occasionally the infection may be seen early in the course and intravenous antibiotics are all that is required. However, this patient has frank abscess formation and, therefore, would require surgery.

Oral or intramuscular antibiotics are not indicated initially. Throat culture may help guide therapy, but should never be a replacement for hospitalization and surgical consultation. Complications include upper airway obstruction, aspiration pneumonia due to rupture of the abscess, and spread to the retropharyngeal or mediastinal spaces. Tonsillectomy may be done in an elective basis 3 to 4 weeks after the inflammation resolves. Acute tonsillectomy may be performed for significant airway obstruction or other complications.
Mometasone furoate (Nasonex) 100 mcg (2 sprays) once daily per nostril
Explanation
The treatment options for patients with allergic rhinitis are numerous, and choosing which medication to use in a particular patient is based on his/her clinical symptomatology as well as its timing, efficacy, cost, and side effects.

Intranasal corticosteroid sprays (e.g., mometasone furoate, fluticasone propionate/Flonase, etc.) have revolutionized the treatment of allergic rhinitis, and evidence-based literature shows that these medications are more effective than non-sedating antihistamines. In some cases, they are also less expensive. Because intranasal corticosteroid sprays also can shrink hypertrophic nasal mucosa seen in allergic rhinitis, increasing airway patency and enhancing drainage, these medications are also crucial in treating allergy patients prone to recurrent sinusitis. Side effects are limited, with epistaxis being the most bothersome.

Numerous over-the-counter (OTC) and prescription antihistamines are available. First generation antihistamines (diphenhydramine, brompheniramine, and chlorpheniramine) offer immediate but temporary control of many of the most troubling symptoms of allergic rhinitis. While these medications are inexpensive, they are usually associated with higher rates of drowsiness. Second generation antihistamines (cetirizine, fexofenadine (Allegra), loratadine, and desloratadine (Clarinex)) boast less sedation, but still can cause some levels of drowsiness and are usually more expensive, even those that are now over the counter (loratadine and cetirizine). Other potential side effects of oral antihistamines include xerostomia (dry-mouth), dizziness, decreased urination, and blurred vision.

Intranasal anticholinergic agents (ipratropium bromide) can be helpful as adjunct therapy when rhinorrhea is a major symptom. However, these nasal sprays are not as effective as intranasal corticosteroids for treating allergic rhinitis and are more useful for treating vasomotor rhinitis.

Oxymetazoline is an intranasal alpha agonists that causes vasoconstriction. It may be used for relief of nasal congestion caused by allergic rhinitis. However, it is not recommended to be used long-term, owing to the risk of rebound vasodilation and development of dependence.

As stated above, allergy patients can be prone to both acute and recurrent/chronic bacterial rhinosinusitis as a result of allergy-induced hypertrophy of the nasal mucosa and impaired osteomeatal complex drainage. While antibiotics (e.g., amoxicillin) may be necessary in these patients to treat the associated infection, they are not indicated in the current care of this patient.
Pseudomonas A
Explanation
Pseudomonas aeruginosa is a Gram-negative facultative bacilli that grows on MacConkey as a nonlactose fermenter (colonies are not pink). Colonies can appear to have a blue to purple hue due to the production of pigments, and they may also produce a grape-like odor. The organism is oxidase positive, citrate positive, and does not ferment carbohydrates. The organism is a major pathogen and a common cause of nosocomial infections. Because it is a common nosocomial pathogen, they tend to multiply resistant organisms when isolated in the hospital setting. The organism can cause infections in all areas of the body, and these infections can range from mild to life threatening in severity. Pseudomonas aeruginosa infections of the ear are associated with swimming ("swimmer's ear"), an external otitis. Injury, wet humid conditions, inflammation, and maceration can predispose the external auditory canal to Pseudomonas aeruginosa infections. External otitis due to Pseudomonas aeruginosa is common in humid southern climates.

Moraxella catarrhalisis a Gram-negative cocci that is relatively plump and occurs in pairs. The organism was until recently called Branhamella catarrhalis. Moraxella catarrhalis is oxidase positive, catalase positive, non-motile, oxidation and fermentation glucose negative, and nitrate negative. Growth is good on blood and chocolate agar but variable on MacConkey agar. Moraxella catarrhalis is generally resistant to penicillin due to the overwhelming incidence of B-lactamase production among various strains. The organism is a saprophytic organism of the upper respiratory tract and occasionally of the female genital tract. It is a commonly isolated pathogen in pediatric patients and immunocompromised or debilitated adults (especially in the hospital setting). Moraxella catarrhalis plays an important role in otitis media and sinusitis, as well as nosocomial pneumonia and various other infections.

Streptococcus pneumoniae is a Gram-positive cocci that occurs in pairs and is "lancet" shaped. The organism is catalase negative, alpha-hemolytic on blood agar, grows best at 35° C with a 5% CO2 atmosphere, is negative for bile esculin as well as failing to grow in 6.5% NaCL, and is bile soluble. Streptococcus pneumoniae is the number 1 cause of acute otitis media (the 2nd being Haemophilus influenzae, and the 3rd being Moraxella catarrhalis). In children, it is the cause of otitis media in 40 - 50% of the cases in which an etiological agent is isolated. In adults, it is found to also be the major cause of otitis media. Prior viral respiratory infections are thought to be contributory to the predisposition and development of Streptococcus pneumoniae otitis media due to the congestion of the opening to the eustachian tube. The organism can cause a variety of other infections including bacteremia and meningitis.

