Diagnostic Methods

Diagnostic Test

Measures

Indications
Family history of
childhood SNHL
In-utero infection
Abnormal facial features

Neonates

Audiometry

Capacity to hear
sound
Children

Adults

Birth weight < 1500 g

Severe
hyperbilirubinemia
History of prenatal
ototoxic medication
exposure
Bacterial meningitis
Very Apgar score
Respiratory failure
requiring ventilation for
> 5 days
Known syndrome with
hearing loss
Any concern about
hearing, speech,
language, or
developmental delay
Infections associated
with SNHL
Head trauma with loss of
consciousness or skull
fracture
Known syndrome with
hearing loss
Ototoxic medications
Otitis media with
effusion > 3 months
Perceived hearing loss
Abnormality on PE
Ototoxic medications
Loud noise exposure
Severe head trauma
Infections associated
with hearing loss
Family history of hearing
loss
Hypoxia or respiratory
failure
Tinnitus

Result

Test Interpretation
Parameters

Other
Severity of Hearing Loss
Normal = 0 - 25 dB
Mild = 25 - 45 dB
Moderate = 45 - 65 dB
Severe = 65 - 85 dB
Profound = 85+ dB

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Diagnostic Methods
Diagnostic Test

Measures

Indications

Weber Test

Conductive verus sensorineural

loss in unilateral hearing loss

Unilateral hearing loss

Rinne Test

Test Interpretation
Parameters
Tone louder in poorer
Conductive Loss
ear
Result

Sensorineural Loss Tone louder in better ear

Tone louder at ear with
normal hearing

Compares patient's air

and bone conduction
hearing

POSITIVE
Hearing loss
NEGATIVE
Type A
Type B

Tympanometry

Type C

Measure of middle ear

pressure and tympanic
membrane compliance

Hearing loss
Type AS

Type AD

Ear Canal
Volume
Speech
Audiometry
Laryngoscopy

Amount of space in the

external ear canal

Capacity to hear and

understand speech

Visualization of the
larynx

Other

Hearing loss

Small
(< 0.5)
Normal
Large
(> 2.5)

Tone louder at ear with

sensorineural loss
Tone louder on mastoid
with conductive loss
Normal
Perforation of fluid
(flat tympanogram)
Eustachian tube
dysfunction
(negative pressure)
Normal pressure
equalization with a rigid
TM
Normal pressure
equalization with flaccid
TM or ossicle
disarticulation
Obstruction or stenosis
in the EAC
0.5 - 2.5
TM perforation
Speech Reception Threhold (SRT)
How quiet a patient recognize speech

Unable to hear people when they speak to them

Hoarseness
Neck Mass
Chronic sinusitis

Suspected cancer
Foreign body
Chronic cough

Neck or cardiac surgery Obstructive sleep apnea

Referred pain
Hemoptysis

Shortness of breath
Recurrent otitis media

Normal Speech
Discrimination

> 88%

Speech Discrimination
How well a patient understands
speech
Indirect Laryngoscopy
Use of an instrument to visualize an
image or reflection of the larynx
Direct Laryngoscopy
Straight visualization of the larynx

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Diagnostic Methods
Diagnostic Test

Measures

Indications

Result

Test Interpretation
Parameters

Patient is sitting in
"sniffing" position

Advantages
Performed in exam room
No anesthesia
Quick
Disadvantages
Gag reflex
Low quality image
Cannot see entire larynx

Grasp tongue with gauze

Mirror
Laryngoscopy

Visualizing the larynx

using a mirror

upper lip with finger

Procedure

Warm mirror placed on

soft palate and uvula
without touching back of
the throat
Apply topical
decongestants and
anesthesia

Flexible
Fiberoptic
Laryngoscopy
Direct
Laryngoscopy

Radiograph

Use of a flexible scope to

examine the larynx

Best quality method of

examining the larynx
Uses x-rays to view a nonuniformly composed
object

Sinus Magnetic
Resonance Imaging

Strong magnetic fields and

radiowaves are used to form
images of the sinuses

Computed
Tomography

Computer-processed xrays produce

tomographic images of
specific areas in an object

Advantages
More comfortable than mirror
No gag reflex
Better visualization
Higher quality image than mirror
Quick
Disadvantages
Bad-tasting medicines
Choking sensation with anesthesia
No biopsy
No mid-line view of larynx

Scope passed through

nasal passage
Procedure
Examine the
nasopharynx,
oropharynx,
hypopharynx, and larynx
Need for better
Need to palpate the
visualization of the
vocal cords
larynx
Prior to laryngeal
intubation
Laryngeal treatment
Biopsy of the larynx

Avoid breaking the teeth or pinching

the lips

Waters (Maxillary)
Air fluid levels in the sinuses

Views
Caldwell (Frontal)

Neoplasms

Mucoceles

Encephaloceles

Systematic Approach to
Interpretation

Orbits
Orbit wall
Maxilla
Nasal septum
Turnbinates
Sinuses
(anterior posterior)

Other

Good for showing air fluid levels in

the maxillary and frontal sinuses
Not good for showing mucosal
thickening and soft tissue
abnormalities
Does not image detailed bone
structures well
Mucosa can be improperly
represented as inflammation.
First choice in nasal and sinus
imaging
CTs turn out better when the patient
is maximally treated to reduce
inflammation.

