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Ophthalmology, ENT & Dermatology Revision Tutorial Main symptoms in Ophthalmology • Red eye • Sudden (or subacute) loss of vision • Gradual deterioration of vision • (Diplopia) • (Transient visual symptoms) • (Others) Bacterial Acute angle closure conjunctivitis glaucoma Keratitis Viral Red Eye conjunctivitis BILATERAL UNILATERAL Allergic Uveitis conjunctivitis Episcleritis Dry eyes Scleritis Question 1 A 65-year-old woman presents with a red left eye and blurry vision associated with nausea and headache which started this morning. On examination of the left eye, there is significant conjunctival injection and the pupil does not respond to light. Right eye is normal on examination. What is the definitive treatment for this condition? A. Topical beta blocker eye drop B. Topical steroid eye drop C. Anti VEGF injection D. Laser peripheral iridotomy E. Vitrectomy Question 1 A 65-year-old woman presents with a red left eye and blurry vision associated with nausea and headache which started this morning. On examination of the left eye, there is significant conjunctival injection and the pupil does not respond to light. Right eye is normal on examination. What is the definitive treatment for this condition? A. Topical beta blocker eye drop B. Topical steroid eye drop C. Anti VEGF injection D. Laser peripheral iridotomy E. Vitrectomy Diagnosis: acute angle closure glaucoma Glaucoma = spectrum of diseases that cause damage to optic nerve **Intraocular pressure (IOP) can be raised or normal** Normal tension glaucoma Ocular hypertension = raised IOP with no damage to optic nerve Closed angle glaucoma = raised IOP , the drainage angle is blocked by the iris Open angle glaucoma = raised IOP is not due to blockage of drainage angle. (Instead due to structural changes of trabecular meshwork etc.) More common than closed angle. Can be acute, chronic or acute on chronic. Acute angle closure glaucoma Risk factors: Old age, female, family history, shorter axial length (hypermetropia/long- sightedness), Asian ethnicity Clinical features: Red eye, eye pain, headache, nausea, vomiting, haloes Fixed mid-dilated pupil Cornea oedema (OE: ‘hazy cornea’) => blurry vision IOP typically >50 (normal 11-21) Management (acute): Immediate ophthalmology referral, can go blind within few hours Reduce pressure: Lay patient supine, IV acetazolamide, topical timolol and latanoprost, aparaclonidine Anti-inflammation: topical dexamethasone Constrict pupil to pull iris off the lens: topical pilocarpine Definitive treatment: Peripheral iridotomyAcute angle closure glaucoma Question 2 A 20-year-old university student presents with 3 days of right-eye pain, redness, photophobia, and a progressive decrease in his vision. The patient wears contact lenses and admits he often does not remove his contact lens before going to sleep. What is the most likely causative organism involved in this case? A. Herpes simplex virus (HSV) B. Herpes zoster virus (HZV) C. Neisseria gonorrhoea D. Pseudomonas aeruginosa E. Acanthamoeba Question 2 A 20-year-old university student presents with 3 days of right-eye pain, redness, photophobia, and a progressive decrease in his vision. The patient wears contact lenses and admits he often does not remove his contact lens before going to sleep. What is the most likely causative organism involved in this case? A. Herpes simplex virus (HSV) B. Herpes zoster virus (HZV) C. Neisseria gonorrhoea D. Pseudomonas aeruginosa E. Acanthamoeba Diagnosis: keratitis Bacterial keratitis Keratitis = inflammation of the cornea Top 3 causative bacteria • Staph aureus • Staph epidermidis • Pseudomonas aeurginosa (contact lens wearer) Contact lens wearer with fresh-water exposure: Acanthoemeba Clinical features • Red eye • Pain (Pain out of proportion if acanthoemba) • Blurred vision • Photophobia • OE: opaque patch on cornea that stains with fluorescein, hypopyon Management: Refer ophthalmology: - Corneal scrap and/or viral swab - Topical antibiotics - Chlorhexidine for acanthoemba (>3 month course!) Viral keratitis Causes: • HSV type 1—Herpes simplex keratitis • HZV—Herpes Zoster Ophthalmicus Herpes simplex (HSV) keratitis Risk factors: contact lens use, corneal abrasion, poor immune function Clinical features: Foreign body sensation Photophobia Blurred vision Reduced corneal sensation Dendritic lesion on fluorescein staining Management: Topical acyclovir (can be initiated by GP) Oral acyclovir (specialist only) Topical steroid (specialist only) Herpes Zoster Ophthalmicus = VZV infection of ophthalmic division of trigeminal