Haemophilus influenzae is a Gram-negative cocco-bacillus that is small and light staining. It will only grow on chocolate agar due to the organism requiring the presence of growth factors hemin and NAD for growth. In chocolate agar media, the growth factors (found in red blood cells) are released in the media, while in blood agar media, the growth factors are trapped within the red cells and thus are unavailable to Haemophilus influenzae. Haemophilus influenzae is the 2nd most common cause of otitis media. Otitis media due to Haemophilus influenzae most commonly occurs between the ages of 6 months to 5 years. The organism can cause a variety of other infections, most importantly meningitis in children as well as sinusitis.

Bacteroides fragilis is a Gram-negative anaerobic bacilli. Biochemical reactions of significance are growth at 20% bile, indole positive, and resistance to kanamycin/vancomycin/colistin. The organism will only grow under strict anaerobic conditions. It can be a cause of chronic otitis media infections and is frequently found concomitantly with other organisms such as streptococci, staphylococci, and Pseudomonas aeruginosa.
Erythrogenic toxin
Explanation
Erythrogenic toxin (streptococcal pyrogenic exotoxin) is produced by Streptococcus pyogenes. The toxin is responsible for the rash of "scarlet fever". The toxin has been shown to exhibit pyrogenicity and cytotoxicity. It usually appears at the 2nd day of infection, on the upper part of the chest, spreading to the rest of the trunk out towards the rest of the body, with the palms, soles, and face being spared.

Exfoliative toxin, produced by Staphylococcus aureus, is responsible for scalded skin syndrome (SSS), wherein the patient appears to have acquired a burn of the skin. There is extensive scalding and flaking desquamation of the epidermis. The syndrome is especially common in infants and small children.

Elastase is an extracellular protease that is produced by Pseudomonas aeruginosa. The protease is associated with the organism's virulence due to tissue destruction and bacterial invasion. Elastase is necrotizing to the skin, cornea, and lung; it is capable of producing hemorrhage.

Enterotoxin is produced by various bacteria. In Clostridium perfringens, the production of this toxin causes the symptoms of food poisoning. Clostridium perfringens type A is most associated with this toxin production. Enterotoxin is thought to act as a superantigen, which causes a massive release of inflammatory mediators and induces a calcium ion-dependent breakdown of permeability.

Exotoxin (diphtheria toxin) is produced by Corynebacterium diphtheriae. The toxin inhibits protein synthesis in mammalian cells, but not bacteria. It affects all cells in the body; the heart, nerves, and kidney are impacted the most.
Correct Answer: Bilateral laser peripheral iridotomy
This is a procedure during which a puncture-like opening is made near the base of the iris in order to decrease intraocular pressure in patients with angle-closure glaucoma. While there are various medications used to treat acute episodes, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. If this occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally.

Left laser peripheral iridotomy is not the correct answer. While there are various medications used to treat acute episodes of angle-closure glaucoma, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. Narrow anterior chambers always occur bilaterally. If acute angle-closure glaucoma occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally as opposed to being done in JUST the affected eye.

IV acetazolamide is not the correct answer. This medication is given in episodes of acute angle-closure glaucoma in order to decrease the intraocular pressure. It is typically given in a single 500mg IV dose followed by 250mg orally 4 times daily. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient's underlying issue is narrow anterior chambers.

Oral glycerol is not the correct answer. This medication is an osmotic diuretic that can be given 1-2 g/kg in order to decrease a patient's intraocular pressure during an acute episode of angle-closure glaucoma. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient's underlying issue is narrow anterior chambers.

Topical timolol 0.25% is not the correct answer. This medication is a topical β-adrenergic blocking agent used twice daily chronically in patients who have chronic glaucoma. The disorder does not require the acute lowering of intraocular pressure such as angle-closure glaucoma. Topical timolol would not be effective in lowering intraocular pressure in patients with angle-closure glaucoma.
Hearing loss can be recognized at the bedside as either sensorineural or conductive through the Rinne and Weber tests. In this case, the Rinne test bone conduction (BC) lasts longer than air conduction (AC) in the right ear ( affected ear) and the Weber test lateralizes to the right ear (affected ear). Normally AC lasts longer than BC because of the amplifying effects of the eardrum and middle ear. If BC is longer than AC, the patient is likely to have conductive deafness. Both tests in this patient indicate a conductive hearing loss in the right ear probably produced by cerumen impaction since there is no apparent evidence of middle-ear disease. In sensorineural hearing loss, both AC and BC are equally diminished.

Right ear sensorineural hearing loss due to Meniere's disease is incorrect. The patients Rinne and Weber test results indicate conductive hearing loss confined to the right ear not sensorineural hearing loss. There is no evidence of Meniere's disease.

