Thursday, August 6, 2015

EENT List of Most Commons for Physician Assistant Students

Most Commons in HEENT for Physician Assistants
HEENT (EENT) makes up 9% of the PANCE and is one of the most common “bread and butter” medicine topics you’ll come across. Below is a combination of “most commons”, “buzzwords”, and other clinical pearls I have come across since completing my didactic year. I compiled this in order to help myself prepare for the PANCE and for rotations. I hope it helps you in your studies as well.
  1. Head
    1. Bell’s Palsy - most common acute disease involving a single nerve and most common cause of acute facial nerve paralysis
      1. Onset within 72 hours
      2. Loss of taste sensation in anterior ⅔ tongue (chorda tympani)
  1. Ears

Acute Otitis Media
Otitis Externa - Bacterial
Otitis Externa - Fungal
MC: viral (45-70%), S. pneumo (25-50%), H. Flu (15-30%), M. Cat (20%)
MC (pediatric): S. pneumo
MC Path: Pseudomonas (50%), S. aureus/St. pneumo (40%), sterile (10%)
MC Path:
Aspergillus-niger (black), -flavus (yellow), or -fumigatus (gray)
Candida albicans (white)
Pain when supine or leaning forward, pulling on ear
Fever, hearing loss, aural fullness, pressure
PE: red TM, purulence, pre- or post-auricular LAD with cervical LAD, loss of cone of light
Associated rhinitis
Ruptured TM = drainage
Tuning fork: BC > AC
Pain with movement of pinna or eating
Conductive hearing loss
PE: swollen, red, yellow/green discharge, foul smelling, pre- or post-auricular LAD
+/- cellulitis of face

Tuning fork: BC > AC
Weeping, pain, hearing loss, aural fullness
PE: swollen, hyphae +/- spores, moist/wet-appearance
TX: most resolve spontaneously
Mild: no ABX, reevaluate 2-3 d
Uncomplicated, previously untreated: HD (80-90 mg/kg/d) Amoxicillin or Augmentin x 10-14 d or IM ceftriaxone
Switch ABX 48-72 h if no resp.  
PCN allergy: Sulfonamide + Erythromycin or Clindamycin, FQ
Do not use: antihistamines, decongestants
TX: hygiene, clean, otowick, topical analgesics
Otic drops: Ciprodex, Floxin
Contraindicated: irrigation or Gentamicin/Tobramycin with perforated TM
TX: hygiene, clean
Topical antifungal powder +
Antifungal otic drops: acetic acid, Vosol
Prophy: 1:1 ETOH/white vinegar in each ear after showering
Contraindicated: Lotrimin with perforated TM
Chronic Otitis Media (recurrent)
3+ AOM in 6 months OR
4+ AOM in 1 year

Autophony - can hear your echo
SX: continued pressure or fullness after resolution of infection, hearing loss, tinnitus, increased sensitivity to loud noises, not painful
PE: dull TM with  decreased movement, hearing loss, speech delay
Serous Otitis Media
HX: recent viral URTI, sinus infection, flare of allergies, flying while congested, recent AOM, adenoid hypertrophy, nasopharyngeal mass

TX: resolves slowly (up to 12 weeks), follow up 4-6 W, nasal steroid sprays, short course of PO steroids

Do not use: antihistamines, decongestants
Fullness, hearing loss, pressure, popping/gurgling after a yawn or blowing nose, dizziness or swimming sensation
Unilateral or bilateral

PE: retracted TM, amber or “coca cola” colored fluid, displacement of cone of light, air bubbles behind TM, pneumatic otoscopy reveals decreased movement of TM
Tuning fork: BC > AC
Chronic negative pressure thins the TM and retracts, adhering to middle ear -> squamous epithelium forms inside and expands
Worsening hearing loss
Chronic discharge, fullness
Not painful
History of AOM or previous surgery
PE: pearly white mass, squamous debris, discharge
Conductive hearing loss
Necrotizing (Malignant) Otitis Externa

MC: diabetics, immunocompromised
MC pathogen: pseudomonas
Deep severe pain
Drainage, swollen red canal
Granulation tissue, osteomyelitis at skull-base, pain with talking/chewing
CN 7 and 12 involvement

TX: control DM, oral FQ
MC pathogen: S. pneumo, S. aureus
Fever, malaise, hearing loss, +/- headache
History of ABX use without improvement
PE: swollen over mastoid, redness, tenderness, LAD, outward protrusion of pinna

TX: IM ceftriaxone or IV ABX
CT Scan, refer to ENT

Labyrinthitis (otitis interna), vestibular neuronitis, vestibular neuritis
Etiology: viral, head injury, stress, allergy
Rapid onset severe vertigo (3-5 days), nausea, vomiting, imbalance
Preceding URTI
+/- nystagmus (severe)
Symptoms regress over 3-6 weeks