nerve (CNV) Clinical features: • Prodromal period (fever, headache, eye pain) • Pain and vesicles unilaterally along nerve distribution • Vesicles on the tip and side of the nose (Hutchinson’s sign) = ocular inflammation and corneal denervation Management: Oral antiviral treatment (e.g. acyclovir 800mg 5 times daily for 7-10 days) to be given within 3 days of vesicles erupting Topical steroidsEpiscleritis and Scleritis Uveitis Inflammation of parts of the uveal tract: iris, ciliary body, choroid (blood vessel layer) Anterior uveitis = inflammation of iris (iritis) and/or ciliary body Intermediate uveitis = inflammation of vitreous Posterior uveitis = inflammation of choroid or retina Panuveitis = inflammation of all structures of uveal tract Uveitis • Red eye, eye pain (except for posterior uveitis), photophobia • **PMHx – arthritis, reactive arthritis, IBD)litis, psoriatic – MS – Sarcoidosis Infective causes of anterior uveitis: HSV, VZV, TB, syphilis Causes of posterior uveitis: CMV, toxoplasmosis Anterior uveitis aka iritis OE: - Keratic precipitates = clumps of inflammatory cells on cornea - Posterior synechiae = adhesion between lens and iris cause pupils to look irregular - Hypopyon = collection of white cells in bottom of anterior chamber Tx: For inflammation: topical steroids (dilating eye drops) eg atropine,cs cyclopentolate, homatropine Bacterial Acute angle closure conjunctivitis glaucoma Fixed mid dilated pupil Purulent discharge N+V No follicles Viral Red Eye Keratitis conjunctivitis Contact lens Watery/clear discharge HSV keratitis: ‘dendritic Follicles under lid ulcer’ BILATERAL UNILATERAL Allergic Uveitis conjunctivitis Itchy ++ Ankylosing spondylitis, Papillae (bumps that are arthritis, IBD bigger than follicles) Episcleritis Dry eyes Pinkish-red eye develop over 1 Scleritis day with no/mild pain Deep boring pain and redness ‘Gritty’, ‘burning’ onsent over a few days No discharge Central retinal Giant cell artery occlusion arteritis SUDDEN VISION LOSS Central retinal vein occlusion PAINLESS PAINFUL Vitreous haemorrhage Diabetic retinopathy Optic neuritis Vitreous Retinal Retinal vein detachment detachment occlusion Question 3 – Diagnosis? A. Diabetic retinopathy B. Retinal artery occlusion C. Retinal vein occlusion D. Vitreous haemorrhage E. Vitreous detachment Question 3 – Diagnosis? A. Diabetic retinopathy B. Retinal artery occlusion C. Retinal vein occlusion D. Vitreous haemorrhage E. Vitreous detachment Question 4 – Diagnosis? A. Diabetic retinopathy B. Retinal artery occlusion C. Retinal vein occlusion D. Vitreous haemorrhage E. Vitreous detachment Question 4 – Diagnosis? A. Diabetic retinopathy B. Retinal artery occlusion C. Retinal vein occlusion D. Vitreous haemorrhage E. Vitreous detachment Retinal vein occlusion Present: - Sudden painless loss of vision - OE: haemorrhage (in the retina) ‘Blood and thunder’ = central RVO Branch retinal vein occlusion Non-ischaemic RVO = macular oedema caused by leaky blood in macula. No RAPD. Tx: intravitreal anti-VEGF injections. RAPD present. = macular oedema + ischaemia. Ischaemic causes neovascularisation. Tx: Anti-VEGF and PRP laser Complication: Neovascularisation in the iris -> rubeotic glaucoma / neovascular glaucoma (a secondary glaucoma) Retinal artery occlusion Present: - Sudden painless loss of vision - OE: pale retina with cherry red spot Central RAO Branch RAO Tx: Urgent ophthalmology review – no tx, vision cannot be saved Urgent TIA clinic appointment – tx to reduce risk of cardiovascular events, no driving until seen in clinic Vitreous haemorrhage Abnormal vessels Rupture of normal vessels Others Diabetic retinopathy Posterior vitreous ….. detachment Neovascularisation from Retinal tear ….. retinal vein occlusion Progression: 1. Vitreous floaters – part of the ageing process. ‘Floaters’, ‘cobwebs’. No tx required. 2. Posterior vitreous detachment = vitreous gel collapse and separates from retina (see pic). Sudden ‘flashing lights’. 