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Auricular
Hematoma
Cerumen
Impaction
Acute Bacterial
Otitis Externa

Cause

Signs and Symptoms

Swollen auricle

Large cerumen buildup causes

occulsion of the external auditory
canal

Ceramen mass in external auditory canal

Chronic Otitis Externa

Frequent recurrence of
otitis externa

Malignant Otitis
Externa

Temporal bone destruction

due to otitis externa

Myringosclerosis

Scarring of the tympanic

membrane

Acute Tympanic Membrane

Perforation
Chronic Tympanic Membrance
Perforation

Rupture of the tympanic

membrane

Chronic Suppurative
Otitis Media

Otitis media in the presence of a

tympanic membrane perforation or
tympanostomy tube

Eustachian Tube
Dysfunction

Dysfunction of the
pharyngotympanic tube

Hearing

Ear fullness

Cholesteatoma

Non-cancerous skin cyst that

grows in the middle ear

Conductive hearing loss

Bone destruction

Hearing

Ear fullness

Acute Otitis
Media

Sudden infection of the

middle ear

Medications

Removal
Remove purulent debris (suction)
Topical antibiotics

Pain at auricle
Pain at tragus
Hearing loss
Yellowish otorrhea
Fullness
Itching
Inflammation
Pain at auricle
Pain at tragus
Hearing loss
Otorrhea
Fullness
Itching
Spores
Green / gray hue growth
Fuzzy growth
Antibiotic drops fail
Eczema
Associated Chronic Skin
Psoriasis
Conditions
Seborrheic dermatitis

External auditory canal

infection due to fungus

Buildup of nonpurulent
fluid in the middle ear

Treatment

Bolster both sides of auricle with

dental rolls

Acute Fungal
Otitis Externa

Serous Otitis
Media

Laboratory
Result

Incision and drainage

Physical trauma to the auricle which

causes shearing of the tissues and a
perichondral hematoma

Bacterial infection of the

external auditory canal

Test

Chronic ear pain and drainage > 2 - 3 months

Hearing

Scar tissue visible

Hearing

Otorrhea (chronic)

Ear pain (acute)

Bleeding (acute)

Middle ear infection

symptoms

Otorrhea

Otorrhea culture (if antibiotics fail)

Remove debris

Topical antifungals

Other

Cauliflower Ear
Failure to repair auricular hematoma
leads to permanent remodeling of
the auricle
Counterindications for Removal
Prior ear surgery
Perferated tympanic membrane
Painful during removal
Etiologies
Streptococcus
Fluoroquinolone
Staphylococcus
Pseudomonas
Acetic acid ear Etiologies
drops
Aspergillus
Candida
Clotrimazole
CASH powder
CCDB powder

Topical steroid cream (eczema)

Water and vinegar lavage
Avoidance of trauma (ex: Q-tips)
CT or MRI
with contrast

Temporal bone
destruction

EMERGENCY
Usually caused by P. aeruginosa
Typically seen in elderly or
immunocompromised

Immediate referral

Surveillance
Topical antibiotics
Tympanoplasty
Topical antibiotics

Quinolone

Surgery
Etiologies
Nasal allergy
Upper respiratory infection
Nasopharynx mass
Anatomic irregularities

Surveillance (if acute)

Nasal steroid spray
Bilateral myringotomy with tube
placement (chronic)
Surgical excision
Surveillance
Nasal steroids
Tinnitus

Steroids

Myringotomy with tube placement

Ear pain

Hearing

Tinnitus

Ear fullness

Sharp pain with otorrhea (perforation)

Oral antibiotics

Etiologies
Chronic Eustachian tube disorders
Acute otitis media
Barotrauma
Hearing loss may be present for 3 - 4
months
Complications
Mastoiditis
Labyrinthitis
Meningitis / intracranial abscess
TM perforation
Tympanosclerosis
Facial nerve paralysis

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Fever

Otalgia
Tenderness with
protrusion of auricle

Acute
Mastoiditis

Spread of otitis media to

the mastoid air cells

Post-auricular erythema

Bullous Myringitis

Middle ear inflammation

with blisters on the tympanic
membrane

Ear pain

Swelling

Ear pain

Otologic Causes

Sensorineural
Hearing Loss

Reduction in the ability to

interpret sound due to a
dysfunction in the
hearing pathway beyond
the oval window

Most Common
Etiologies

Sudden Sensorineural
Hearing Loss

Any form of sensorineural

hearing loss that has
occurred within 72 hours

Conductive
Hearing Loss

Hearing loss that occurs due

to dynfunction prior to sound
conduction through the oval
window

Vertigo

Inappropriate experience of
the perception of motion due
to dysfunction of the
vestibular system

Treatment

Medications

Vertigo

Ear fullness

Tinnitus

Antibiotics
Macrolides
Pain management

ENT referral
Prednisone

Most Common
Etiologies

Qualities of Tinnitis

Other

IV antibiotics
ENT consult
Admission
Mastoidectomy

Otitis externa
Otitis media
Myringitis
Ear canal abscess
Ear tumor
Herpes Zoster
Cholesteatoma
Acute tympanic
membrane perforation
Viral labyrinthitis
Acoustic neuroma
Ototoxicity
Idiopathic sudden
sensorineural hearing
loss
Autoimmune hearing
loss
Noise-induced hearing
loss
Hypothyroidism
Meniere's diseae
Presbycusis

Dizziness

Abnormal sound

Any abnormal sound in

the ear

Laboratory
Result

Pain with coughing or

sneezing

Otalgia

Tinnitus

Test

Steroid treatment

Cerumen impaction
TM perforation
TM retraction
Serous otitis media
Acute otitis media
Cholesteatoma
Otosclerosis
Sound in quiet
environments
Frequency
Pulsatile
Roaring
Breathing
Clicking

Determine cause
Treat underlying disease

Etiologies
Mycoplasma
H. flu
Strep. pneumo
Referred Pain Etiologies
Temporomandibular dysfunction
Oral pain
Sinusitis
Musculoskeletal neck pain
Neck lymphadenopathy
Parotitis
Trigeminal neuralgia
Head, neck, and throat cancer
Ototoxic Medications
Amnioglycoside antibiotics
Vancomycin
Erythromycin
Chemotherapy
Loop diuretics
Salicylates
Quinine

EMERGENCY
Etiologies
Viral labyrinthitis
Autoimmune disease
Vascular compromise
Always due to defects / diseases /
obstructions of the external auditory
canal, tympanic membrane, middle
ear space, or ossicles.

