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Wright, 2010 1
Physical Assessment: An Physical Assessment: An Interactive Workshop for Interactive Workshop for
College Health NursesCollege Health Nurses
Physical Assessment: An Physical Assessment: An Interactive Workshop for Interactive Workshop for
College Health NursesCollege Health Nurses
Wright, 2010
Wendy L. Wright, MS, RN, ARNP, FNP, FAANPWendy L. Wright, MS, RN, ARNP, FNP, FAANPFamily Nurse PractitionerFamily Nurse Practitioner
Owner Owner –– Wright & Associates Family HealthcareWright & Associates Family Healthcare
Let’s Talk About Some
C Common Problems
Eye Complaint: History• Chief complaint
• HPI, including the following associated
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HPI, including the following associated symptoms:– Pain, itching, discharge, tearing, blurring, visual
acuity changes, foreign body sensation, photophobia, halo vision
History (continued)• Present status of visual function
– Corrective lens, glasses and use– Last eye examination
• Medications
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M– Systemic– Ocular
• Allergies • Past history
– Ocular disease– Systemic disease
History (continued)• Surgeries (if pertinent)• Family History
– Ocular diseases S t i di
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– Systemic diseases
Physical Examination• Eyebrows
– Note quantity and distribution of hair– Note any scaling or lesions
**Eyebrows are symmetrical and evenly distributed; No d n ss s lin thinnin f th l t l 1/3
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dryness, scaling, or thinning of the lateral 1/3.
**Thinning of the lateral 1/3 of the eyebrow-hypothyroidism
**Scaling-seborrheic dermatitis
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Eyelids• Lids should close in unison to cover the entire eye
– Upper lid margin rests on the superior border of the iris– Lower lid margin rests on the inferior border of the iris– Palpebral fissure: Space between the upper and lower lid
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** Lids close in unison to cover entire eye. The upper lid margin is at the superior border of the iris and the lower lid is at the inferior border of the iris.
Abnormalities of Eyelids• Widening of the palpebral fissure
– Hyperthyroidism (Exopthalmus)• Decrease in palpebral fissure size
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– Dehydration (Endopthalmus)• Ptosis
– Cranial Nerve III Dysfunction– Muscular Dystrophy
Exopthalamus
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Ptosis
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Lid Margins• Lid Margins
– Skin tone– Inversion or Eversion
L i
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– Lesions
** The lid margins are appropriately colored; No lesions, edema, inversion or eversion.
Abnormalities of the Lid Margins• Lesions: Hordeolum, Chalazion• Edema: Allergic Conjunctivitis, Crying, Infection• Entropion: Inversion of Lid Margin
– Spasm or scarring of the lid
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– Eyelashes often invert and irritate the conjunctiva and cornea
• Ectropion: Eversion of Lid Margin– Aging– Exposes the conjunctiva to bacteria– Eye does not drain properly-tearing
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Entropion
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Ectropion
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Eyelashes• Note
– Color– Distribution
Direction in which they point
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– Direction in which they point– Discharge
**Eyelashes are ____ in color, evenly distributed, outward pointing; No discharge or thinning.
Abnormalities of Eyelashes• Thinning
– Make-up– Trichotillomania– Alopecia
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Alopecia• Discharge
– Conjunctivitis– Blepharitis– Dacryocystitis
Blepharitis
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Dacryocystitis
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Conjunctiva• Conjunctiva
– Clear covering over the visible parts of the eye (except the cornea)
– Protective covering for the eye• Bulbar
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Bulbar– Clear covering and the blood vessels that cover the
sclera• Palpebral Conjunctiva
– Thin covering above and below the eyeball– Forms deep recesses that fold forward to join the eyelid
Normal Conjunctiva
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Conjunctiva• Bulbar and Palpebral Conjunctiva
– Color– Injection– Lesions– Foreign bodies
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– Foreign bodies
**Conjunctiva is clear and appropriately colored; No injection, pallor, lesions, or foreign bodies.
Abnormalities of the Conjunctiva• Injection
– Conjunctivitis, Irritation from Contact Lens, Iritis, Glaucoma• Pallor
– Anemia• Lesions
P l h d l l ll
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– Pterygium: An opaque, triangular shaped conjunctival lesion usually seen nasally and able to extend over the cornea. May interfere with vision.