Left ear sensorineural hearing loss due to Meniere's disease is incorrect. This patient's hearing tests indicate a conductive hearing loss in the right ear. In sensorineural hearing loss both AC and BC are equally diminished. Symptoms of Meniere's disease are not present.

Left ear conductive hearing loss due to middle-ear disease is incorrect. The patient's hearing tests indicate a conductive hearing loss in the right ear not the left.

Right ear sensorineural hearing loss due to acoustic neuroma is incorrect. There is no evidence of sensorineural hearing loss or acoustic neuroma in this patient.
Daily cleaning with a damp cotton and baby shampoo

The scenario presented above depicts a patient with anterior blepharitis, which is a common disorder seen in primary care; it typically consists of a recurrent bilateral inflammation of the lid margins that involves the eyelid skin, eyelashes, and associated glands. Commonly, the underlying cause is seborrhea, which usually originates in the scalp, eyebrows, or ears. Sometimes, anterior blepharitis can be ulcerative, and the origin in the presented case is staphylococci. Anterior blepharitis can typically be resolved and controlled by cleaning the affected areas daily using a damp cotton applicator, warm water, and a baby shampoo mixture. The object of the daily cleaning is to remove the visible scales as efficiently as possible. None of the other listed options are an appropriate treatment plan for anterior blepharitis.

Patients can also be diagnosed with what is known as posterior blepharitis, which is an inflammation of the meibomian glands of the eyes. It is usually staphylococcal in origin, and it typically presents with significantly worse signs and symptoms, such as hyperemic lids, the presence of telangiectasias, inflammation of the gland or their orifices, or even abnormal secretions; tears may be described as being frothy or greasy. More significant cases of posterior blepharitis can lead to conjunctivitis, hordeola, chalazions, eyelash trichiasis, or even corneal vascularization and thinning. Treatments for posterior blepharitis may consist of long-term oral antibiotic therapy, short-term topical steroids, or short-term topical antibiotics eye drops; if significant complications are evident, an ophthalmologist referral is indicated.
Estropia
The corneal light reflex test, also called the Hirschberg test can reliably differentiate pseudoesotropia from true esoptropia. The corneal light reflex or small white dot on the front of the eye should be in the same position in each pupil. It is normally just slightly nasal to the center of each pupil. If the position is different in each pupil, then some type of strabismus is present. A prism dipoter (PD) is the unit measuring the deflection of light passing through a prism equal to a deflection of 1 cm at a distance or 1 meter. Infantile esotropia characteristically presents as a constant, moderate-to-large angle measuring approximately 25 to 60 PD with alternate fixation. Infants presenting at 2 to 4 months of age with constant esotropia of 40 PD or greater are valid candidates for surgical repair.

Pseudoesotropia, or a false appearance of esotropia, is caused because the normal wide bridge of the nose covers most of the conjunctiva on the inner aspect of the eyeball. More white conjunctiva is visible lateral than medial to the iris.

Many cataracts or lens opacity in children are actually acquired within the first several years of life. A normal and equal red reflex in each eye will exclude cataracts. This is best done with the room lights dimmed and an ophthalmoscope held about 2-3 feet away from the infant so both pupils can be seen simultaneously, making comparisons easier. Dark lens opacities signify possible cataracts that will eventually produce a gray or white pupillary reflex or leukocoria. It is then best evaluated by a slit-lamp after pupillary dilation.

Most glaucoma can also be excluded with a normal and equal red reflex. Glaucoma is a common, progressive disease characterized by elevated intraocular pressure causing progressive damage to the optic nerve resulting in atrophy and blindness. This is due to improper development of the eye's aqueous outflow system. Diffuse corneal haze will obscure the pupil and iris markings; in addition, the symptomatic triad of epiphora or excessive tearing, photophobia, and blepharospasm is evident.

Retinoblastoma can also be detected with an abnormal red reflex test. The affected eye will appear with the cat's eye, white reflex, or leukocoria. Although rare, retinoblastoma is the most common malignant tumor in children that can be familial or sporadic and can be unilateral or bilateral. Bilateral disease is almost always familial. A mutation of a tumor suppressor gene on chromosome 13 appears to be responsible for tumor development. It may also present with strabismus, hyphema, and periocular inflammation resembling orbital cellulitis.

Amblyopia, or poor or blurry vision, in an otherwise normal appearing eye is caused by either no or poor transmission of the visual image for a sustained period of dysfunction or disuse during early childhood. This can be due to strabismus, anisometriopia, or vision obstructing disorders that result in an opaque ocular media such as with cataracts or corneal scarring from forceps injury. Unless an obvious abnormality is present, amblyopia may have no obvious signs.
intranasal corticosteroids
flonase!
The scenario above is describing a common presentation of allergic rhinitis, most likely leaning more towards the seasonal rhinitis. Based on this diagnosis, the most appropriate first-line treatment is intranasal corticosteroids (ICS). The use of ICS for treatment of allergic rhinitis has essentially been a revolution; evidence-based reviews have found ICS to be much more effective and much less expensive than oral antihistamines. They are also less sedating. Key components of ICS therapy that must be addressed with all patients when prescribing them include appropriate training on usage as well as educating the patient that it will typically take 2 or more weeks to note any improvement.