Central Vertigo
Peripheral Vertigo
Gradual and continuous symptoms, mild to moderate
Focal signs, nausea, vomiting, hearing loss (rare)
Acute and intermittent symptoms, but severe hearing loss, tinnitus, fullness
Hearing loss, severe nausea and vomiting, diaphoresis
Etiology: MS, brain tumor, head injury, medications
TX: Valium, Meclizine

    1. Acute otitis media - most common diagnosis for acute office visits in children
      1. Most common complication: tympanic membrane perforation
      2. Untreated complications - leads to facial nerve paralysis (Bell’s Palsy), cerebral venous sinus thrombosis, mastoiditis, short/long term hearing loss, speech delay, bacterial meningitis, intracranial abscess, TM perforation
      3. Bagel ear - bulging TM
    2. Most common cause of hearing loss: cerumen impaction
    3. Most common cause of unilateral sensory hearing loss: viral neuritis
    4. Presbycusis - Most common type of hearing loss in elderly
    5. Most common neuropathy associated with acoustic neuroma: loss of corneal reflex due to trigeminal involvement
    6. Bilateral nystagmus with cold caloric testing - signifies intact cortex, midbrain, and brainstem
    7. Recurrent unilateral serous otitis media - consider oropharyngeal cancer
    8. Drugs that cause nystagmus - MALES TIP
      1. Methanol
      2. Alcohol
      3. Lithium
      4. Ethylene glycol
      5. Sedative hypnotics, Solvents
      6. Thiamine depletion and Tegretol (carbamazepine)
      7. Isopropanol
      8. PCP, Phenytoin
    9. Medications that cause hearing loss: aminoglycosides, antineoplastic agents, loop diuretics, salicylates
    10. Meniere's Disease (endolymphatic hydrops) - excessive endolymph fluid in the cochlea overstimulates hairs causing vertigo and sudden hearing loss with aural fullness; most commonly unilateral and appears in adults
      1. SX: sudden vertigo, aural fullness or pressure, tinnitus, fluctuating hearing loss, nausea/vomiting, lasts hours
      2. TX: low salt, high water diet, diuretics, intratympanic steroids
        1. Avoid ETOH, caffeine, tobacco
    11. Dix-Hallpike Maneuver - diagnoses benign positional vertigo (eye twitching occurs), which is provoked by head movements or positioning
      1. Nystagmus - always positional, brief, and fatigable
      2. Rotatory nystagmus (posterior canal BPPV) - Epley maneuver
      3. Lateral nystagmus (lateral canal BPPV)  - Lempert Maneuver
      4. Vertical nystagmus (superior canal BPPV) - Deep head hanging maneuver
    12. Weber Test - sound is louder in ear with conductive loss
    13. Acoustic Neuroma (vestibular schwannoma) - tumor of 8th CN
      1. SX: unilateral hearing loss, vertigo (late), unsteadiness, tinnitus
      2. Bilateral acoustic neuroma - associated with Neurofibromatosis type II
      3. Decreased corneal sensitivity, diplopia, headache, facial weakness
      4. LP: elevated protein
      5. TX: MRI
  1. Eyes
    1. Basic Anatomy of the Eye
      1. Myopia - “nearsighted”; vision rays come into focus in FRONT of retina
      2. Hyperopia - “Farsighted”; vision rays come into focus BEHIND retina
        1. Presbyopia - farsightedness caused by old age
      3. Strabismus (heterotropia) - eyes do not align (cross-eye)
      1. Hordeolum - occurs on upper or lower eyelid; red and painful; spontaneously resolves
        1. Abscess of Meibomian gland (internal) - points toward conjunctiva
        2. Glands of Zeis (external, stye) infection at eyelid margin, pointing outward
      2. Chalazion - obstruction of meibomian gland (granuloma) or internal posterior hordeolum; painless, non-tender, non inflamed swelling (nodule) developing over the course of weeks (chronic)
        1. TX: hot compress, oral doxycycline or tetracycline
    2. Pterygium (Surfer’s Eye) - commonly grows from the nasal side of the conjunctiva
    3. Eyelid Malposition
    4. Retinoblastoma - child with blurry vision and abnormal pupillary reflex with a white reflex upon fundoscopic exam
    5. Subconjunctival hemorrhage - bleeding of the conjunctival or episcleral blood vessels into the subconjunctival space; painless; self limiting - lasts 2 weeks
    6. Blepharitis - conjunctival and lid margin inflammation
      1. Slit lamp exam: greasy appearance of lid margin with scaling around the base of the lashes
    7. Hypopyon - accumulation of white inflammatory exudate in the anterior chamber
      1. SX: painful, red eye
      2. Slit lamp exam: localized, white, flocculent infiltrate in anterior chamber
    8. Hyphema - blood in anterior chamber resulting from tears in ciliary body or iris root vessels; most common in children (70%)
      1. RF for rebleeding: sickle cell disease or trait, black, ASA use, prior low visual acuity, hyphema > ⅓ anterior chamber, treated after 24 hours, elevated IOP
      2. 4 S’s of Hyphema (Complications)
        1. Staining of the cornea
        2. Synechiae - iris adheres to cornea or lens
        3. Secondary rebleeds on 2-5th day (20%)
        4. Significantly increased IOP
      3. TX: Rest, elevation of head, topical steroids, avoid ASA/NSAID
    9. Welder’s Flash - severe eye pain and multiple pinpoint areas of fluorescein uptake representing ruptured corneal epithelial cells
      1. Slit lamp exam: Diffuse Punctate Keratopathy
    10. Most common pathogens of
      1. Acute Dacryocystitis: Staph aureus and beta-hemolytic streptococci
      2. Chronic Dacryocystitis: candida albicans, anaerobic streptococci, staphylococcus epidermidis
      3. SX: painful erythema over the tear duct at nasal side of eye with small amount of pus draining from tear duct
    11. Dacryoadenitis - acute inflammation of the lacrimal gland seen in sterile inflammatory disease
      1. SX: abrupt onset swelling of upper eyelids, laterally;
      2. Most due to gram positive bacteria, but EBV most common virus
    12. Normal range of intraocular pressure (IOP): 10-23 mmHg