– Pinguecula: Yellow nodules usually seen at 3 and 9 o’clock on the conjunctiva. No visual changes.
Pinguecula
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Pterygium
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Sclera• Sclera
– White portion of the eye– May look buff-colored or pale yellow in the periphery
• Note
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– Color– Texture– Lesions
**Sclera are white, smooth; No lesions or icterus.
Sclera
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Abnormalities of Sclera
• Yellow sclera– Physiologic or pathologic jaundice– Resolving subconjunctival hemorrhageR d i l
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• Red appearing sclera– Subconjunctival Hemorrhages
Note: It is actually the bulbar conjunctiva not the sclera that becomes jaundiced or red.
Excessive Vomitting Causing Subconjunctival Hemorrhages
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Cornea• Cornea
– Portion of the anterior aspect of the eye which when viewed from the side, protrudes forward
– Transparent covering that protects the eye– Avascular covering over the iris and pupil
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Avascular covering over the iris and pupil• Note (Use a penlight and view from the side)
– Appearance– Shiny– Lesions– Corneal Light Reflex
Cornea
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Cornea
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Cornea**Cornea are smooth, transparent, and
shiny; No lesions or opacities
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shiny; No lesions or opacities. Corneal light reflex is symmetric bilaterally.
Abnormalities of the Cornea• Arc
– Corneal arcus or arcus senilis– Thin gray-white arc or circle that lies close to the
edge of the cornea or edge of the iris
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– Causes: aging, african americans, hyperlipidemia• Abrasion
– Mild injury to the cornea– Causes include foreign body, trauma, contact lens– Symptoms: pain, photophobia, discharge
Corneal Abrasion
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Herpes Simplex
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Abnormalities of the Cornea• Corneal Ulceration• Opacities
– Cataracts
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– Scarring• Asymmetric Corneal Light Reflex
– Strabismus (esotropia or exotropia)
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Corneal Ulcer
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Asymmetric Corneal Light Reflex
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Exodeviation
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Iris• Iris– Colored portion of the eye– Contains muscle that surround the pupil and
control pupillary sizeh l d
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– These muscles are innervated by CN III• Note
– Appearance– Shape
Iris• Note– Color– Detail– Anterior Chamber
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** Iris is round, symmetric, ____ in color, and with clear detail. The anterior chamber is without blood or pus.
Iris
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Abnormalities of the Iris• Hyphema: Blood in the anterior chamber
– Trauma• Hypopion: Pus in the anterior chamber
– Infection• Anterior uveitis (formerly iritis):
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• Anterior uveitis (formerly, iritis):– Moderate pain, decreased vision, pupil is small and will
become irregular over time– Becomes irregular because the swelling distorts the pupil– Associated with many systemic disorders
• Rheumatoid arthritis, SLE, Ankylosing spondylitis
Abnormalities of the Iris• Iris Color Is Not Identical
– Heterochromia Iridis– If this is seen, suspect Horner’s syndrome– Horner’s syndrome: Sympathetic nerve
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y y pdisruption, most often in the neck. Iris is lighter in color, ptosis of eyelid, loss of sweating on forehead, and pupil is smaller (all on the affected side)
• Brushfield Spots– Down’s Syndrome
Pupils• Pupils
– Normally round – Range in size from 3-7 mm– Allow images and light to enter
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Allow images and light to enter– They change in size to adjust for light and to
focus on an image• Note
– Size– Shape– Regularity
Pupils• Note
– Symmetry– Newborn
• Response to direct light
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p g– Older child
• Response to direct and consensual light
** Pupils are ____mm, round, regular and equal bilaterally and respond briskly to direct and consensual light.
Accommodation• 3 things occur when a person changes focus from a
distant to a near object– The pupils constrict– The eyes converge– The lenses become convex (can not view this)
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– The lenses become convex (can not view this)• Procedure
– Have person focus on an object on a distant wall. Then place an object 10 cm in front of the face. Have the individual switch focus from the distant object to the near object. Have them continue to follow the object as it is brought in toward the nose.