3. Retinal detachment, retinal tear - if the vitreous gel that peels away also pulls away the retina with it. Sudden painless vision loss. Tx: Emergency vitrectomy surgery. Vitreous haemorrhage OE: Absent red reflex, cannot see the fundus (back of the eye) Management: 1. Ultrasound B scan to visualize back of eye, looking for retinal tear or retinal detachment 2. Treat according to cause If retinal tear/detachment present: emergency vitrectomy If no retinal tear/detachment: watch and wait, PRP once resolved Diabetic retinopathy (DR) • 60% of T1DM have DR after 30 years • Pathogenesis: damage to capillaries -> leakage and occlusion of capillaries -> retina hypoxia • Complications: Macular oedema (‘diabetic macular oedema’) Neovascularisation (‘proliferative diabetic retinopathy’) Diabetic retinopathy classification Non proliferative vs proliferative Mild NPDR– any of: Microaneurysms Haemorrhage Exudates Cotton wool spot Moderate NPDR - any of: Venous beading Severe haemorrhage Severe NPDR – any of: Venous beading in >=2 quadrants Haemorrhage is all 4 quadrants IrMA (intraretinal microvascular abnormalities) = abnormal branching of capillaries to supply areas of non-perfusion (not the same as neovascularization) Proliferative DR (PDR): NeovascularisationMicroaneurysm Dot blot haemorrhages Hard exudate Cotton wool spot Intraretinal Neovascularisation microvascular abnormality (IRMA) Central retinal Giant cell artery occlusion arteritis SUDDEN VISION Temporal headache Pale retina, cherry red Raised ESR, CRP spot PMR LOSS Central retinal vein occlusion PAINLESS PAINFUL Blood and thunderstorm Vitreous haemorrhage No view of fundus retinopathy Absent red reflex Optic neuritis Vitreous Retinal Reduced colour vision detachment detachment Rocclusionin RAPD Cobwebs, floaters, flashing lights Other features of multiple sclerosis Gradual vision loss Age-related Central visual macular field degeneration Open Peripheral angle vision glaucoma Cataract Diabetic retinopathy Question 5 A 79-year-old man complains of blurry vision which he believes has been developing at least over the past few months. He is finding it difficult to read books. No other symptoms. Appearance on examination: What is the diagnosis? A. Age-related macular degeneration B. Cataract C. Diabetic retinopathy D. Hypertensive retinopathy E. Presbyopia Question 5 A 79-year-old man complains of blurry vision which he believes has been developing at least over the past few months. He is finding it difficult to read books. No other symptoms. Appearance on examination: What is the diagnosis? A. Age-related macular degeneration B. Cataract C. Diabetic retinopathy D. Hypertensive retinopathy Picture shows drusens E. Presbyopia over the macula Question 6 What further investigation should the patient get? A. Ophthalmoscopy B. Optical coherence tomography C. Tonometry D. Ultrasound B scan E. Visual field test Question 6 What further investigation should the patient get? A. Ophthalmoscopy B. Optical coherence tomography C. Tonometry D. Ultrasound B scan E. Visual field test Age-related macular degeneration (AMD) • Most common cause of irreversible vision loss in the UK • Idiopathic • Affects macula = central vision loss; peripheral vision normal • OE: drusens (= lipid deposits in the macula), geographic atrophy • Dry vs Wet AMD differentiated with OCT scan – Dry: drusens, no tx – Wet: drusens + leakage of blood into maculaAMD Diplopia a. third cranial nerve palsy b. fourth cranial nerve palsy c. sixth cranial nerve palsy d. blow out fracture e. thyroid eye disease f. myasthenia gravis Transient visual symptoms a. Migraine b. Amaurosis fugax c. Idiopathic intracranial hypertension Other diagnoses a. Blepharitis b. Internal hordeolum (stye) c. Chalozion d. Periocular tumours e. Pre-septal and post-septal (orbital) cellulitisEar, Nose & Throat Ear discharge – top 5 ddx 1. Acute otitis media 2. Chronic otitis media (cholesteoma) 3. Otitis externa 4. Ear wax 5. Trauma Question 7 A 29-year-old swimmer presents to GP complaining of an itchy ear associated with some discharge. It started 3 days ago. On examination: What is the diagnosis? A. Acute otitis media C. Ear waxeotoma D. Otitis externa E. Otitis media with effusion Question 7 A 29-year-old swimmer presents to GP complaining of an itchy ear associated with some discharge. It started 3 days ago. On examination: What is the diagnosis? A. Acute otitis media – bulging tympanic membrane B. Cholesteotoma – chronic smelly ear discharge, hearing loss C. Ear wax D. Otitis externa – itchy, external ear canal occluded E. middle ear without infection, dull tympanicluid in membrane +/- visible fluidBulging tympanic membrane in AOM Dull tympanic membrane with visible fluid level in OME Eustachian tube dysfunction Accumulation of keratinizing squamous cells (cholesteatoma) Question 8 A 9-month-old baby presents with a 1-day history of increased irritability and tugging of his right ear. One week ago, he suffered from an upper respiratory infection, which has since resolved. On otoscopy of the right ear, there is erythema and bulging of the tympanic membrane. What is the most appropriate treatment? A. Aciclovir B. Amoxicillin C. Co-amoxiclav D. Grommet insertion E. Paracetamol Question 