Central Retinal Artery Occlusion (cherry red spot, ischemic retina): flow through CRA occluded
Associated: atherosclerotic thrombosis, embolus, giant cell arteritis
SX: sudden painless loss of vision in one eye (unilateral)
PE: pale-gray retina, APD, cherry dot
Irreversible damage to retina after 90 minutes - IMMEDIATE CONSULT (decrease IOP & arterial dilation)
Central Retinal Vein Occlusion (Blood & Thunder Fundus): sudden, painless unilateral vision loss, 50+
PE: macular edema, cotton wool spot, massive superficial/deep hemorrhage with vitreous involvement

MC Associated: HTN, POAG
Age Related Macular Degeneration (ARMD): loss of central vision clarity, long smoking history, metabolic syndrome, FH, female, white, age 50+
PE: drusen formations, retinal atrophy

TX: Anti-VEGF intravitreal injections
Dry AMD (Nonexudative)
Wet AMD (Exudative)
Buildup of drusen
Mild - asymptomatic
Moderate - some vision loss
Severe - central blind spots
TX: vitamins to slow process
Choroidal neovascularization
Early - mild distortion
Late - central blind spot

Differential of Red Eye with Decreased Visual Acuity
Halos around lights”  (bilateral)
Dull or severe pain, blurry vision, frontal headache, lacrimation, +/- nausea and vomiting
Pain more severe in dark
RF: asians, eskimos, hyperopes, elderly
IOP: 40-80 mmHg (sudden increase)
TX: IV mannitol, pilocarpine, IV acetazolamide, iridectomy
Visual changes begin peripherally
Gradual, painless loss of vision

More common than acute
4% of patients 40+

Most common cause: outflow obstruction through trabecular meshwork
Acute Iritis (anterior uveitis): inflammation of the ciliary body and iris
SX: eye/periorbital pain, consensual photophobia, hypopyon, irregular pupil,

Floaters, headaches, dilated ciliary vessels (ciliary injection or flush), “cells and flare” in anterior chamber, keratic precipitates (KP) on posterior surface of cornea

TX: refer to ophthalmology +/- rheumatology, steroid and dilating drops
Corneal Abrasion
Multiple vertical linear abrasions (ice rink sign) under upper eyelid suggests foreign body
MC etiology: contact lenses

TX: cycloplegic, topical NSAID, topical antibiotic, oral analgesics/sedatives

Contraindicated: topical steroids, patching
Herpes Simplex (HSV) Keratitis
Etiology: HSV-1
SX: painful eye, blurred vision, conjunctivitis, photophobia, tearing
Slit lamp exam: dendritic ulcer (branch-like) lesion
Hutchinson’s sign: herpetic lesion on tip of nose (nose and cornea supplied by nasociliary nerve)
TX: most spont. resolve in 3 weeks
Contraindicated: topical steroids or patching
Bacterial (Microbial) Keratitis
SX: rapid onset red, painful eye with discrete corneal infiltrate, photophobia, and decreased vision +/- hypopyon

Most common: pseudomonas (contact lens wearers), Enterobacter

VISION THREATENING PROCESS - rapid progression (24-48 h), REFER
If small, peripheral - FQ every 1-2 h
Conjunctival Injection
Anterior vessels - produce more redness, move with conjunctiva and constrict with vasoconstrictors