Abnormalities of the Pupils• Aniscoria: Inequality of the pupils
– Normal Variation: Respond normally to light– Increase in Intracranial Pressure
A t A l Cl Gl
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– Acute Angle Closure Glaucoma• Severe pain• Decreased vision• Pupil is dilated• Cornea is cloudy• Increase in intraocular pressure
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Abnormalities of the Pupils• Miosis
– Equally constricted pupils– Drugs, morphine, bright light
• Mydriasis
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My– Equally dilated pupils– Anticholinergic agents, mushrooms, increased
intracranial pressure• Inability to accommodate
– Cranial nerve defect (III, IV, VI)
Visual Acuity• Visual Acuity
– Test of central vision– Controlled by cranial nerve II (Optic)
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– Use a Snellen Chart (wall or hand-held)• Stand 20 feet from wall chart • Place hand held Snellen 13 inches from face
Visual Acuity• Infants
– Central vision is present, may just see light– Optimum distance for visualization: 8-12 inches– Assess by checking direct and consensual response to
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Assess by checking direct and consensual response to light, blinking, extending the head in response to a bright light (Optical blink reflex) and blinking in response to a quick movement of an object toward the eye
• 2-4 weeks, should be able to fixate on objects• 5-6 weeks, coordinated eye movements
Visual Acuity• Child
– Vision: 20/200 at 1 year old, 20/40 at 3, 20/30 at 4-5 years of age
– No test that accurately measures acuity in child < 3– Can test using a hand held Snellen chart or a wall
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– Can test using a hand-held Snellen chart or a wall chart
– Letters and Lazy E are the best tests• Older Child and Adult
– Adult visual acuity is reached at approximately 6 years of age
Visual Acuity
Vi l A it i OD OS d
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Visual Acuity is ____OD, ____OS, and ____OU (corrected or uncorrected)
Abnormalities of Visual Acuity
• Absence of a direct or consensual response to light, absence of blinking, negative optical blink reflex, or failure to blink when an object is moved quickly
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to blink when an object is moved quickly toward the eye: Blindness
• Asymmetric Visual Acuity: Amblyopia
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Red Eye• Differential falls into the following categories
– Infections with or without trauma (conjunctivitis)– Inflammation with or without trauma (uveitis)– Vascular (subconjunctival hemorrhage)
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( j g )– Systemic diseases– Allergies– Chemical– Acute glaucoma
Non-vision Threatening Causes of Red Eye
• Subconjunctival hemorrhage• Hordeolum• Chalazion
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Chalazion• Blepharitis• Conjunctivitis• Dry eyes• Corneal abrasions
Hordeolum• Etiology
– Obstruction of the glands of Zeiss– Staphylococcal aureus is the most common
causative organism
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g• History
– Swollen, red, painful lesion on the lid margin– Itchiness of the eyelid
Hordeolum• Physical examination
– Erythematous, tender nodule on the margin of the eyelid
– Surrounding edema
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g• Treatment
– Warm compresses-20 minutes qid– Antimicrobial ointment or drops– Good eye hygiene and handwashing
Hordeola
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Hordeola
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Internal Hordeola
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Chalazion• Etiology
– Obstructed meibomian glands– Chronic inflammatory lesion that grows inward as
it enlarges
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g– May become infected
• History– Lesion on the outside of the eye– May become slightly inflamed– Usually non-tender
Chalazion• Physical examination
– May or may not visualize a nodule on the outside of the eyelid
– Visible on the inside of the lid– May become erythematous tender and edematous
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– May become erythematous, tender and edematous• Treatment
– None– Antimicrobial agent if infected– Surgical management
Chalazion
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Chalazion
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Chalazion
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Chalazion Removal
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Case Study 1: TM• TM is a 19 y.o.w.m student with a 2 day history of
yellow discharge & redness in both eyes.– Began approximately 2 weeks after developing a cold– Associated with a mild blurring of the vision and itching– Denies pain photophobia other visual changes headache
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– Denies pain, photophobia, other visual changes, headache – Has done nothing to treat– Meds: none; Allergies: NKDA, NKEA– PMH: Noncontributory– PE: Visual acuity 20/20 OD, OS, OU; 4 mm preauricular