8 A 9-month-old baby presents with a 2-day history of increased irritability and tugging of his right ear. One week ago, he suffered from an upper respiratory infection, which has since resolved. On otoscopy of the right ear, there is erythema and bulging of the tympanic membrane. What is the most appropriate treatment? A. Aciclovir B. Amoxicillin C. Co-amoxiclav D. Grommet insertion E. Ibuprofen and paracetamol Question 9 Which of the following is not an indication for immediate antibiotics in acute otitis media? A. Any child under 1 year old B. Bilateral AOM in child under 2 years old C. Otorrhoea D. Redness behind the ear E. Systemically unwell Question 9 Which of the following is not an indication for immediate antibiotics in acute otitis media? A. Any child under 1 year old B. Bilateral AOM in child under 2 years old C. Otorrhoea – suggests perforation D. Redness behind the ear – suggests mastoiditis E. Systemically unwell Treatment for AOM Analgesia Oral antibiotics after 2 days st • 1 line: oral amoxicillin Consider immediate antibiotics if: • Systemically unwell • Signs of mastoiditis or brain abscess • Perforation leading to otorrhoea • Bilateral infection and <2 y.o. • < 3 months old Otitis media Acute otitis media • Pain, erythema and fever, cloudy tympanic membrane on examination. • Most commonly due to respiratory viruses. If bacterial, Strep pneumoniae (40%), H. influenzae (25% to 30%), and Moraxella catarrhalis (10% to 15%). Chronic otitis media • Mucosal: TM perforated in presence of recurrent or persistent ear infection. • Squamous: TM retracted + cholesteatoma Otitis media with effusion (glue ear) • Collection of fluid in middle ear without signs of acute inflammation. • No perforation of TM Question 10 A patient is examined: Weber’s test: sound lateralises to the left ear Rinne’s test: air conduction is louder than bone conduction in both ears. What is the diagnosis? A. Right conductive hearing loss B. Left conductive hearing loss C. Right sensorineural hearing loss D. Left sensorineural hearing loss Question 10 A patient is examined: Weber’s test: sound lateralises to the left ear Rinne’s test: air conduction is louder than bone conduction in both ears. What is the diagnosis? A. Right conductive hearing loss B. Left conductive hearing loss C. Right sensorineural hearing loss D. Left sensorineural hearing loss Weber and Rinne Weber: • Conductive hearing loss: Sound lateralises towards (louder) in affected ear • Sensorineural hearing loss: Sound lateralises away from affected ear Rinne: • Normal: air > bone • Conductive: bone > air • Sensorineural: air > bone Question 11 A patient is examined: Weber’s test: sound lateralises to the left ear Rinne’s test: bone conduction is louder than air in left ear What is the diagnosis? A. Right conductive hearing loss B. Left conductive hearing loss C. Right sensorineural hearing loss D. Left sensorineural hearing loss Question 11 A patient is examined: Weber’s test: sound lateralises to the left ear Rinne’s test: bone conduction is louder than air in left ear What is the diagnosis? A. Right conductive hearing loss B. Left conductive hearing loss C. Right sensorineural hearing loss D. Left sensorineural hearing loss Question 12 A 30-year-old patient presents with heavy bleeding from her left nostril. There is no history of trauma. The patient has been appropriately applying pressure to the septum and sucking on ice cubes but these measures have not helped. Anterior rhinoscopy reveals the following (see image). What is the most appropriate management? A. Cautery B. Discharge with safety netting C. Endoscopic artery ligation D. Nasal packing with Merocel Question 12 A 30-year-old patient presents with heavy bleeding from her left nostril. There is no history of trauma. The patient has been appropriately applying pressure to the septum and sucking on ice cubes but these measures have not helped. Anterior rhinoscopy reveals the following (see image). What is the most appropriate management? A. Cautery B. Discharge with safety netting C. Endoscopic artery ligation D. Nasal packing with MerocelEpistaxis Most epistaxis occur in Little’s Area (aka Kisselbach’s plexus) = where 4-5 arteries anastomose. Sphenopalatine artery. Traumatic epistaxis: anterior ethmoidal artery NB All traumatic nose injuries: rhinoscopy to rule out septal haematoma (must drain urgently) Rhinitis, Rhinosinusitis • Rhinitis = inflammation of lining of nose (mucous membrane) – Congestion, sneezing, itching, nasal discharge (anterior or posterior nasal drip) • Rhinosinusitis = inflammation of linig of nose + paranasal sinuses – plus facial pain or reduced sense of smell ‘Chronic rhinosinusitis’ if >12 wks Rhinitis Treatment: 1. Avoid triggers. 