Posterior - stationary and less red
Viral Conjunctivitis (pink eye)
Most common: adenovirus
Associated symptoms: recent URTI, no resolution with eye drops
SX: unilateral or bilateral, benign, self-limiting (2-4 weeks), preauricular adenopathy, epiphora, hyperemia, chemosis, follicular conjunctival injection, subconjunctival hemorrhage
TX: supportive (cold compress, lubricants - artificial tears), hand hygiene
Bacterial Conjunctivitis
Associated: steroid or OTC eye drops, contact lens wearers, age, sexual activity, immunodeficiency
Segmental or diffuse injection, purulent discharge, “mattering” or lid margin, difficulty prying open lids after awakening

Topical FQ and erythromycin
Seasonal Allergic Conjunctivitis (SAC)
SX: Itching, history of rhinitis, clear discharge, conjunctival injection +/- chemosis, +/- eyelid edema
Summer, Spring, Fall
Usually symptom free in winter
Vernal Keratoconjunctivitis (VKC)
Bilateral, chronic inflammation or “Spring catarrh” summer conjunctivitis
Shield ulcer (pathognomonic) caused by inflammatory mediator release
Onset in puberty
Most common in males
Giant Papillary Conjunctivitis (GPC)
RF: contact lens overuse, plastic prosthetic eye
First: itching with mucoid discharge
TX: stop wearing contact lenses
Atopic Keratoconjunctivitis (AKC)
Bilateral, inflammation of conjunctiva AND eyelids, eczematoid dermatitis of eyelid with dry, scaly, inflamed skin
Associated with atopic dermatitis (eczema)
TX: topical antihistamines, mast cell stabilizers, olopatadine, topical NSAID (ketorolac), topical steroid (prednisolone)
Gonococcal Conjunctivitis (neonatal = ophthalmia neonatorum)

N. gonorrhoeae or C. trachomatis

Pain, tenderness, hyperemia, chemosis
Purulent, mucoid or mucopurulent
May ulcerate, resulting in vision loss
Episcleritis: inflammation between conjunctiva and sclera (episcleral tissue)
Mild, self-limiting, recurrent
Vessels blanch with topical vasoconstrictors
2 Types
Simple: intermittent (1-3 months), lasts 7-10 days, mod-severe inflammation, spontaneously resolves after 2-3 weeks
Nodular (shown): prolonged, acute onset, mild-mod + systemic disease

TX: none required +/- oral NSAID
Scleritis: inflammation of the sclera
Diffuse or Nodular
SX: awakened from sleep due to deep boring pain, vessels will not blanch or move with topical vasoconstrictors

Hard Exudate: deep yellow with sharp margins; circinate
Leakage from pre-capillary arterioles

Ex. von Hippel Lindau disease, radiation, HTN
Most common cause: DM
Cotton Wool Spots (soft exudates): fluffy gray-white patches; near optic disc

Due to ischemia of superficial retina (microvasculature)
Neural micro infarctions

Ex. HIV, connective tissue disease, DM
Most common cause: HTN
Most common funduscopic exam finding in AIDS patients (CMV retinitis)
Retinal Drusen: clusters of yellow-orange spots, centered around fovea
Metabolic debris from retinal pigment epithelium

Most common cause: ARMD
Diabetic Proliferative Retinopathy
Prolonged hyperglycemia causes:
1. Basement membrane thickening
2. Decreased pericytes (hyperproliferation)
3. Microaneurysms
4. Neovascularization
Neovascularization breaks through ILM (inner limiting membrane) leading to tractional retinal detachment
Early proliferative retinopathy
Non-proliferative Retinopathy
Hard exudates
Papilledema: optic disc swelling caused by increased intracranial pressure (ICP)
Bilateral, develops over hours to weeks
Transient obscurations of vision (lasts seconds)
ICP: most commonly occurs bilaterally
Optic Neuritis: optic nerve swelling causes destruction of myelin sheath

Papillitis - head of optic nerve
Retrobulbar neuritis - posterior nerve

Most common cause: Multiple sclerosis
Normal ICP

Sudden unilateral loss of central vision
MC symptom: blurry or “foggy” vision
Pain with movement of affected eye (NOT RED)
Central scotoma, central change in color perception
PE: swollen disk, APD
TX: IV/oral steroids
Any opacity of the lens, whether visually significant or not

Most common cause: age related nuclear sclerosis

SX: glare, myopic shift, multiple images due to refraction, blurry vision

Complication: endophthalmitis
Retinal Hemorrhage
Causes: HTN, retinal vein occlusion, DM, shaken baby syndrome or severe head trauma
Vitreous Hemorrhage: extravasation (leakage) of blood into areas in and around vitreous humor