node
Viral Conjunctivitis• Etiology– Adenovirus is the most common cause– 40 strains available– Recent studies have shown that they can remain viable
on plastic and metal surfaces for up to 1 month
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on plastic and metal surfaces for up to 1 month• Symptoms
– Watery discharge, foreign body sensation, redness– URI symptoms are common including sore throat and
fever– Often bilateral
Viral Conjunctivitis• Signs
– Normal visual acuity, PERRLA, EOMI, Fund nl– Mucoid-slightly watery discharge
Mild diff i j ti
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– Mild, diffuse injection– Preauricular lymphadenopathy
• Treatment– Symptomatic only– Cool compresses– Strict eye hygiene
Viral Conjunctivitis
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Viral Conjunctivitis
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Viral Conjunctivitis
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Bacterial Conjunctivitis• Etiology
– Staphylococcal– Streptococcus pneumoniae/pyogenes
Haemophilus influenzae
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– Haemophilus influenzae– Neisseria
• Symptoms– Redness, swelling, purulent discharge, itching– No symptoms until eye complaints began
Bacterial Conjunctivitis• Signs– Normal visual acuity, PERRLA, EOMI, Fund nl– Diffuse injection– No ciliary injection
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y j– Unilateral at onset
• Treatment– Topical antimicrobials x 5-7 days– Warm compresses qid x 10-20 minutes– Strict eye hygiene given contagion
Bacterial Conjunctivitis
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Bacterial Conjunctivitis
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Vision Threatening Red Eye Disorders
• Corneal Infections or Ulcerations• Hyphema• Hypopion
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• Iritis/Uveitis• Acute Angle Closure Glaucoma• Orbital Cellulitis• Chemical injury (particularly-alkali)
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Case Study 3: TYTY is a 6 yowm who presents with his mom
for an evaluation of (R) pink eye. Began this am. Denies discharge, itching, recent URI. Mom denies trauma but does report strange occurrence yesterday. He failed
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strange occurrence yesterday. He failed to respond to her calling. When he finally came, he reported being asleep outside.
PE: Absent red reflex-OD; Visual acuity 20/100 (OD); 20/30 (OS); Pupil-slightly constricted (OD). Unable to view the fundus (OD)
Hyphema• Definition– Bleeding into the anterior chamber of the iris– Causes include trauma or surgery
• Symptoms
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ymp m– Pain, red eye, blood in anterior chamber– Blurred or Absent vision
• Signs– Absence of the red reflex– Blood in the anterior chamber– Increased IOP
Hyphema• Signs
– Decreased visual acuity– Injected conjunctiva (mild-severe)
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Hyphema
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Complication of Hyphema
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Hyphema• Treatment
– Always assume that the globe is ruptured as 25% have other serious ocular injuries
– Shield the eye and refer immediately
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y y– Can lead to devastating visual complications
including blood staining of the cornea, glaucoma, atrophy of the optic nerve
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Reasons to Refer Immediately• Sudden unilateral loss of vision• Lacerations that involve the lid margin or
tear duct apparatus• Ocular pain photophobia ciliary injection
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• Ocular pain, photophobia, ciliary injection• Corneal ulceration• Hyphema or Hypopion• Pupillary distortion• Central or deep foreign body• Iritis or scleritis
Blowout Fracture
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Blowout-Fracture
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Aerosol Can Explosion
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Otitis MediaJohn...
• John is a 19 year old male who is new to the practice. Presents with a 3-day history of right ear pain, nasal discharge and fever of 102. I s d i it bilit d s d sl d Increased irritability, decreased sleep and appetite. Last urine-2 hours ago. – PE: Ears: Canals pale white. Right TM erythem, edem
and without movement. Left TM-slightly retracted. Nasal mucosa pink. Tonsils pink: no exudate. Nodes: nonpalpable, nontender; Lungs: clear bilaterally
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Ear Canal• Anatomy Overview :
– The external canal is an S-shaped pathway leading to the middle ear
It is approximately 2 5 cm long covered with a thin layer of– It is approximately 2.5 cm long, covered with a thin layer of very sensitive skin.
– The canal is protected and lubricated with cerumen, secreted by the sebaceous glands in the distal 1/3 of the canal.