Amplification (hearing aid)

Hearing tests
Patient education
Anxiety relief
Background noise
Stop tinnitis-inducing medications
Avoid caffeine / nicotine
Tinnitus retraining therapy

Subjective Tinnitus
Sound that only the patient can hear
Objective Tinnitus
Sound that the examiner may be able
to hear

VideonystagmoRotational dizziness

Elevator sensation

Assessment
Tests
CT

Tilting room

MRI

Rotary chair
Fistula test
Temporal bone
Internal auditory
canal
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Benign Paroxysmal
Positional Vertigo

Cause

Displaced otoliths in the

semicircular canals

Signs and Symptoms

< 1 minute
Vertigo symptoms
when head is still

Intermittent episodes
Vertigo symptoms
with supine head
movements

Test

Dix-Hallpike
Maneuver

Increased endolympathic
fluid pressure

Classic Triad of
Meniere's Disease

Treatment

Medications

Vertigo that has lasted

hours

Other

Epley maneuvers
POSITIVE
Canalith repositioning
Diuretics
Sodium diet
Anti-vertigo medications
Endolymphatic sac decompression
Gentamycin injection

Episodic SNHL

Mnire's
Disease

Laboratory
Result

Dyazide

Selective vestibular nerve resection

Roaring tinnitus

Labyrinthectomy
Steroid therapy

Vestibular Neuritis

Infection or inflammation of
the semicircular canals

Severe vertigo

Labyrinthitis

Infections or inflammation of
the inner ear

Vertigo

Hearing

Acoustic Neuroma

Slow-growing non-cancerous tumor

arising from Schwann cells

Asymmetric SNHL
Imbalance
(not vertigo related)

Tinnitus
Brainstem compression
symptoms

Septal Deviation
Septal Perforation

Alignment of the septum away from

the midline

Nasal Mucositis

Aperture in the septum

Irritation or infection of
the nasal mucosea

Imbalance
Physical therapy
Steroid therapy
Physical therapy
MRI with
Contrast

Observation
Internal auditory
Stereotactic radiation
canal
Surgery

Bent septum
Hole in the septum

Epitaxis

Sore tip of nose

Crusts

Antibiotic therapy

Bactroban
Polysporin
Keflex
Clindamycin
Amoxicillin

Conservative antibiotic therapy

Nosebleed
Manual compression

Epistaxis

Bleeding in the nasal

cavity
Systemic Causes

Allergic
Rhinitis
Vasomotor
Rhinitis

IgE-mediated reaction causes

mast cells and basophils to
release histamine,
leukotriene, serotonin, and
prostaglandins

Non-allergy mediated
inflammation causes
rhinitis

Clotting disorder
Hypertension
Leukemia
Liver disease
Medications
Thrombocytopenia

Cautery
Packing
Surgery

Nasal congestion

Rhinorrhea

Allergen avoidance

Sneezing

Itching

Nasal saline lavage

Watery eyes

Allergic shiner

Turbinate hypertrophy

Etiologies

Afrin

Nasal steroid therapy

Antihistamine therapy
Leukotriene inhibitor
Immunotherapy

Fluticasone
Budesonide
Mometasone
Benadryl
Fexofenadine
Cetirizine
Loratadine
Monteleukast

Local Risk Factors

Digital manipulation
Septal deviation
Inflammation
Cold, dry air
Foreign body
Posterior nosebleeds are more
severe, and possibly life-threatening,
than anterior nosebleeds.
Common Allergens
Grass / tree pollen
Mold
Dust
Dander

Temperature
Exercise
Foreign body
Fumes
Food
Medication
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Rhinitis
Medicamentosa

Drug-induced rhinitis caused by

the overuse of topical
decongestants

Viral Rhinitis

Upper respiratory tract

infection due to a virus

Signs and Symptoms

Rhinitis symptoms

Rebound congestion

Sore throat

Nasal congestion

Rhinorrhea
Cough

Fever
Malaise

Test

Laboratory
Result

Nasal Polyposis

Acute Bacterial
Rhinosinusitis

Non-cancerous growths in
the nasal cavity

Samter's Triad

Upper tooth pain

Purulent nasal discharge

Nasal congestion

Chronic
Sinusitis

Sinusitis that lasts for

more than 12 weeks

Viral
Pharyngitis

Viral infection of the

pharynx

Strep
Pharyngitis

Infection of the pharynx

by Strepococcus

Acute Tonsillits

Viral or bacterial infection of

the tonsils

Mononucleosis

Infection, by Epstein Barr virus or

cytomegalovirus, that causes the
proliferation of mononuclear
leukocytes

Surgery
Antibiotic therapy
Augmentin (1st line)

2nd Line
Antibiotics

Pathogens

Diffuse erythema
Dysphagia
Fever
Upper respiratory illness
symptoms
Sore throat
Odynophagia
Fever
Airway obstructive
symptoms
Defined borders

Fever

Subacute Sinusitis
Sinusitis for 4 - 12 weeks
dose
Augmentin
Doxycycline
Levofloxacin
Moxifloxacin
Clindamycin / 3rd
Gen Ceph.