Age 50+
50-70% of acutely symptomatic patients have retinal detachment
Most common cause: proliferative diabetic retinopathy

Others: trauma, retinal detachment

“Flashing lights”, floaters
Blurry vision, reddish tint, photopsia (brief flashes of light in periphery)
Most asymptomatic  
Retinal Detachment

Peripheral -> central vision loss
TX: inferior - patient sits up
superior - patient lies down
Preceded by posterior vitreous detachment: photopsia, floaters, feeling of heaviness in eye
Painless vision loss
Curtain of darkness” with peripheral flashes or spider webs and floaters
Gray detached retina
Amaurosis Fugax

Etiology: atherosclerosis (retinal artery emboli), carotid stenosis
“Fleeting blindness” or “curtain coming down vertically into field of vision
Painless, transient (quickly returns), unilateral visual loss
Lasts 2-20 minutes  
Non-arteritic Anterior Ischemic Optic Neuropathy (NAION): damage to optic nerve head from microvascular occlusion
RF: HTN, DM, hypercholesterolemia, smoking
Sudden upon awakening, non-painful, unilateral optic disc swelling
Afferent pupillary defect (APD), most upper or lower half of visual field
Age: 50-70
Visual loss does not progress or recover
Resolves 4-8 weeks

Arteritic Anterior Ischemic Optic Neuropathy (AION): damage to optic nerve head from microvascular occlusion

Age: 70-90 (older)
Severe visual loss, jaw claudication, temporal artery tenderness, temporal headache, unintentional weight loss, fatigue, myalgias, loss of appetite
Significant APD
DX: STAT ESR, temporal artery biopsy
TX: high dose steroids to prevent blindness in contralateral eye

Hypertensive Retinopathy
Hallmark: Diffuse arteriolar narrowing (AV nicking)
Osteogenesis Imperfecta (brittle bone disease, Lobstein syndrome)

Blue-gray sclerae due to underlying choroidal veins showing through a thin sclera (defective Type 1 collagen)

Most common type of OI: Type 1

    1. Cellulitis
      1. Most common cause of orbital cellulitis: Staphylococcus aureus
      2. Most common cause of periorbital (preseptal) and orbital infections: Staph aureus, Strep pneumo, and H. flu

Periorbital (preseptal) Cellulitis
Gross lid edema, chemosis
Toxic, febrile
Proptosis, limitation of ocular mobility
+/- decreased vision
Lid edema, chemosis ONLY

NO proptosis, limitation of motility, or decreased vision

      1. SX: decreased visual acuity, IOP (“Squishy eye”), bloody chemosis, visible wound of cornea/sclera, change in anterior chamber depth, displacement of pupil or shape, prolapse of ocular tissue (brown)
      2. Lateral canthotomy contraindicated if suspected ruptured globe!
      1. SX: Pain, eccyhmosis, bloody chemosis, resistance to retropulsion
        1. Afferent pupillary defect (APD)
        2. Increased IOP
    1. Most common pathogens causing bacterial conjunctivitis: Staph aureus, Strep pneumo, H. flu
    2. Most common cause of vision loss in patients 24-70 - Diabetic retinopathy
    3. Most common cause of vision loss in patients 65+ - Age related macular degeneration (ARMD)
      1. Most common cause of drusen - ARMD
    4. Most common cause of exudates: Diabetes
    5. Viral conjunctivitis - most commonly caused by Adenovirus
    6. Red-green color blindness - one of the most common genetic disorders, affecting 7% of all males
    7. Most common findings associated with orbital floor fractures: diplopia, globe lowering, numbness over the cheek (V2)
    8. Most common causes of preventable vision loss: amblyopia (lazy eye), diabetic retinopathy, glaucoma
    9. Marcus Gunn Pupil (Afferent Pupillary Defect) - due to optic nerve damage or retinal detachment
      1. DX: Swinging Flashlight Test - decreased bilateral pupillary constriction when light shown in affected eye
      2. Most common conditions: ischemic optic neuropathy (ION), glaucoma, optic neuritis
    10. Seidel Test - assesses the presence of anterior chamber leakage in cornea, including post-trauma, corneal perforation or degeneration
    11. Tangential Light Test - determines the presence of narrow angle glaucoma or perforating corneal injury; if part of the iris is in the shadow, the angle is narrow
    12. Cycloplegics vs. Sympathomimetics
      1. Cycloplegics - inhibits parasympathetic stimulation which constricts the iris and inhibits the ciliary muscle, paralyzing the ciliary muscle and causing loss of accommodation (ex. atropine and cyclopentolate, scopolamine, tropicamide)
      2. Sympathomimetics -  stimulates iris’ dilator muscle