Otitis Media• Symptoms
– Fever– Pain
Di h f– Discharge from ear– Tugging or batting at the ear– Irritability, crying, lethargy– Decreased appetite– Decreased sleep– Recent URI
Otitis Media
• Signs– Red, bulging tympanic membrane
– Retracted with pus, fluid or air bubbles
– No movement with insufflation
– Inability to see normal landmarks
– Occasionally-hole in the tympanic membrane
Ears• Auricles
– Position– Size
Lesions– Lesions– **Auricles are level with the outer canthus of the eye
and symmetric. They are proportionate in size to the body without lesions or deformities
Abnormalities of the Auricle
• Small or Low-Set Ears: Congenital Defects– Accutane exposure in utero
• Large Protruding Ears: Fragile X SyndromeLarge Protruding Ears Fragile X Syndrome• Protruding Ears: Mastoiditis
EARS• Ear Canal
– Before age 6, pull auricle down, back, and out– Color– Lesions– Discharge– Foreign body– **Ear canals are pale white with a _____amount of
hair present. There are no lesions, discharge or foreign bodies
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Abnormalities of the Ear Canal• Erythema and discharge: Otitis
externa• Foreign bodyg y• Cerumen• Cholesteatoma
EARS• Tympanic Membrane
– Color– Appearance– Bony Landmarks– Cone of Light– Insufflation– **Tympanic membrane is pearly gray, moveable, and
intact AU. The bony landmarks are clearly visible. The cone of light is at 5 o’clock on the right and 7 o’clock on the left. There is no erythema, perforations, or retractions.
Variations of Tympanic Membrane
Normal TMNormal TM
Acute OMAcute OM
Otiti M diOtiti M diOtitis Media Otitis Media with Effusionwith Effusion
Abnormalities of the Tympanic Membrane
• Erythematous, Bulging TM: Otitis Media• Retracted TM: Eustachian Tube
Dysfunction, Serous OMB ll TM B ll M• Bullae on TM: Bullous Myringitis
• Perforation: Trauma, OM, Flying
AOM• S. pneumoniae
– Gram-positive diplococci
• => 25% PCN-resistant via altered protein- binding sites
• Very unlikely to resolve on own
• Usually the sickest
Acute OM• H. influenzae
– Gram-negative bacilli• =>40% amoxicillin-
resistant via beta-lactamase productionlactamase production
• M. Catarrhalis– 90-95% beta-lactamase
producing– Likely to resolve on own
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• Mycoplasma• Intensely painful• Treatment is with
lid
Bullous Myringitis
a macrolide
Pathogens Responsible for Otitis Media
• S. Pneumoniae– Children: 25-36%; Adults: 20-35%
• H InfluenzaeH. Influenzae– Children: 15-23%; Adults 6-26%
• M. Catarrhalis– Children: 15-20%; Adults: 2%
• Viral
Duration of Treatment for AOM
• Regimens evaluated– Numerous treatment options were evaluated
• Treatment success evaluated at 12–14 days • ResultsResults
– Similar response in all patients between short-course (eg, 5 days) and standard-course (eg, 10 days) therapy
– Patients <2 years old and those in a daycare setting may achieve better results with 10-day therapy
Treatment for Otitis Media
• Plan– Therapeutic
• Decongestants/antihistamines: not shown to • Decongestants/antihistamines: not shown to be effective
• Auralgam: analgesic for the ear• Warm compresses• NSAIDs/Tylenol
Otitis Media• Plan
– Educational
• No smoke exposure
• Finish all medication
• Consider ventilation tubes
Acute Bacterial RhinosinusitisAcute Bacterial RhinosinusitisAcute Bacterial RhinosinusitisAcute Bacterial Rhinosinusitis
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Diagnosis, Guidelines, and Diagnosis, Guidelines, and TreatmentTreatment
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Maria• 21 year old female with an 11 day history of nasal
discharge; Initially clear. Within last 3 days has become green, thick. Significant amount of post-nasal drip and pain over both cheeks. Temp: 99.6-101 Denies ear pain st cough sob Had 1 sinus 101. Denies ear pain, st, cough, sob. Had 1 sinus infection 3 years ago.– PMH: Noncontributory (Nonsmoker, No allergies)– PE: Nasal mucosa erythem, green discharge. Maxillary-
2+ tender.
Incidence of Acute Bacterial Rhinosinusitis (ABRS)
• 31 to 35 million cases annually• Highest in Midwest and South• Highest in Fall, Winter, and Springg p g• Incidence increased by almost 20% in past 11 years
– 15 million office visits per year
Need Reference:Need Reference:
Costs of Acute Bacterial Rhinosinusitis (ABRS)
• Fifth most common diagnosis for which antibiotics are prescribed– Accounted for 7% to 12% of all antibiotic
prescriptions from 1985 to 1992 p p– Over 70 million restricted days of activity
• 250,000 surgeries per year
Sinus and Allergy Health Partnership. Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg Otolaryngol Head Neck Surg 2000;123(1 part 2):S12000;123(1 part 2):S1––S32.S32.