See Treatment
section

Nasal saline lavage

Nasal steroid therapy
Afrin (4 days or less)

Nasal discharge
S. penumo
H. flu
M. cat
S. aureus
Klebsiella
Pseudomonas
Proteus
Enterobacter
Anaerobic bacteria
Fungi
Edema
Pain
Lymphadenopathy

Tylenol

Pathogens
Adenovirus
Parainfluenza
Coronavirus
Rhinovirus

Allergy treatment
Steroid therapy

Headache
Double Sickening
(New onset after
infection)

Mucolytics
Ibuprofen

Fever (severe Sx)

Infection of the
sinuses

Other

Prednisone

Rest

Chronic rhinitis
Aspirin sensitivity
Nasal polyposis
Asthma

Local facial pain

Medications

Supportive therapy

Fatigue
Allergic rhinitis

Treatment
Stop topical decongestants
Substitute with nasal steroids or
antihistamines
Afrin taper
Prednisone therapy

Look for antibiotic resistance as the

cause of antibiotic failure.

Non-contrast Possible structural

Sinus aspirate culture
Sinus CT
abnormality

Usually resolves in 3 - 7 days

OTC supportive medications

Ulcers (possible)
Dysphagia
Bright erythema
( exudate)
Tender
lymphadenopathy
Malaise

Tonsil hypertrophy

Possible visible bacterial

colonies

Asymptomatic

Fatigue

Malaise

Sore throat

Lymphadenopathy

Hepatosplenomegaly

Rapid Strep
Test

1st Line
Antibiotics
POSITIVE
2nd Line
Antibiotics

PenVK
Bicillin
Amox / clav
1st Gen Ceph.
Clindamycin
Clarithromycin

See Treatment
section

Group A Strep pyogenes is a

common bacterial pathogen.

CBC

Atypical
lymphocytes

Monospot

POSITIVE

OTC medications
Pain control
Steroid therapy
Seatbelt counseling
Avoid contact sports
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Test

Peritonsillar
Abscess

Collection of mucopurulent
material in the peritonsillar
space

"Hot potato" voice

Severe throat pain
Trismus
Uvula deviation
Copious salivation
Severe malaise

Extended neck
Dysphagia
Asymmetric swelling of
soft palate
Fever
History of tonsillitis

Ludwig's Angina

Cellulitis of the floor of the

mouth

Neck edema

Tongue protudes
upward

Parotitis
Sialadenitis

Painful swelling of the parotid gland

Expressable pus

Pain

Painful swelling of the salivary gland

Erthyma

Edema

Sialolithiasis

Calculus in the salivary

duct

Salivary gland edema

Salivation

Laboratory
Result

Acute Laryngitis

Sudden infection or
inflammation of the larynx

Hoarseness

Vocal Cord Nodule

Callus of the vocal cords

Hoarsness

Thyroglossal Duct Cyst

Benign mass in the thyroglossal duct

Branchial Cleft Cyst

Cystic swellings in the anterior part

of strenocleidomastoid

Squamous Cell Carinoma

on the Ear

Cancerous mass on the

external ear

Glomus Tympanicum

Highly vascular, benign tumor that

arises from the paraganglia in the
middle ear

Nasal Osteoma

Benign bony growth of the

nasal cavity

Squamous Papilloma

Warts of the nasal cavity by

HPV

Cancerous-like appearing tumor

Inverted Papilloma

Pre-malignant tumor, due to HPV,

of the nasal cavity

Polyp-appearing tumor

Juvenile Angiofibroma

Benign tumor of the nasal

cavity

Incision and drainage

Augmentin

Antibiotic therapy with anaerobic

coverage

Clindamycin

Warm compresses
Hydration
Warm compresses
Sialagogues
Surgery (if severe)

Most commonly located at the

submandibular duct

Occupations like teachers, singers,

and phone operators have a higher
incidence for hoarsness.

Treat underlying disease

Voice rest
Fluids

Sore throat
Fever

Etiologies
Viral infection
Vocal misuse
Exposure to noxious agents

Smoking cessation

Bilateral masses on the

vocal cords

Other

Airway management
Antibiotic therapy
Surgery
Antibiotic therapy
Sialagogues

Symptoms between meals

Raspy voice

Medications

Often follows tonsillitis

Sore throat
Dysphagia
Cough
Hemoptysis
Reflux
Heartburn
Allergies
History of smoking
History of alcohol
Recent surgery
Thoracic surgery

Hoarseness

Treatment

Endoscopy

Masses on vocal
cords

Midline mass of midline cartilage that moves up

with tongue movement
Unilateral, round mass
Non-tender mass
on neck
Biopsy of auricle AND external
auditory canal
Surgical excision with radiation

Tumor on ear

Lymph node dissection (if metastasis)

Tumor on tympanic membrane

Nasal obstruction

Adolescent

Protuding mass

Unilateral epistaxis

Temporal
Bone CT with
Contrast
CT

Determine extent
Surgical excision
of growth
Bony growth

Surgical excision

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Laboratory
Result

Condition / Disease

Cause

Signs and Symptoms

Nasal Squamous Cell

Carcinoma

Malignant tumor of the nasal

cavity

Cancerous mass

Biopsy

Squamous cell
carcinoma

Tornwald Cyst

Cystic mass

MRI

Cystic growth

Mucocele

Cyst that is midline in the back of the

nasopharygneal cavity
Cyst that not midline in the back of
the nasopharygneal cavity