Bilateral optic disk swelling
Unilateral optic disk swelling
Raised intracranial pressure, malignant hypertension
Optic neuritis, ION, central retinal vein occlusion, intracranial optic nerve compression, posterior scleritis

  1. Nose
Acute Viral Rhinosinusitis
(common cold, URI)
Etiology: adenovirus
Incubation: 2-4 d (3 day shed)
Direct contact, droplets
Influenza virus
Incubation: 1-4 d (infectious day before to 5 days after onset)
MC Etiology: antecedent viral URI, allergies, tumors, FB, deviated septum or polyps
MC sinus: maxillary (cheek pain), ethmoid (retro orbital pain), frontal (lower forehead)
MC pathogens: S. pneumo, H. flu, M. Cat
Const SX: Fever, chills, malaise
Rhinorrhea - clear, watery
Nasal congestion, sneezing
Sore throat, non-prod cough
Myalgia, headache
PE: low fever, nasal/throat erythema, congested turbinates/discharge, sinus tenderness, cervical LAD
Abrupt onset fever
Sore throat, retro-orbital headache, myalgias, malaise, nonproductive cough
PE: fever, clear nasal discharge, pharyngeal erythema, cervical LAD
Major Symptoms
Facial pressure or pain worse with bending forward
Nasal obstruction, discharge (purulent), hyposmia
Minor Symptoms
Fever, fatigue
Headache, halitosis, dental pain, cough, ear pressure
2 Major OR 2 Minor + 1 Major
PE: purulent discharge, PND, halitosis, sinus tenderness, transillumination of sinuses
Resolves 5-8 days
Analgesics: ASA, Tylenol, NSAIDs
Topical analgesics - Chloraseptic
Nasal saline washes, humidifier
Decongestants - Sudafed, Afrin
Mucolytic - Mucinex
Antihistamines - Benadryl, Claritin, Zyrtec, Allegra
Symptoms last 3 days to 2 weeks
Antipyretics, bedrest
Oseltamivir (Tamiflu) within 40 hours of symptom onset

IM/ID Vaccine for anyone >6 months up to 5 years and >50 years old
Nasal spray: non-preg 2-49
Acute: lasts <30 d with complete resolution
Subacute: 30-90 d with complete resolution
Chronic: >90 d with persistent symptoms

Non-contrast CT Scan - first line (chronic, unresponsive)
Sinus aspirate culture - gold standard

First line: Amoxicillin, Cefdinir (Omnicef) 10-14 d
Beyond 2 W: Augmentin, Cefuroxime
Chronic: add inhaled steroids
Severe: Levaquin, Bactrim
PCN Allergy: Azithro, Clarithro
Hydration, humidifiers, saline sprays
Decongestants: topical or PO
Analgesics: NSAID, Tylenol
If allergic: nasal steroids, antihistamines
Refer to ENT immediately: changes in vision, mentation, or periorbital edema

    1. Sinusitis - Maxillary most commonly affected, followed by ethmoid
      1. Most common etiology for acute sinusitis: antecedent viral URI
      2. Most common bacterial pathogens: strep. pneumo, H. flu, M. cat.
    2. Orbital Cellulitis - associated with ethmoid sinus
      1. SX: fever, eyelid edema, ptosis, proptosis, chemosis
    3. Osteomyelitis - Frontal sinus most commonly affected
      1. SX: fever, headache, doughy edema over bone, large forehead abscess
    4. Allergic rhinitis (Type 1 Allergic RXN) - Boggy blue turbinates and nasal swab showing eosinophils
      1. Initially IgE mediated, then recruits neutrophils, eosinophils, lymphocytes
      2. SX:
        1. Irritative: sneezing, itching, rhinorrhea
          1. TX: antihistamines
        2. Congestive: congestion, stuffiness
          1. TX: decongestant (Sudafed, Afrin), anti-leukotriene
      3. DX: RAST Test or Skin Allergy Test (more sens/spec)
      4. First line: antihistamines, topical nasal steroids
      5. Adjunctive: mast cell stabilizer
    5. Vasomotor rhinitis - most common in anxious patients (non-allergic, unknown etiology), causes congestion & profuse rhinorrhea
      1. TX: topical anticholinergics (ipratropium bromide)
    6. Aspirin induced asthma (Samter's triad) - aspirin precipitates acute bronchospasm in patients with nasal polyps and asthma
      1. Triad: nasal polyps, asthma, Aspirin-sensitivity
    7. Nasal polyposis - usually bilateral; if unilateral, consider tumor; congestion & fullness
    8. Rhinitis medicamentosa - rebound rhinitis following sudden cessation of topical decongestants (3-5 d)
      1. SX: extreme nasal obstruction, pressure
      2. “3 sprays, 3 times daily, for 3 days”
    9. Squamous cell carcinoma - most common form of nasopharyngeal cancer
    10. Most common cause of Septal Hematoma: nasal trauma
      1. Saddle nose deformity - complication if untreated
    11. Toxic Shock Syndrome (TSS) - previous nasal packing for anterior nosebleed
      1. Etiology: toxin releasing S. aureus
      2. SX: fever, nausea, vomiting, and hypotension
    12. Most common cause of Epistaxis: digital trauma
      1. “Colder, older, males” - most commonly occurs in colder months, older population, and males
      2. Most common type of epistaxis: anterior epistaxis
Anterior epistaxis
Posterior epistaxis
Origin: Kiesselbach plexus
Visualized easily