Oral antihistamines are a viable alternative for treatment of allergic rhinitis, but they should not be considered first line. If the patient is unable to tolerate ICS or proper usage cannot be executed, oral antihistamines could potentially be initiated.

Oral steroids and oral decongestants are not indicated for the treatment of allergic rhinitis.

Intranasal decongestants should not be prescribed to any patients who are diagnosed with allergic rhinitis, and they should be discouraged in general. These over the counter nasal sprays will lead to a condition known as rhinitis medicamentosa after around 5 - 7 days of treatment; a characteristic of this condition is severe rebound nasal congestion. Increased and longer use of intranasal decongestants will further worsen this condition, creating a viscous and endless cycle.
Urgent referral to an otolaryngolist
Acute laryngitis, as in the patient scenario above, is most common cause of hoarseness in patients of all ages. More commonly acute laryngitis symptoms will last a week or more even after the resolution of an upper respiratory infection. Typical treatment at that point in time includes avoidance of vigorous use of his/her voice (such as singing or shouting) until it returns to normal. Often the source of acute laryngitis is viral in origin, but there has been incidence of M. catarrhalis and H. influenzae isolated from the nasopharynx of these patients. For this reason, antibiotics are occasionally prescribed to lessen the severity of hoarseness and cough.

Certain age groups are risk factors and should lead a provider to a more aggressive search for the diagnosis of acute laryngitis. New or longer than 2-weeks duration of hoarseness in a patient who is known to be a heavy smoker (and especially in a patient who is male) is one of those red flags. This should sway one to contemplate squamous cell carcinoma of the larynx until it can be proven otherwise. Squamous cell is the most common malignancy of the larynx and appears exclusively in patients with a history of significant tobacco use, especially men aged 50-70 years. Our patient above substantially fits into this category. Another disturbing component is his unintentional weight loss that is revealed during the review of system questioning; this is of course a constitutional symptom/sign that cannot be missed.

For the reasons listed above, the correct answer is an urgent referral to an otolaryngologist for initiation of evaluation to confirm the suspected diagnosis. Further observation has an extremely low probability of bringing resolution, as is also the case with reassurance and observation. A pulmonology referral is not indicated at this time, and although the patient has the potential of having laryngopharyngeal reflux, the pertinent positives at this point more towards a type of malignancy.
nasal polyps
This patient most likely has nasal polyps, a consequence of long-term rhinosinusitis. Nasal polyps are benign mucosal masses that protrude into the nasal canal and may be unilateral or bilateral. They are associated with chronic allergies and diminished sense of smell.

A deviated nasal septum can produce decreased nasal airflow and present with some congestion-like symptoms. However, the physical exam reveals the septum lying off midline, without the mucosal masses characteristic of polyps.

A nasal foreign body could present with a similar history of nasal congestion and rhinorrhea, but is more frequent in young children at risk for putting objects into their noses. The physical exam would readily identify and distinguish a foreign body from nasal polyps.

Neoplasms, such as nasopharyngeal carcinoma, are rare in comparison to the prevalence of nasal polyps and are typically asymptomatic until late in the disease process. A nasopharyngeal carcinoma is most common in patients of southern Chinese ethnicity. Symptoms might include rhinitis or nasal obstruction, similar to the presentation of this patient. However, a neoplasm may be more likely to include pain, nasal hemorrhage/bleeding, and unilateral symptoms if symptoms were present.

Rhinitis medicamentosa is a condition resulting in severe rebound nasal congestion after prolonged and/or frequent use of nasal decongestants, such as phenylephrine. There are typically no distinguishing physical exam findings from this condition.
Staph Aureus
Staphylococcus aureus is a gram-positive staining cocci that is catalase positive, coagulase positive, and frequently beta hemolytic on blood agar. It is probably the 2nd most common bacterial isolate of human infections behind Escherichia coli and the most common cause of bacterial endophthalmitis. The organism has been described as an etiologic agent of many infections, including but not limited to, conjunctivitis, endocarditis, septicemia, abscesses, and urinary tract infections. The conjunctivitis caused by Staphylococcus aureusis usually characterized as non-severe where there is little to no lid edema, scant purulent discharge, and normal cornea; however, in some cases the presentation can be severe.
Chlamydia trachomatis is an obligate intracellular parasite with a unique biphasic life cycle. It does not gram stain, and laboratory procedures used for diagnosis include isolation in tissue culture, EIA detection of antigen, immunofluorescent staining, cytologic examination for intracytoplasmic inclusions, and by the demonstration of nucleic acid by direct hybridization or by amplification techniques. It can cause inclusion conjunctivitis and ocular trachoma. The inclusion conjunctivitis presents as an acute follicular conjunctivitis and is usually self-inoculated from an infected genitourinary site. The patient frequently complains of a foreign body presence in the eye. These symptoms are usually unilateral, and in the first 2 weeks, there is a mucoid discharge that becomes purulent.