Leukoplakia

Hyperkeritosis of the
mucous membrane

Hairy Oral
Luekoplakia

Viral leukoplakia

Erythroplakia

Lesion of the mucous

membrane

Red plaques

Lesion growth

Lichen Planus

Autoimmune skin condition

White, lacy, reticular

lesion

Flat-topped, shiny,
violaceous papules

Gingivitis

Inflammation of the gums due

accumulation of Gram (-) bacteria in
the biofilm

Erythema

Swelling

Periodontitis
Caries

Loss of bone that

supports the teeth
Infection that causes the
demineralization and destruction of
the hard tissue of the teeth

History of smoking

Oral cavity infection

by Candida albicans

Pseudomembranous
Candidiasis
Erythematous
Candidiasis
Angular Cheilitis

Types of oral
candidiasis

Treatment

Medications

Other

Surgical excision

Well-demarcated, white
plaques

White plaques on mucosa

Bleeding

Tenderness

Visible periodontal
pocket

Inflammed gingiva

Related Factors

Diabetes
Osteoporosis
AIDS
Syndomes
Socioeconomic status

White, chalky spots

(early)

Dark spots (late)

Painful mucosa

Oral
Candidiasis

Test

White plaques that ruboff

Pain
Red, atrophic mucosa

Central papillary atrophy

Median rhomboid
glossitis
Oral commissures
Erthema

Phenytoin
Cyclosporin
CCBs

Can be reversible

More common in
Smoking aggravates periodontitis
Pathogens
Porphyromonas gingivalis
Actino. actinomycetemcomitans
Prevotella intermedia
Bacteroides forsythus
Treponema denticola
Improve oral hygiene
Fillings

White growths
Xerostomia
Endocrine dysfunction
Immunosuppression
Medications
Trauma
(chronic irritation)
Blood diseases
Tobacco
Underlying red /
bleeding mucosa
Burning

Associated Conditions

Improve oral hygiene

Medications (can cause or exacerbate
the condition)

Nystatin

Antifungal treatment

Fluconazole

Clotrimazole

Also known as thrush

Common occurs in the
immunocompromised
Types of Oral Candidiasis
Pseudomembranous
Erythematous
Hyperplastic
Angular cheilitis
Associated with broad-spectrum
antibiotic or steroids

See Oral Candidiasis

Associated with antibiotcs and

dentures

Chronic candidiasis
Saliva pooling
Scaling of the lips

Also known as perleche

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Signs and Symptoms

Test

Laboratory
Result

Treatment

Asymptomatic or symptomatic

Oral Herpes
Simplex Virus
Infection

Oral infections
most commonly
due to HPV-1

Lymphadenopathy

Fever

Chills

Nausea

Irritability

Fever blisters

Gingivostomatitis
(children)

Pharyngotonsillitis
(adults)

Medications

Maalox /
Kaopectate
Palliative care

Valcyclovir

Penciclovir
Antiviral therapy
Acyclovir

Mucosa attached to bone

Aphthous
Ulcers
Antiresorptive
Drug-Related
Osteonecrosis
of the Jaws

Oral Cancer

Ulcers in the mucosa

of the oral cavity

Ulcerations inside the oral cavity

No blisters
Movable mucosa
Allergies
Genetics
Nutrition
Hormones
Possible Etiologies
Hematological
Infections
Trauma
Stress

Other
Primary Infection
Multiple small vesicles collapse to
form ulcers
Enlarged painful and erythematous
gingiva
Perioral lesions are common.
Heal in 5 - 15 days
Secondary Infection
Reactivation of virus
Viral shedding
Targets epithelium
Triggered by UV, stress, pregnancy,
trauma, menstruation, systemic
diseases, and cancer
Fever Blister or Cold Sore
Recurrent herpes labialis
15 - 50% of US population
Herpetic Whitlow
HPV growth on the tips of dentists
who previously did not use gloves
Unlike Herpes, ulcerations occur with
unattached mucosa.
Heal spontaneously in 10 - 14 days
Rule-Out Diseases
Celiac disease
Cyclic neutropenia
Malnutrition
Immunosuppression
IBD

Surveillance

Topical steroids

Visible bone where the gingiva should be located

Degradation of the
gingiva and mandible due
to drug side effects

Bisphosponates

Denosumab

Neoplasm of the oral

cavity

Bevacizumab
Leukoplakia
Ulcer
Papillary growths
Loose teeth
Paresthesias
Sore throat

Fossamax
Boniva
Reclast
Zometa
Aredia
Prolia
XGEVA
Avastin
Erythroplakia
Mass

Oral pain
Bleeding sore

Tobacco and alcohol

Viruses
Genetic derangements
Loss of
immunosurveillance

Cisplatin
5-Fluorouracil

Induration with fixation

Symptoms last more than 2 weeks

Etiologies

Surgery
Radiation therapy
Chemotherapy

Carboplatin
Paclitaxel

Types of Oral Cancers

Squamous cell carcinoma
Lymphomas
Salivary gland tumors
Sarcomas
Melanoma
Other (odontogenic or metastasis)

Docetaxel
Targeted therapy
Combination therapy

Methotrexate
Ifosfamide

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Unilateral Sensorineural
Hearing Loss