TX: anterior nasal pressure
Origin: sphenopalatine artery’s lateral nasal branch
Unable to visualize bleeding site, blood trickles down oropharynx and both sides of nose, unable to control with pressure
TX: posterior-anterior packing or balloon tamponade device  

  1. Mouth/Throat
    1. Centor Criteria for diagnosis of Strep Throat - Fever > 38 C, lack of cough, tonsillar exudate, tender anterior cervical LAD (3 out of 4 present, sensitive)
Etiology: Strep (GAS), Staph
Incubation: 12 h - 4 d
Etiology: Coxsackie A&B, adenovirus, rhinovirus, echovirus, HSV
Prodromal: 2-5 d (infectious)
SX > 1 week
Odynophagia, dysphagia,  cough, hoarseness
Fever, anterior cervical LAD (60%)
+/- Purulence
PE: tonsillar exudates
SX < 1 week
Odynophagia, dysphagia, cough, hoarseness
LAD, myalgia, malaise, fever
Exudate - think EBV
Posterior cervical LAD
Splenomegaly, hepatomegaly
Sore throat
Fever, malaise
hairy leukoplakia” - lateral tongue; will not scrape off
Rapid strep test (specific, less sensitive) - not required

CBC - lymphocytosis
Mono-spot test (specific, not sensitive), reveals previous infection
IgM & IgG titer to VCA, EA, EBNA (2-3 d for results)
1: Benzathine PCN, Pen-V K
2: Clinda, Amox, Cefuroxime
3: Levaquin, Cipro

Do not treat with Ampicillin: causes measles-like rash & type 3 immune-complex GN
Supportive: hydration, Tylenol
HSV: acyclovir
Avoid contact sports & being hit in abdomen

Adolescents or adults
Incubation: 2-3 d
Hot potato voice (dysarthria)
Drooling, sore throat, low fever, trismus (lock jaw), odynophagia
Ipsilateral otalgia
Unilateral swelling of soft palate, uvula deviation

IV hydration
IV Clindamycin or PCN
Intraoral drainage
Elective tonsillectomy
Retropharyngeal Abscess
Etiology: B-hemolytic Strep
Common 6 M to 3 y/o
Prefer supine position
Dysphagia, muffled voice, stridor, drooling
Fever, dyspnea, stiff neck
Cervical LAD
Lateral XR: wide retropharyngeal space at C4, air/fluid level
PE: Uvula/tonsil displaced away from abscess
IV antibiotics
ICU admission
Corynebacterium diphtheriae (gram + rod) - exotoxins
MC: first decade of life
Sore throat, dysphagia, fever, tachycardia
Gray-black membrane - do NOT try to remove

Antitoxin (CDC)
N. gonorrhoeae
Asymptomatic or presents like bacterial/viral pharyngitis
Tonsillar hypertrophy

IM Ceftriaxone
Treat for Chlamydia - Azithromycin
MCC: Candida albicans
Cheesy, creamy mucosal plaques
Gram stain
Budding yeast with pseudohyphae
Can be scraped off
Oral Nystatin (swish & swallow)
PO Fluconazole
Oral Cancer
Age: 50-60 with PMH of ETOH or smoking
SX: weight loss, localized pain
Odynophagia, dysphagia, oral mass, LAD, CN involvement

Non-suppurative: paramyxovirus (mumps), influenza A, Coxsackie A, CMV, echovirus, Sjogren’s
Suppurative: Staph, strep
SX: Pain, swelling, pus from Stensen's duct (parotid)
1. Clindamycin
2. Cefuroxime, Amox
Hydration, warm compress, lemon drops