Pseudomonas aeruginosa is a gram-negative rod, non-lactose fermenting, oxidase-positive motile bacteria. Pathogenesis is due to its minimal nutritional requirements, relative resistance to antibiotics, and a host of other invasive and toxinogenic substances that it produces. It can cause a keratitis that is rapid in its development. The infection is usually the result of a previous injury to the eye, which causes an interruption in the epithelial surface and allows bacterial invasion of the underlying stroma. Scrapings from the floor of the ulcer exhibiting gram-negative rods are strongly indicative of Pseudomonas aeruginosa and should necessitate treatment.

Haemophilus aegyptius is a gram-negative coccobacillus, non-motile, fastidious bacteria requiring the presence of special factors for its growth on agar media. These factors are hemin and nicotinamide adenine dinucleotide, which are present in chocolate agar but not on other isolation media. The organism is indigenous to humans. It is an important cause of a purulent conjunctivitis called "Pink Eye" and can occur in outbreaks because of its contagious nature. The diffuse pink color of the sclera and the presence of a serous or purulent discharge are virtually diagnostic of Haemophilus aegyptius infection. Leukocytosis is absent. The infection is not acute in presentation.

Bacillus cereus is a gram-positive (or gram-variable) rod that is aerobic, spore-forming, and is ubiquitous in nature. Bacillus cereus is an important cause of food poisoning. It has also been recognized as an ocular pathogen. The ocular infection is acute in presentation and requires aggressive intervention to save the eye. The presence of progressive corneal deterioration and ring abscess formation is a complication of panophthalmitis caused by Bacillus cereus. Except for infections with Pseudomonas aeruginosa, this finding is almost pathognomonic of Bacillus cereus. Because of the seriousness of the infection, early diagnosis is important. Patients presenting with ocular infections after trauma or in the setting of drug abuse should arouse suspicion.

Acanthamoeba is a free-living amebae that can cause granulomatous amebic encephalitis and keratitis. It can not be cultured by routine culture methods. Detection is usually made by observing the free living motile organisms in a wet prep preparation. Acanthamoeba keratitis is a slow-developing corneal infection that occurs in healthy people and is usually associated with contact lens wearers. Symptoms include blurred vision, conjunctivitis, tearing, severe pain to the eye, and photophobia. The keratitis achieves an advanced stage in several days to several months and can exhibit patchy stromal infiltrates and dendriform epithelial involvement without frank corneal ulceration in its early stages.

Candida albicans is a yeast. Yeasts appear on gram stain as large gram-positive organisms, approximately 3-5 times larger than gram-positive cocci, and are nonhemolytic on blood agar. They are aerobic and generally grow well on most non-selective agar media. Endophthalmitis due to yeast is generally a common and serious complication of intravenous drug use. Candida albicans is the most common fungal cause. It is usually of hematogenous origin where the patient has infective endocarditis or some other infective process occurring. The symptoms are blurred vision, decreased vision, white cotton appearing exudative lesions in the choroid and retina with vitreous haziness, and eye pain. A definitive diagnosis is made by obtaining vitreous fluid for gram stain and culture.
retinoblastoma
The most likely diagnosis is retinoblastoma, as it is the most common primary ocular tumor in children below 5 years of age. 90% of cases are diagnosed below 3 - 4 years of age. The index case is a 1.5-year-old boy who has presented with a recent appearance of squint and absence of normal red reflex in the left eye, replaced instead by a white pupillary reflex (leukocoria). This is due to reflection of light from the white-colored tumor and loss of vision in that eye. The diagnosis is further supported by calcification seen in the globe in the X-ray of the skull. Fundoscopy may show the tumor as a white mass, which may be small and flat or may be large and protuberant. Orbital inflammation, hyphema, and irregular pupil are seen in advanced stages of the disease. Retinoblastoma gene is a recessive gene located on the chromosome13 at the 13q 14 regions, and the tumor may arise from any of the nucleated layers of the retina.

Besides direct observation, ultrasonography or CT scan may help to confirm the diagnosis and demonstrate calcification within the mass. As biopsy can lead to the spread of the tumor, histopathological confirmation of the tumor can be made only after removal of the affected eye

Retinal detachment in infants and children more commonly occurs due to trauma, secondary to other abnormalities like myopia, or after cataract surgery. It can also occur in diabetes, sickle cell disease, and retinopathy of prematurity. Presenting signs can be loss of vision, secondary strabismus (squint), nystagmus, and leukocoria (white pupillary reflex). Calcification seen on an X-ray of the skull in retinoblastoma is absent in retinal detachment. Also ultrasonography and neuroimaging may be required to establish the cause of detachment.

Congenital glaucoma (elevated intraocular pressure) usually manifests during the first 3 years of life. The classical triad of symptoms of congenital glaucoma are epiphora (excessive lachrymation), photophobia (sensitivity to light), and blepharospasm (squeezing of the eyelids). These symptoms are due to corneal irritation. As the cornea and sclera are more elastic during early childhood, the elevated intraocular pressure therefore leads to expansion of the eyeball, including the cornea, and development of buphthalmos (ox eye), which means a large eye. This leads to corneal edema and conjunctival congestion. The cornea may become cloudy. There is no white pupillary reflex or calcification in the globe seen on an X-ray of the skull.