New Definition of RhinosinusitisTake into consideration:Take into consideration:
Fluids that lie Fluids that lie within cavities of within cavities of nose and sinusesnose and sinuses
Mucosa of Mucosa of both nose and both nose and
sinusessinuses
Pathophysiology of ABRS• Normally, bacteria is removed from the sinuses by
the mucous and the action of the cilia • Ostia of a sinus becomes blocked • Bacteria is normally present in the sinusBacteria is normally present in the sinus• Once the sinus opening is blocked, the bacteria is
trapped and begins to grow in number• Mucosa of the sinuses become inflamed and
swollen; The body responds by sending neutrophils to the area
• Result: Increased production of thick, green discharge; Pain in affected sinus(es)
Acute Bacterial Rhinosinusitis
• Same pathogens as Acute Otitis Media– S. pneumoniae (31%)– H. Influenzae (21%)– M. Catarrhalis (2%)– Group A strep (2%)– Anaerobes (6%)
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Diagnosis of ABRS
Headache • Fever
A diagnosis of ABRS may be made in adults or children with A diagnosis of ABRS may be made in adults or children with symptoms of a viral upper respiratory infection that have not symptoms of a viral upper respiratory infection that have not improved after 10 days or have worsened after 5 to 7 daysimproved after 10 days or have worsened after 5 to 7 days
Symptoms:Symptoms:• Headache• Facial pain/pressure• Nasal drainage• Nasal congestion• Postnasal drip• Hyposmia/anosmia
• Fever• Halitosis• Cough• Fatigue• Maxillary dental pain• Ear fullness/pressure
Sinus and Allergy Health Partnership. Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg Otolaryngol Head Neck Surg 2000;123(1 part 2):S12000;123(1 part 2):S1––S32.S32.
CT Findings in Maxillary Sinusitis
N d SiNose and Sinuses
NOSE AND SINUSES• Skeleton
– Structure– Midline
– **Skeleton is straight and midline without deformities or deviations.
Nose and Sinuses• External
– Vestibule– Ala Nasi
B id– Bridge– Tip– Columnella
NOSE AND SINUSES• Nares
– Patency– Foreign Body
– **Nares are patent. No foreign bodies– **Discharge from one nare: Foreign
body
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Anatomy and Physiology• Internal
– Air enters the nasal cavity through the nares bilaterally– Air then passes into a widened area known as the
vestibule and then on to the nasopharynxS– Septum
• Medial wall of the nasal cavity• Supported by bone and cartilage• Covered with mucous membranes• Well supplied with blood
NOSE AND SINUSES• Septum
– Position– Perforation– **Septum is midline and intact without p
deviations, ulcerations, or perforations.– **Deviation may be present in some children,
particularly after a nasal fracture or birth process, and may interfere with nasal breathing.
NOSE AND SINUSES• Mucosa
– Color– Discharge– Edema– Polyps
** k d h d h d h – **Mucosa is pink and without discharge, edema, erythema, or lesions.
– **Erythematous Mucosa: Viral or Bacterial Infection: – **Pale, Boggy Mucosa or Polyps: Allergic Rhinitis
Anatomy and Physiology• Turbinates
– 3 sets: Inferior, middle and superior– Located laterally– Bony structures
Protrude into the nasal cavity– Protrude into the nasal cavity– Functions
• Increases surface area of the nose & mucosa • Cleans the air• Warms the air• Humidification
NOSE AND SINUSES• Turbinates
– Color– Edema
Discharge– Discharge– **Lower and middle turbinates are darker in color than
the mucosa and without edema or discharge.– **Erythematous, Edematous Turbinates: Sinusitis– **Pale, Boggy Turbinates: Allergic Rhinitis
Sinuses• 4 sets of sinuses
– Maxillary– Ethmoid– Sphenoidp– Frontal
– **All are present at birth, except the frontal, which develops at 1 year of age
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Anatomy Slide
Accessed at AAAAI Patient Resource Center.Accessed at AAAAI Patient Resource Center.