Unilateral hearing loss due to a

defect in the hearing pathway
beyond the oval window

Bilateral
Sensorineural Hearing
Loss

Bilateral hearing loss due to a

defect in the hearing pathway
beyond the oval window

Signs and Symptoms

Sudden SNHL
Acoustic neurome
Intracranial trauma or
CVA
Hypertension
Atherosclerosis
Hypothyroidism
Lyme disease
Syphillis
Astigmatism

Refractive
Error

Reduced visual acuity

Strabismus

Eyes are not properly

aligned with each other

Amblyopia

Decreased visual acuity

resulting from abnormal
development

Keratoconjunctivitis
Sicca

Hyperopia
Myopia

Chalazion
Blepharitis

Inflammation or infection
of the eyelids

Entropion

Inward turning of the

lower lid

Ectropion

Outward turning of the

lower lid

Dacryocystitis

Inflammation of the
nasolacrimal sac

Medications

Diabetes mellitus
Ototoxic medications
Presbycusis
HIV
Autoimmune diseases
Refractive errors in both
horizontal and vertical
axes
Farsightness
Nearsightness

Astigmatism
Caused by irregularly shaped cornea
Hyperopia
Eyeball is too short
Myopia
Eyeball is too long
Presbyopia
Eye loses accomodation
Esotropia
Inward strabismus
Exotropia
Outward strabismus
Can be corrected if caught early

Eyes are looking in two different directions

Visual acuity
Strabismus
Uncorrected refractive
Conditions leading to
errors
Cataracts
Dryness
Redness

Red, swollen eyelid

Tender eyelid

Hard eyelid

Conjunctival erythema

Tear
Osmolarity

Artificial tears
Poor quailty

Cyclosporine

Lubricant ointments
Humidifiers

Internal hordeolum is an abscess of

the meibomian gland.

Warm compresses
Remove contacts

Irritation

Topical antibiotics

Incision (if severe)

Nontender eyelid
Burning
Itching
Congenital
Aging
Scarring
Spasm
Congenital
Aging
Associated Factors
Scarring
Mechanical
Facial nerve palsy
Pain, swelling, tenderness, and redness over the
inner aspect of lower eyelid

Remove scales and wash

Warm compresses
Topical antibiotics
Steroid therapy (if inflammation of
the cornea and conjunctiva)

Discharge

Etiologies
Anterior = Staphylococci
Posterior = Rosacea

Caused by the degeneration of the lid

fascia

Associated Factors

Tearing

Other

Noise-induced trauma

Photophobia

Cyst in the eyelid that is caused by

inflammation

Treatment

Acute labyrinthitis
Mnire's disease

Dry eye caused by decreased tear

Foreign body sensation Difficulty moving eye lids
production or poor tear quality

Hordeolum

Laboratory
Result

Natural loss of visual

acuity with age

Presbyopia

Infection that blocks

sebaceous glands at the base
of the eyelashes

Test

Common with advanced age

Antibiotic therapy
Warm compresses
Surgery
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Pre-Septal Orbital
Cellulitis
Post-Septal
Orbital Cellulitis

Cause

Infection of the tissues

superficial to the orbital
septum
Infection of the tissue deep in
the orbital septum

Orbital Cellulitis

Inflammation of the orbit

Viral
Conjunctivitis

Viral infection of the

conjunctiva

Bacterial
Conjunctivitis

Infection of the
conjunctiva by
bacteria

Signs and Symptoms

Eyelid edema
Skin tenderness

Erythema
Pain

Test

Laboratory
Result

CT

No limitation in eye movement

Assessment
(if severe)

Erythema
Pain
Visual acuity
Limited eye movement
Papillary defect
Eye movement pain

Treatment

Medications

Antibiotic therapy
Close follow up

Eyelid edema
Skin tenderness

Fever

Proptosis

Erythema

Eyelid edema

EMERGENCY
Immediate referral

Clindamycin
Metronidazole
Cephalosporin
Vancomycin

Immediate antibiotics
Supportive treatment
Hand washing
Cold compresses
Surveillance
Change contacts

Unilateral or bilateral
Watery discharge
symptoms
Foreign body sensation
Pharyngitis
Fever
Malaise
Preauricular adenopathy
Unilateral or bilateral
symptoms

Purulent discharge

Pharyngitis

Foreign body sensation

Fever

Malaise

Conjunctival inflammation
due to an allergic reaction

TrimethoprimPolymyxin B
Antibiotic therapy
Erythromycin

OTC histamines
Itching

Erythema
Vasoconstrictor agents

Viral conjunctivitis
symptoms

Foreign body sensation

Pseudomembranes

Corneal infiltrates

Epidemic
Keratoconjunctivitis

Keratitis in addition to
conjunctivitis

Pinguecula

Benign yellow colored,

conjunctival nodule

Yellow nodule

Pterygium

Fleshy, triangular encroachment of

the conjunctiva onto the nasal side of
the cornea

Tissue stretched towards in nose

Bloody conjunctiva

Subconjunctival
Hemorrhage

Blood vessel breaks just

underneath the surface
of the eye

Conreal Abrasion

Corneal scratch

Risk Factors

Excruciating eye pain

Foreign body sensation

Can cause optic nerve damage if not

treated quickly

Most common cause is adenovirus

Preauricular adenopathy

Allergic
Conjunctivitis

Other

Newborn Etiologies
Chlamydia
Gonorrhea
Children Etiologies
S. pneumoniae
H. influenzae
Adult Etiologies
Streptococcus
E. coli
Pseudomonas
Often associated with atopic disease
like allergic rhinitis, eczema, and
asthma