A cataract is an opacity in the lens and may cause significant impairment of vision. It may be an isolated defect or may be a part of a generalized disorder. Common causes are intra uterine infections like rubella, cytomegalovirus infection, toxoplasmosis, metabolic disorders like galactosemia, and chromosomal disorders like trisomy 13, 18, and 21. Trauma to the eyeball is a major cause of cataract in children. The red reflex may be absent or may be irregular or there may be a white pupillary reflex. The retina and the blood vessels may not be visualized due to the lenticular opacities. Nystagmus may be present. Poor visual fixation, squint, and poor social smile may be seen later on. Calcification in the globe is not present in cataract.

Persistent hyperplastic primary vitreous (PHPV) is caused by persistence of portions of the fetal hyloid vascular system and the associated fibromuscular tissue. The condition is usually unilateral, and the affected eye is smaller than normal. The anterior chamber is shallow, and the lens is also smaller than normal. Other presenting signs are white pupillary reflex (leukocoria) strabismus and nystagmus. The course is progressive and outcome is poor.

The major complication is spontaneous intraocular hemorrhage, swelling of lens caused by rupture of posterior capsule, and glaucoma. Sometimes the distinction between PHPV and retinoblastoma can be difficult. Ultrasonography and CT scan can be useful diagnostic aids that may show calcification within the mass in the case of retinoblastoma.
Basal cell carcinoma
The lesion being described in the above patient scenario is most likely to be basal cell carcinoma. Key characteristics of lesions of basal cell include having a pearly, papular, erythematous patch that is usually larger than 6 mm or possibly appearing as a non-healing ulcer. The areas in question will commonly be found on sun-exposed areas of the body, specifically the face, trunk, or lower legs.

Squamous cell carcinoma appears as a non-healing ulcer or a wart-like nodule. This also is due to long time sun exposure and is especially common in patients who are fair-skinned or those that are organ transplant recipients.

Malignant melanoma is another type of skin cancer that patients may present with but the characteristics are distinctly different from the 2 previous skin cancers described. Malignant melanoma lesions may be flat or raised, and they have irregular borders; initially, they are usually a pigmented area on the skin that has recently noticeably changed in appearance. Clinicians and patients will use the mnemonic "ABCD" rule when evaluating pigmented areas: asymmetry, border irregularity, color variegation, and diameter ? 6 mm.

Actinic keratosis is skin lesions that are not a form of cancer. These are small (0.2 - 0.6 cm) macules or papules that typically flesh-colored, pink, or even slightly hyper-pigmented. They possess a sandpaper consistency and may be tender when palpated. These also occur in sun-exposed area of the skin in fair skinned patients.

Actinic lentigines are also known as liver spots. They commonly present in older patients on areas that have significant exposure to the elements of weather, in such areas as the dorsum of the hand, wrist, and forearm. Lesions of actinic lentigines are also a benign condition.
noise induced hearing loss
It is estimated that 12% of American youth between 12 and 19 years of age have noise-induced hearing loss (NIHL). The louder the sound, the shorter the time it takes to cause hearing loss. Continuous exposure to sound >85 dB can cause damage. There may be a genetic predisposition to NIHL. Damage can be caused by a single sound, such as a gunshot or explosion, or continuous exposure to loud noises. Sometimes, a single loud noise can cause a temporary loss called a threshold shift, which produces ringing in the ears after the event. An early symptom of noise induced hearing loss is trouble understanding speech when there is increased background noise. Symptoms may include distorted or muffled speech, ringing in the ears, or difficulty in hearing in the classroom. Loud noises damage hair cells in the inner ear that send noise impulses to the brain.

Otoscopic examination is generally normal, and rarely reveals tympanic membrane disruption or damage to the ossicles. The Weber test, done by holding a tuning fork on the middle of the patient's head, is only useful with asymmetric hearing loss. The sound localizes to the side with a conductive hearing loss or away from the side with a sensorineural hearing loss. When the sound is heard in the middle of the forehead, it indicates either that hearing is normal or there is a symmetric hearing loss. The Rinne test, done by placing a tuning fork over the mastoid and then moving it to the external auditory canal when sound can no longer be heard, demonstrates air conduction > bone conduction with normal or sensorineural hearing loss and bone conduction > or equal to air conduction with conductive hearing loss.

Chronic NIHL usually requires 10 - 15 years of chronic exposure with constant noise, which is more damaging than intermittent noise. It is always sensorineural, equal bilaterally, rarely produces a profound loss, no longer progresses when the noise is removed, and higher frequencies are more commonly affected. The loss is permanent. It is seen in a wide variety of occupations including factory workers, miners, armed forces, aviation workers, railroad workers, and construction workers.