NOSE AND SINUSES• Sinuses
– Maxillary– Frontal
• Tendernessenderness• Erythema• Transillumination
• **Frontal and Maxillary sinuses are nontender and without erythema or edema
• **Tenderness: Sinusitis• **Erythema: Abscess
Treatment of Acute Bacterial Rhinosinusitis
• Nonpharmacologic Therapies– Nasal lavage– Cold steam vaporizerp– Increased water intake
Management Strategies in ABRS
• Decongestants– Can be very helpful for a number of individuals
• AntihistaminesSh ld t b d l ll i t– Should not be used unless allergic component
– 2nd generation antihistamines• Topical corticosteroids• Corticosteroids• Antimicrobials
Allergic Rhinitisg
Impact of Allergic Rhinitis in the United States
• 17 million individuals have allergic rhinitis– This accounts for 14% of the US population
Recent prevalence studies show that it may be present in – Recent prevalence studies show that it may be present in 31.5% of all adults
• 10-20% of this number is children– Most common chronic medical condition of childhood
• 79.5 million Americans have undiagnosed allergic rhinitis
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Symptoms of Allergic Rhinitis• Nasal congestion• Sneezing• Profuse watery
discharge from nose
• Cough• Mouth breathing• Fatigue• Irritabilityg f m
and/or eyes• Itching of nose, eyes,
and palate• Frequent clearing of
the throat• Nose picking• Grimacing or
twitching
• Decreased appetite• Decreased hearing• Hoarse voice• Decreased smell• Sniffling• Epistaxis
Physical Examination Findings in the Individual With Allergic Rhinitis
• Pale, boggy mucosa and turbinates
• Allergic shiners
• Watery discharge in nose and eyes
• Ulcerations on nasal mucosa
• Allergic salute• Conjunctival injection• Cobblestoning• Allergic facies• Dennie’s lines
mucosa• Pharyngeal edema• Lymphoid tissue• Nasal polyps• Long eye lashes• High arched palate
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PHARYNGITISPHARYNGITIS
Pharyngitis
• Epidemiology– 30 million patients seen yearly in US for pharyngitis
– Most often seen in colder monthsMost often seen in colder months
– Peak age: 5-8 years; however with increase in # of children in daycare at younger age, it is occurring in younger children
– Tonsils serve as our 1st line of defense against respiratory pathogens
Pharyngitis• Epidemiology
– Tonsils are small in infancy– Increase in size until approximately 10 years of
d th thage and then they regress– Pathogens for pharyngitis spread via person to
person– Pathogen
• Group A Beta hemolytic strep• 1/3-1/2 of cases in children aged 2 - 14• Non-group A strep• Viral pharyngitis: 1/2 of cases in infants < 2
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Pharyngitis• Epidemiology
– Group A Beta Hemolytic Strep• Most interest because of its association with severe
complicationscomplications
• Peritonsillar abscesses, rheumatic fever, post-streptococcal glomerulonephritis - complications
• Rheumatic fever: 20/100,000 people in early 1900’s, now 1:100,000
• Recent increase in cases
• Many cases in individuals without sore throat
Pharyngitis
• Symptoms– Group A Beta Hemolytic Strep
• Rapid onset of sore throat• Fever 103-104• Swollen glands• Children often complain of abdominal pain• Usually-no URI symptoms• Headache• Decreased appetite• Dysphagia• Irritability
Pharyngitis
• Symptoms– Viral Pharyngitis
• Usually not a severe sore throatUsually not a severe sore throat
• Low grade temp
• Mild swollen glands
• Associated with URI symptoms
MOUTH• Anatomy and Physiology
– Lips– Tongue– Mucosa– Uvula– Tonsils– Posterior Pharynx– Dentition– Gingiva
MOUTH• Anatomy and Physiology
– Lips– Tongue– Mucosa– Uvula– Tonsils– Posterior Pharynx– Dentition– Gingiva
MOUTH• Lips
– Color– Moisture
Lesions– Lesions– Abnormalities
• **Lips are appropriately colored and moist; No lesions or abnormalities
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Abnormalities of the Lips• Blue: Cyanosis• Abnormal Development: Cleft Lip• Vesicles: Herpes Simplex, ImpetigoVesicles Herpes Simplex, Impetigo• Thin Upper Lip: Fetal Alcohol
Syndrome
Mouth
MOUTH• Tongue
– Position– Size– Deviation– Lesions– Coating– Frenulum
• **Tongue is straight, appropriate size and midline. It is lightly papillated without lesions or coating. Frenulum is intact.