    1. Infectious Mononucleosis (EBV, CMV) - infects B-lymphocytes
    2. First line treatment for Group A beta-hemolytic strep: PCN
      1. PCN Allergy: Clindamycin or Erythromycin
      2. Most common sequelae: post-strep GN, rheumatic heart disease
    3. Dental abscess treatment - Clindamycin or Augmentin
    4. Dental caries - most common chronic disease in children
    5. Most common cause of xerostomia: medications (antihistamines and antidepressants)
    6. Most common form of glossitis: vitamin B12 deficiency
    7. Nutritional deficiencies leading to aphthous ulcers: B12, Folate, Iron
    8. Sialadenitis - most commonly affects the submandibular gland due to stasis of flow of saliva
      1. Infectious (children, post-op) - most commonly S. aureus, Strep pneumo, E. coli, H. flu
      2. Obstructive (more common form) - most common in middle-aged men
    9. Sialolithiasis (mealtime syndrome) - pain and swelling of submandibular gland worse with thought, smell, sight or taste of food
    10. Ludwig’s Angina - abscess of the submandibular, submental, or sublingual space
      1. Most common origin: lower second and third molar
      2. Most common agents: hemolytic strep, staph, mixed anaerobic/aerobic bacteria
    11. Alveolar osteitis (dry socket) - severe pain, foul mouth odor, and taste several days after tooth extraction
    12. Most common site affected in oral cancer: lateral ventral tongue
    13. Oropharyngeal thrush - most common oral manifestation of AIDS
    14. Epiglottitis - most common in 2-4 year old boys
    15. Viral pharyngitis - most common cause of pharyngitis
      1. Most commonly caused by Coxsackie A & B
    16. Most common viral agents of laryngotracheitis - parainfluenza virus I, II, III
      1. Most common bacterial agents: S. aureus, Strep. pneumo
    17. Herpangina - caused by Coxsackievirus group A
    18. Sjogren syndrome - most common in women 50+
      1. SX: diminished lacrimal and salivary gland secretion (dry mouth and eyes), salivary gland enlargement, arthritis
      2. Etiology: lymphatic infiltration of lacrimal/salivary glands

MC: 2-4 y/o boys
Etiology: HIB (children)
Child: fever, irritable, dysphonia, dysphagia
Drooling, inspiratory stridor
Adults: recent viral URI, severe pain, dysphagia, drooling, muffled voice
Clinical DX
High WBC, neutrophils
Lateral view: “Thumb print sign”
ABX: 3rd Gen Cephalosporin, Unasyn
Etiology: M. Cat, H. flu, N. gonorrhoeae
Non-infectious: reflux
Sudden onset hoarseness, rhinorrhea, cough, sore throat

Self-limiting: 2 weeks
Voice rest, hydration
Cough suppression - no antihistamines
Chronic Laryngitis

> 2 weeks


  1. I'm surprised to see anything to do with eyes on the PANCE, I thought PAs weren't qualified to work for that specialty. Seeing as how I'm pre-PA and have been working with an ophthalmologist, do you happen to know if you ever see PAs working in that specialty?

    1. PAs are expected to do ophthalmic exams in any setting if any eye problems arise and know when there is an abnormality to refer. They can treat for simple things, like conjunctivitis, but like general physicians, they must know their limitations and know when they should refer to ophthalmologists. There aren't many PAs working in the ophthalmology field, but they are out there.

    2. ^^^ The person above is exactly correct. We aren't expected to know everything as PAs. Just like other family physicians we have to know our limits and know when to refer, but we should have a basic understanding to know and recognize the signs/symptoms of emergencies.

  2. Hey Paul, the info in your website is wonderful!!!
    One quick question need your advise..

    I read your previous article saying.. you do recommend the book of "The Color Atlas of Family Medicine" for family rotation.. now it has app (2013) about 94 bucks.. but the same company makes another app for another book of "The Atlas of Emergency Medicine" (2015) about 200 bucks..... I am new and currently doing family rotation right now, but will do ER later... do you recommend to buy both? or do you think I can buy ER one, do you think it can apply to family practice setting currently i am doing right now??? or ??? what you think? they are expensive.. I did research, but not useful results.. If possible, can you give me some advise plz, thank you very much in advance!!!


    1. I would probably read reviews on each and make that decision yourself. I'd hate to recommend one and it not be quality. If you plan on keeping it and using it for a long time, I would probably invest in the higher paying one if it is worth the money. Again, read reviews on each and decide whether you think the other is worth the extra $100. I would not recommend buying both, though.

    2. Thank you very much for your inputs!!!

  3. Hey Paul! Great site! Would you be able to upload these study guys as a pdf or word doc so that i can download it? This site is super informative!

    1. Hi GatorACE - great question! I'm actually working to format these into study guides for students. Give me a few more months and I should have everything worked out! Thanks for the motivation!

    2. Hi Paul ! This is awesome, any updates on being able to save it as a PDF? Maybe I just can't find it? Would love to have it for my subway commute

    3. Hey Christine,

      Great question! I have not released these as PDFs because I do not own the copyrights to the images.


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