Meniere's Disease presents with attacks that may include vertigo, tinnitus, and hearing loss. Affected individuals tend to be sensitive to loud noises. Attacks may last from 20 minutes to 24 hours. Hearing loss is usually unilateral and usually progresses to a permanent sensorineural hearing loss. Typical age of onset is 40 - 60 years. It is rare in children. Both the cochlear and vestibular systems are affected.

Otosclerosis may appear as early as 7 - 8 years of age, but it most commonly presents between 15 and 35 years. Hearing loss and tinnitus are the presenting symptoms but vary in severity and rate of progression. Dizziness occurs in some. Causes may include a prior history of frequent otitis media leading to ossicular discontinuity, necrosis of the incus, and replacement of the union between the incus and stapes with a fibrous band. Most commonly, otosclerosis produces a conductive hearing loss due to fixation of the footplate of the stapes in the niche of the oval window. However, it may cause sensorineural hearing loss if it involves other areas of the cochlea. Surgical treatment generally consists of stapedectomy in both children and adults or cochlear implant in advanced cases. Flourides have been used and may slow or halt the progression of the disease. Sodium fluoride, an enzyme inhibitor, reduces osteoclastic bone resorption and may rebuild pseudohaversian bone.

Congenital stapes fixation is detected in the initial 10 years of life and presents with a non-progressive hearing loss. Acquired stapes immobility resulting from typmanosclerosis that fills the oval window with tympanosclerotic plaques. It often results from chronic otitis media and is more common than otosclerosis. Paget's Disease and osteogenesis imperfecta result in stapes fixation and present clinically like otosclerosis. Audiometric evaluation shows conductive hearing loss with absent stapedius reflex.
Peritonsilar abscess
This patient is clearly suffering from a peritonsillar abscess. This occurs when an active infection penetrates the tonsillar capsule and then involves the surrounding tissue. These patients will have a severe sore throat, odynophagia, trismus, deviation of the soft palate, and an abnormally muffled voice (i.e., a 'hot potato voice').

Oral candidiasis (or thrush) does not present with the symptoms described in the scenario. Typically, oral candidiasis is painful and appears as creamy-white, curd-like patches; overlying erythematous mucosa can be found virtually anywhere in the oral cavity. The white patches can easily be wiped off when attempted.

Laryngitis is lower on the differential diagnosis list because it usually presents with the primary symptom of hoarseness. Laryngitis frequently occurs approximately 1 week after the occurrence of an upper respiratory viral infection that has since resolved.

A dental abscess would cause severe, persistent, throbbing toothache, sensitivity to hot and cold temperatures, sensitivity to biting or chewing, fever, possibly noticeable swelling in the face or cheek, or even lymphadenopathy relating back to the site of the abscess. The symptoms of a dental abscess do not match the clinical scenario presented.

Mononucleosis also presents somewhat differently than the scenario above, making it a less likely diagnosis. Malaise, fever, sore throat (sometimes exudative), lymphadenopathy, palatal petechiae, and even splenomegaly are found in patients with mononucleosis.
This patient has signs and symptoms of perennial allergic rhinitis.

Perennial rhinitis is a type 1 hypersensitivity reaction. Patients are symptomatic throughout the year and usually present with chronic nasal obstruction, rhinorrhea and excessive lacrimation. Sinusitis, nasal polyps, or aspirin sensitivity may complicate it. On examination, the nasal mucosa may be edematous, and is usually pale or bluish in color with thin nasal secretions. Nasal polyps maybe visualized. Conjunctival findings include injection and swelling with occasional chemosis.

The diagnosis is made by a positive history of atopic disease, the characteristic bluish red nasal mucosa and numerous eosinophils in a nasal smear stained with Wright stain.

Positive skin tests help to identify the particular allergen. Perennial allergens include:

1. House dust mites

2. Epidermal antigens produced by pets such as cats and dogs

3. Indoor molds such as spores of aspergillus and penicillium

4. Occupational allergens such as platinum salts and wood dust

5. Cockroach skin casts

Treatment should be based on the patient's age and severity of symptoms. Patients should be advised to avoid known allergens and be educated about their condition. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for mild to moderate disease. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies (e.g., nasal irrigation). With the exception of cetirizine, second-generation antihistamines are less likely to cause sedation and impair performance. Immunotherapy should be considered in patients with a less than adequate response to usual treatments.

Antigen avoidance is most effective when a single agent is responsible for the symptoms. When complete avoidance is impossible (as with house dust), exposure may be reduced by such measures as wet mopping and dusting frequently.

Environmental measures such as air conditioners only reduce indoor mold and pollen counts but would not be the most effective measure for this patient who is allergic to house dust, grass and ragweed pollen.