Abnormalities of the Tongue• Deviation: Cranial Nerve XII Dysfunction• White Coating: Thrush• Thick Frenulum: Tongue Tie• Protruding Tongue: Angelman Syndrome• Ulcerations: Thrush, Apthous Stomatitis,
Coxsackie Virus
MOUTH• Mucosa
– Color– Lesions– Coatingg– Moisture
• **Mucosa is appropriately colored, smooth, and moist without lesions, masses or coating.
Abnormalities of Buccal Mucosa• Coating: Thrush• Ulcerations: Chewing Tobacco;
Apthous Stomatitis; Hand, Foot, and pMouth Disease
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MOUTH• Hard and Soft Palate
– Continuity– Lesions
• **Hard and Soft Palate are continuous without lesions or abnormalitiesabnormalities.
• **Incongruous Hard and Soft Palate: Cleft Palate• **Ulcerations: Thrush, Apthous Stomatitis, Coxsackie Virus • **Coating: Thrush
MOUTH• Uvula
– Position– Color– Lesions
• **Uvula is midline and smooth. It rises with phonation and i i h l i h d i iis without lesions, erythema, or deviation.
• Asymmetry: CN X Dysfunction, Tonsillar Abscess• Erythema: Viral or Bacterial Pharyngitis
MOUTH• Tonsils
– Anterior and Posterior Pillars– Color– Edema– Exudate
• **Tonsils are present bilaterally and without edema, erythema, or exudate.
Abnormalities of the Tonsils• Erythematous, Edematous: Viral or
Bacterial Pharyngitis• Exudate: Bacterial Pharyngitis, y g
Mononucleosis, Viral pharyngitis• Asymmetric Enlargement: Tonsillar
Abscess
MOUTH• Posterior Pharynx
– Color– Lesions– Edema– Exudate– **Posterior pharynx is pink without lesions, erythema,
exudate, or edema.– **Lymphoid tissue: Viral or Allergic Illness– **Exudate and Edema: Strep Pharyngitis
Pharyngitis
• Signs– Group A Beta Hemolytic Strep
• Erythematous edematous tonsils uvulaErythematous, edematous tonsils, uvula
• Exudate
• Lymphadenopathy
• Palatal petecchiae
• Fever
• Rash-scarletina
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Pharyngitis
• Signs– Viral Pharyngitis
• Slightly erythematous tonsils• Slightly erythematous tonsils
• Can have exudate
• URI physical exam findings
Exudative pharyngitisExudative pharyngitisDifferentials include:
Strep pharyngitisPeritonsillar abscess
MononucleosisViral pharyngitis
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Scarletina
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Strawberry Tongue
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Pharyngitis• Plan
– Diagnostic• Throat culture: 24 hour is the gold standard• Throat culture: 24 hour is the gold standard• Quick strep: 85-100% specificity; 31-95%
sensitivity• Must swab both tonsils for best results• Consider mononucleosis
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PharyngitisEven with a best case scenario, 1/3
- 1/2 of cases of strep pharyngitis are missed or di d i hi t d overdiagnosed using history and
physical examination only!!!
MUST DO A THROAT CULTURE
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Remember…Adolescents/Young Adults with mono
have strep have strep pharyngitis 50% of
the time
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Peritonsillar Abscess• Generally begins as an acute febrile
URI or pharyngitis• Condition suddenly worsensy
– Increased fever– Anorexia– Drooling– Dyspnea– Trismus
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Peritonsillar Abscess• Physical examination
– May appear restless– IrritableIrritable– May lie with head hyperextended to
facilitate respirations– Muffled or “hot potato voice”– Stridor may be present– Respiratory distress
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Peritonsillar Abscess• Physical examination findings
– Fiery red asymmetric swelling of one tonsil
– Uvula is often displaced contralaterally and often forward
– Large, tender lymphadenopathy
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Peritonsillar Abscess
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Peritonsillar Abscess
TrismusWright, 2010
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Peritonsillar Abscess
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Peritonsillar Abscess
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Wendy L. Wright, ARNPFamily Nurse Practitioner
Owner – Wright & Associates Owner Wright & Associates Family Healthcare
Amherst, NHemail: [email protected]
