Category: Head, Eyes, Ears, Nose, and Throat (HEENT)

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Common Complaints

• Red Eye
• Decreased Vision
• Trauma to the Eye

Approach to a Vision Complaint

• Step 1: Assess visual acuity
  • Visual acuity is the “vital sign of the eye”
  • Snellen eye chart is best
  • If patient unable to see chart…
    • Count fingers?
    • Able to see light?
• Step 2: Examine the conjunctiva/cornea with fluorescein
  • How to apply fluorescein
    • Recline patient 45 degrees
    • Pull down on lower eyelid to create pocket
    • Place anesthetic eye drops in pocket (ex. tetracaine)
    • Wet the fluorescein strip with eye drops and apply to pocket
    • Have the patient blink to distribute the dye
  • Look under woods lamp for bright “uptake” areas that don’t move with blinking
    • These represent abrasions, ulcers, etc
  • This step is also a good opportunity to evert the eyelids and examine for foreign bodies if appropriate
• Step 3: Examine the anterior chamber with slit lamp
  • “Cell and flare” (example HERE)
  • Representative of iritis, uveitis
  • This is also a good opportunity to examine any other abnormal areas of the eye under magnification!!!
• Step 4: Check intraocular pressure
  • Pressure >20mmHg (especially when unequal) is concerning for acute angle closure glaucoma
  • Multiple tools to measure pressure on market, ask somebody to show you how to use
• Step 5: If appropriate, use ultrasound to evaluate posterior eye
  • Multiple things can be diagnosed with ultrasound of the eye
    • Retinal detachment
    • Optic neuritis
    • Papilledema
    • Foreign bodies

Additional Reading

• Introduction to Slit Lamp (YouTube)
• Cell and Flair (TimRoot.com)

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You must know the FOUR emergent causes of sore throat!

Step 1: Apply the Centor Criteria

• Determines if patients is at risk for Group A strep (“strep throat”)
• 4 Criteria
  • Fever
  • No cough
  • Tonsiller exudates
  • Lymphadenopathy
• Interpretation
  • If patient has ALL of the criteria
    • Treat for strep throat
  • If patient has NONE of the criteria
    • Don’t even test for strep throat
  • If patient has SOME of the criteria
    • Consider testing for strep throat

Step 2: Prescribe Antibiotics

• B-lactams work best
  • Penicillin
  • Amoxicillin
• If patient has allergy, consider alternative agent
  • Azithromycin
  • Clindamycin

Step 3: Pain Control

• NSAIDS
• Steroids

Step 4: Consider EBV (Epstein-Barr Virus)

• Consider in patients not getting better on antibiotics
• Examine for splenomegaly
  • If present, no contact sports

Step 5: Consider the FOUR Emergent Causes of Sore Throat

• Ludwigs angina
  • Airway emergency
  • Infection UNDER the tongue
• Peritonsillar abscess (PTA)
  • Complication of bacterial pharyngitis
  • Causes “trismus” (difficulty opening mouth)
  • Frequently need to be drained
• Retropharyngeal abscess
  • Airway emergency
  • Difficult to diagnose by exam alone
    • Infection is BEHIND airway
    • Seen on lateral neck xray
• Epiglottitis
  • Airway Emergency
  • “The Triad”
    • Drooling
    • Dysphagia
    • Distress (respiratory)
  • Lateral neck xray shows “thumbprint sign”

Additional Reading

• Peds O- Oxygen, Airway, and Respiratory Disorders (EM Clerkship)
• Airway Infectious Disease Emergencies (UNM)

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Minor complaint. Huge SLOE points!

Step 1: Identify Which Tooth is Causing Pain

• Bonus points if you number teeth correctly!
  • Number 1-32
    • Tooth #1 is top right
    • Tooth #32 is bottom right
  • Refer to dental chart for reference

Step 2: Correct Terminology When Making Diagnosis

• Pulpitis
  • Pain in the tooth itself
  • Reversible
    • Triggered by hot/cold etc (then goes away)
  • Irreversible
    • Does not resolve
• Gingivitis
  • Pain of the gingiva around the tooth
• Periapical abscess
  • Pain with percussion of tooth

Step 3: Give Pain Medicine

• NSAIDS have been shown to work best
  • Naproxen
  • Ibuprofen
• Opiates for breakthrough pain
  • Hydrocodone-acetaminophen (Norco)
  • Oxycodone-acetaminophen (Percocet)

Step 4: Consider Antibiotics

• Pulpitis does not require antibiotics
• Gingivitis/Periapical abscess frequently improve on antibiotics
  • Penicillin VK

Step 5: Inferior Alveolar Nerve Block

• Watch HERE

Additional Reading

• Inferior Alveolar Nerve Block (YouTube)
• Common Dental Emergencies (AFP)

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Don’t forget to wear protective gear. Gown up!

Initial Encounter

• History
  • Anticoagulants
  • Easy bleeding/bruising
  • Lightheadedness
• Exam
  • Pallor
  • Tachycardia/Hypotension

Step 1: Put on Personal Protective Equipment

• Gown
• Gloves
• Mask
• Eye Protection

Step 2: Clear Nose and Visualize Bleeding

• Have patient blow out/remove any clot and look for source of bleed
• Kiesselbachs plexus
  • “Anterior” epistaxis
• Sphenopalatine artery
  • “Posterior” epistaxis
    • Most severe/dangerous form

Step 3: Spray In Oxymetazoline (Afrin)

• Hold pressure for 15 minutes after initial application

Step 4: Cauterize With Silver Nitrate

• Avoid bilateral cauterizations
  • Can cause septal perforation
• Anesthetize as necessary
  • 4% lidocaine on gauze and leave in nose for 10 minutes prior to cauterization

Step 5: Pack the Nose

• Multiple commercial products available for this
• The utility of antibiotic prophylaxis at this step is unclear
• Patient goes home with packing in place

Additional Reading

• Epistaxis Management (EM:RAP)