Immunotherapy maybe indicated if a patient continues to experience clinically significant symptoms after appropriate environmental measures, antigen avoidance, and pharmacologic measures have been taken. This is done by injecting an extract of the allergen subcutaneously in gradually increasing doses.
nasopharyngoscopy
Nosebleeds are fairly common in children; they are usually associated with trauma (nose-picking), mucosal friability due to upper respiratory tract infection, and mucosal drying related to environmental conditions. Most episodes are self-limited and require simple measures, such as stopping the bleeding with pressure application (pinching) and comfort care. Recurrent nosebleeds are rarely noted to be due to an underlying anatomic or hematologic abnormality. Patients who require further evaluation are those who:

have very frequent nosebleeds
have bleeding that is difficult to control or localize
have a positive family history of bleeding disorder
have other signs suggestive of a bleeding disorder
In most cases, initial evaluation of patient history and physical examination identifies the source and likely cause of the bleeding. About 90% of nosebleeds occur due to injury to the anterior vascular plexus of Kiesselbach in the anterior nasal septum; this site is usually visible on nasal exam. In this case, the inability to localize the source of the bleeding to the anterior vestibule suggests a more posterior source (bleeding from anterior or posterior ethmoidal or sphenopalatine arteries), which is more difficult to control. Nasopharyngoscopy helps identify the site and direct treatment. If a mass lesion or vascular anomaly is suspected, then CT or MRA may be considered as the next step in evaluation. In this case, chest X-ray would not provide any meaningful information that would help guide management.

For a suspected bleeding disorder, the initial evaluation should include complete blood count with platelet counts, peripheral smear evaluation, prothrombin, time, partial thromboplastin time, and type and cross match sample to be kept if transfusion is anticipated. Based on the initial results, further testing can then be directed towards evaluation for platelet function abnormalities, factor assays, or von Willebrand factor/ristocetin cofactor assay as required.
H influenzae
aemophilus influenzae can cause an acute respiratory obstruction of the upper airways by producing a cellulitis of the supraglottic tissues. Swelling of the epiglottis and aryepiglottic folds with complete obliteration of the vallecular and pyriform sinuses is typical. Children 2 - 7 years of age are prone to this epiglottitis. They will develop acute symptoms quickly, with the initial symptoms being a sore throat, fever, and dyspnea progressing rapidly to dysphagia, pooling of oral secretions, and drooling of saliva from the mouth. The child will many times present as restless and anxious while adopting a sitting position where the neck is extended and chin is protruding to reduce airway obstruction. Characteristically, the epiglottis is red and swollen, and it bears a striking resemblance to a bright red cherry obstructing the pharynx at the base of the tongue. Care should be taken when examining the larynx so as not to induce fatal respiratory obstruction.

Candida albicans (a yeast) is the causative agent of thrush, an infection of the throat and tongue. Thrush is characterized by creamy white curd-like patches on the tongue and on other oral mucosal surfaces. These patches are actually a pseudomembrane consisting of Candida, necrotic tissue, keratin, bacteria, leukocytes, epithelial cells, and food debris. A diagnosis can be made by simply scraping the surface of the lesion and examining for the presence of masses of hyphae, pseudohyphae, and yeast forms. Thrush has become a more common occurrence in children due to the use of inhaled steroids for the treatment of asthma.

Bordetella pertussis (a Gram-negative bacillus) produces an infection that is symptomatic after an incubation period of less than 1 week to more than 3 weeks. This initial symptomatic period is called the catarrhal phase; clinically, patients will exhibit mild conjunctival infection, malaise, lacrimation, rhinorrhea, and a low-grade fever. These symptoms are similar to many upper respiratory or systemic diseases. Within a few days to a week, this phase eventually leads to a dry, nonproductive cough. This cough evolves into a paroxysm that consists of a series of short expiration bursts followed by an inspiratory gasp, which can result in the typical "whoop" of Whooping Cough. The disease will typically produce a leuko/lymphocytosis with a total white blood cells count that can exceed 50,000 cells/mm3. Pulmonary consolidation can be seen on more than 20% in chest radiographs. Coughs, though still paroxysmal, do not always produce the characteristic "whoop" in all patients.

Streptococcus pyogenes is the causative agent of Group A streptococcal pharyngitis, one of the most common bacterial infections of childhood. Streptococcal sore throat primarily occurs in children 5 - 15 years of age, and peak incidence occurs in the first few years of school. Incubation periods are between 2 - 4 days followed by a sudden onset of sore throat, malaise, headache, and fever. Some patients may complain of nausea, abdominal pain, and vomiting. There is redness, lymphoid hyperplasia, and edema of the posterior portion of the pharynx. Tonsils may be enlarged and have grayish white exudate patches on the surface. Tender lymph nodes can be noted at the angles of the mandibles. Temperatures of 101°F or greater are seen and white blood cells counts can exceed 12,000/mm3 with a pronounced left shift. Rheumatic fever can be a complication.

Corynebacterium diphtheriae (a Gram-positive bacillus) is the causative agent of diphtheria, a painful tonsillitis and/or pharyngitis with an associated pseudomembrane production. A presumptive diagnosis can be made by the clinical presentation of a patient with tonsillitis and/or pharyngitis with associated membrane, adenopathy and cervical swelling (especially if associated with membranous pharyngitis and signs of systemic toxicity), hoarseness and stridor, palatal paralysis, serosanguineous nasal discharge with associated mucosal membrane, and a temperature elevation rarely in excess of 103°F. Because of immunization, the disease is not commonly encountered.