Referral

Asymptomatic
Diabetes mellitus
Hypertension
Coughing
Sneezing
Blood thinners
Herbal supplements
Inability to open eye
Blood
Pus

Usually happens on the nasal side of

the eye
Due to a change in the normal tissue
that results in a deposit of protein,
fat, and/or calcium
Associated with constant exposure to
wind, sun, sand, and dust

Surveillance

Excision Indicators

Affects vision
Astigmatism
Ocular irritation

Surveillance

Fluorescein
Examination

Abrasion
fluoresces

Ophthalomologist referral
Topical antibiotics
Follow up within 24 hours

Erythromycin
Ofloxacin
Ciprofloxacin

Avoid aminogylcosides during

treatment

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Cause

Infectious
Keratitis

Ulceration of the cornea

related to infection

Hyphema

Blood in the anterior

chamber

Hypopyon

Puss in the anterior

chamber

Cataracts

Opacity of the lens

Signs and Symptoms

Acute pain

Test

Laboratory
Result

Retinal
Detachment

Retinal Vein
Occulsion

Loss of macular
functionality

Retina dissociates from the

retinal pigment epithelium

Blockage of the retinal

vein

Tearing

Vision

Significant trauma

Inflammation

Retinal artery becomes

blocked

Other
Bacterial / Acanthamoeba Keratitis
Contact lens wearers
Herpes Simplex Keratitis
Characteristic branching ulcer
Fungal Keratitis
Involves plants or agricultural setting

Immediate referral

Ophthalmologist consult
Pathologic neovascularization
Infectious keratitis
Pus covering iris

Ophthalmologist consult
Enodphthalmitis

Painless
Visual acuity

Progressive blurring of
vision

Eyeglasses

Color perception

Constrast sensitivity

Contact prescription changes

Etiologies
Congenital
Traumatic
Systemic disease
Corticosteroid treatment
Uveitis
Etiologies
Age
Smoking
Hypertension
Hyperlipidemia
Vascular insufficiency
UV light exposure
Family history of risk factors

Surgical extraction

Asymptomatic

Central vision loss

Glare sensitivity

Scotomas

Color vision

Intact peripheral vision

Floaters
No erthyma

Light flashes
Painless

Antioxidant therapy
Zinc and copper supplements
Laser retinal photocoagulation

Unilateral vision loss

Vision loss

Painless

Retinal hemorrhages

Optic disc swelling

Venous dilation

Venous tortuosity

Immediate referral

Treat underlying medical conditions

Cotton-wool spots on retina

Retinal Artery
Occlusion

Medications

Photophobia

Glare disability

Macular
Degeneration

Treatment

Monocular vision loss

Painless

Retina edema

Cherry-red spot at the

fovea

Carotid
Ultrasound,
EKG, CT, or
MRI

Assessment for
internal carotid Immediate referral
artery dissection

Associated Factors
Hypertension
Glaucoma
Hyperlipidemia
Hypercoagulability
Obesity
Smoking
Associated with a-fib, endocarditis,
coagulopathies, atherosclerotic
disease, hypercoagulable states, and
temporal arteritis

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Clinical Medicine
Condition / Disease

Diabetic
Retinopathy

Cause

Degradation of the
retina due to diabetes

Signs and Symptoms

Visual acuity

Contrast sensitivity

Color perception

Dark/light adaptation

Nonproliferative
Diabetic Retinopathy

Proliferative Diabetic
Retinopathy

Retinal hemorrhages
Retinal exudates

Open-Angle
Glaucoma

Impaired aqueous outflow

due to the dysfunction of the
eye's drainage system

Asymptomatic

Angle-Closure
Glaucoma

Impaired outflow from an

occlusion of the anterior
chamber

Headache
Mid-dilated pupil
Blurred vision
IOP

Treatment

Medications

Other
Types of Nonproliferative DR
Background retinopathy
Maculopathy
Maculopathy Signs
Edema
Exudates
Ischemia

Preretinal / vitreous
hemorrhages

Retinal edema

Elevated blood pressure

causes retinopathy

Laboratory
Result

Dilated retinal veins

Intraretinal
hemorrhages
Microaneurysms
Cotton-wool spots
Hard exudates
Macular edema
Neovascularization
Vascular fibrosis

Cotton-wool spots

Hypertensive
Retinopathy

Test

Blood pressure control

AV nicking
Gradual loss of
peripheral vision

Enlarged cup-to-disc ratio

Red eye
Nausea / vomitting
Halos
Hard eye

Treat intraocular pressure

Medical therapy
Surgery
Antihistamine therapy
Nasal decongestants
Anterior chamber paracentesis
Laser peripheral iridotomy

Etiologies
Pupillary dilation
Stress
Drugs

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

Antihistamines

Decongestants /
Sympathomimetics

Generic Examples /
Brand Name
diphenhydramine
chlorpheniramine
loratadine
fexofenadine
cetirizine
levocetirizine
azelastine
olopatadine
pseudoephedrine
phenylephrine
oxymetazoline
ephedrine

Mechanism of Action

adrenergic agonists that

vasoconstrict and reduce
edema and mucus production
in nasal tissues

Atrovent

Respiratory muscarinic
receptor blocker

Cromolyn Sodium

NasalCrom

Mast cell stabilizer

Zicam (nasal)