2. Nasal douches 3. If allergic rhinitis: oral anti-histamines. 4. Nasal steroids (best are mometasone and fluticasone as no systemic absorption) 5. Short term only: decongestants, oral steroids Rhinosinusitis • Acute rhinosinusitis (<12 wks) – <10 days: home with simple analgesia and nasal saline irrigation (most likely viral) – >10 days: add intranasal steroids (fluticasone or mometasone) If at least 3 of: discoloured discharge, severe local pain, fever, raised ESR/CRP, double sickening: oral antibiotics to cover for bacterial sinusitis • Chronic rhinosinusitis (>12 wks) – Refer for endoscopy to look for nasal polyps – No polyps: saline, nasal steroids, consider long term abx, consider surgery (CT pre-op) – Polyps: nasal steroids, surgery if no improvement (CT pre-op) Question 13 A 40-year-old woman presents with 4 weeks history of nasal obstruction, discoloured discharge and facial pain. She has been using nasal mometasone for the past two weeks, it initially helped but now her symptoms are back to what they were like before mometasone. Examination reveals purulent nasal discharge and tenderness over left maxillary bone. She is systemically well. What is the most appropriate management? A. Nasal fluticasone B. Oral amoxicillin C. Oral co-amoxiclav D. Oral prednisolone E. Request CT sinuses Question 13 A 40-year-old woman presents with 4 weeks history of nasal obstruction, discoloured discharge and facial pain. She has been using nasal mometasone for the past two weeks, it initially helped but now her symptoms are back to what they were like before mometasone. Examination reveals purulent nasal discharge and tenderness over left maxillary bone. She is systemically well. What is the most appropriate management? A. Nasal fluticasone B. Oral amoxicillin C. Oral co-amoxiclav D. Oral prednisolone E. Request CT sinuses Question 14 – Diagnosis? A. Branchial cyst B. Dermoid cyst C. Thyroglossal cyst D. Sebaceous cyst E. Pharyngeal pouch Question 14 – Diagnosis? A. Branchial cyst – 30s, lump at junction of upper 1/3 and 2/3 of anterior border of sternomastoid muscle (side of neck) B. Dermoid cyst C. Thyroglossal cyst – moves upwards with tongue protrusion D. Sebaceous cyst E. Pharyngeal pouch – elderly, dysphagia, regurgitation, halitosis Neoplasms of salivary glands Benign: Malignant red flags: Hard Rapid growth Tender Overlying skin ulceration Facial weakness Pleomorphic adenomaIndications for tonsillectomy 7 episodes in 1 year 5 episodes per year for 2 years 3 episodes per year for 3 years Obstructive sleep apnoea Quinsy Dermatology With thanks to dermnetnz.org for the images… Question 15 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 15 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 16 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 16 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 17 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 17 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 18 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 18 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 19 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 19 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 20 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis E. Squamous cell carcinoma Question 20 – Diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Melanoma D. Seborrhoeic keratosis – warty, stuck on appearance E. Squamous cell carcinoma Question 21 – Diagnosis? a) Acne conglobate b) Acne fulminans c) Acne vulgaris d) Guttate psoriasis e) Stable chronic plaque psoriasis Question 21 – Diagnosis? a) Acne conglobate b) Acne fulminans c) Acne vulgaris d) Guttate psoriasis e) Stable chronic plaque psoriasis Psoriasis Scaly red plaques Extensor surfaces Stable chronic plaque psoriasis Guttate psoriasis (guttate = raindrops) – Several hundren small lesions – Occurs 2-3 weeks following strep throat Acne • Acne fulmicans = Systemic features (joint pain, pyrexia, hepatosplenomegaly, raised ESR, raised WCC, proteinuria, anaemia) • Acne conglobate = no systemic features Blistering disorders Pemphigus foliaceous - IgG against demoglein 1 - Superficial layer only - superficial it has burstrs because its so Pemphigus vulgaris - IgG against desmoglein 1 and 3 - Blisters with clear fluid - Mucosal symptoms, Nikolsy sign positive Bullous pemphigoid (most common) - Antibodies against basement membrane - Deep layer - Large tense blisters - Itchy - Maculopapular rash prior to blisters