Inhibits rhinovirus
replication in vitro

Codiene

Robitussin AC

Non-Steroidal AntiInflammatory Agents

ibuprofen

Intranasal
Glucocorticoids

-Lactams

aspirin

naproxen
beclomethasone
fluisolide
budesonide
fluticasone
mometasone
ciclesonide
amoxicillin
cephalosporins
clarithromycin

Macrolides

erythromycin
azithromycin

Ketolides

telithromycin

Tetracyclines

doxycycline

levofloxacin

Fluoroquinolones

moxifloxacin

Pharmacokinetics

Rhinorrhea

Cough

Needs sedation

Sneezing

Itching

Conjunctivitis

Nasal pruritis

Allergic conjunctivitis

Runny nose

Sneezing

Cough

Common cold

Contraindications

Adverse Effects

Monitoring / Other

Anticholinergic effects
Sedation

A: Oral, ophthalmic, or
intranasal

Inhibits histamine

Ipratropium

Zinc

Indications

Common cold
A: Inhale
Allergic and non-allergic
Rhinorrhea
perennial rhinitis
Sneezing
Sneezing
Rhinorrhea
A: Nasal
Common cold
Nasal congestion
Allergic conjunctivitis
A: Oral or nasal
Cough
Nasal discharge
Common cold

opoid receptor
agonist
Block COX 1 and 2 enzymes
to inhibit prostaglandin
synthesis

Cough

Common cold
Headache
Ear pain
Myalgias
Malaise
Sneezing
Allergic conjunctivitis
Sneezing

Rhinorrhea

Itching

Nasal congestion

Inhibit cell wall

synthesis

Acute otitis media

Otitis externa

Rhinosinusitis

Pharyngitis

Inhibit bacterial
protein synthesis

Acute otitis media

Otitis externa

Pharyngitis

Bacterial conjunctivitis

Inhibit bacterial
protein synthesis

Acute otitis media

Otitis externa

Inhibits
topoisomerase II

MAO inhibitors

Rebound hyperemia
(chronic use)
Tachycardia (ephedrine)
CNS effects (ephedrine)
Hypertension (ephedrine)
Dry mouth
Anticholinergic effects

Age < 2

Use caution with HTN and

with prostatic enlargement

Faster resolution of symptoms

than others.
Nausea (20%)
Mouth irritation
Bad taste
Permanent asomia (Zicam)

A: Oral
O: 0.5 - 1 hour
D: 4 - 6 hours
M: Hepatic
E: Renal

Binds and activates to

anti-inflammatory and
gluconeogenesis cell
receptors

30S ribosomal
subunit inhibitor

A: Oral, inhale, lingual, or

topical

No more effective with the

common cold cough.

Cardiovascular thrombotic agents

GI effects
Acute kidney injury
A: Nasal
O: Dependent on
symptoms

Nasal irritation

Allergic rhinitis

A: Oral, topical, or
ophthalmic

Pharyngitis

Rhinosinusitis
A: Oral or ophthalmic
Rhinosinusitis

Bacterial conjunctivitis

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Pharmacology
Drug

Carbonic Anhydrase
Inhibitors

-Adrenergic
Blockers

Generic Examples /
Brand Name
acetazolemide
methazolamide
betaxolol
carteolol
levobunolol
metipranolol
timolol

-Adrenergic
Agonists

apraclonidine

Prostaglandin
Analogues

latanoprost
travoprost
bimatoprost
unoprostone
echothiophate
demecarium
carbachol
physostigmine

Cholinesterase
Inhibitors

brimonidine

Mechanism of Action

Indications

Reduces rate of
aqueous humor
formation

Acute angle closure glaucoma

Aqueous humor
production inhibitor

Acute angle closure glaucoma

Lowers intraocular pressure

by suppressing aqueous
humor production

Acute angle closure

glaucoma

Pharmacokinetics

Contraindications

Adverse Effects

Monitoring / Other

Hepatic dysfunction
Severe renal disease
Adrenocortical insufficiency
Severe pulmonary obstruction

Primary open angle

glaucoma

Reduce intraocular pressure

by increasing uveoscleral
outflow

Primary open angle glaucoma

Increases cholinergic
action

Primary open angle glaucoma

Recurrent uveitis
Cystoid macular edema
Recent intraocular surgery

Discolor iris

Asthma
Bradycardia
Hypotension
Recent MI

Incontinence
Bronchospasm

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Decongestants
pseudoephedrine
Sudafed
oxymetazoline
Afrin
phenylephrine
Neo-Synephrine
Antihistamines
diphenhydramine
Benadryl
chlorpheniramine
Chlor-Trimeton
loratadine
Claritin
fexofenadine
Allegra
cetirizine
Zytec
levocetirizine
Xyzal
Astelin
azelastine
Astepro
Optivar
Patanase
olopatadine
Patanol
Pataday
Otic Drops
polymixin B / neomycin /
Cortisporin Otic Solution
hydrocortisone
ciprofloxacin /
hydrocortisone
ofloxacin

Cipro HC
Floxin Otic

Anticholinergic
ipratropium
Atrovent
Mast Cell Stabilizer
cromolyn sodium
Nasalcrom
Intranasal Corticosteroids
beclomethasone
Beconase AQ
ciclesonide
Omnaris
Flonase
fluticasone
Veramyst
mometasone
Nasonex
Glaucoma Medications
dorzolamide / timolol
Cosopt
latanoprost
Xalatan

Ophthalmic Antibiotics
ciprofloxacin
Ciloxin
erythromycin
Ilotycin
sulfacetammide
Bleph-10