NR602 / NR-602 Midterm Exam Review (Latest): Primary Care of the Childbearing & Childrearing Family Practicum - Chamberlain | Qwivy

NR 602 Midterm Review

Chalazion

Chalazion is a chronic sterile inflammation of the eyelid resulting from a lipogranuloma of

the meibomian glands that line the posterior margins of the eyelids (see Fig. 29-7). It is

deeper in the eyelid tissue than a hordeolum and may result from an internal hordeolum or

retained lipid granular secretions.

Clinical Findings

Initially, mild erythema and slight swelling of the involved eyelid are seen. After a few days

the inflammation resolves, and a slow growing, round, nonpigmented, painless (key finding)

mass remains. It may persist for a long time and is a commonly acquired lid lesion seen in

children (see Fig. 29-7).

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Management

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• Acute lesions are treated with hot compresses.

• Refer to an ophthalmologist for surgical incision or topical intralesional corticosteroid

injections if the condition is unresolved or if the lesion causes cosmetic concerns. A

chalazion can distort vision by causing astigmatism as a result of pressure on the orbit.

Complications

Recurrence is common. Fragile, vascular granulation tissue called pyogenic granuloma

that enlarges and bleeds rapidly can occur if a chalazion breaks through the conjunctival

surface.

Types of Conjunctivitis

Type Incidence/Etiology Clinical Findings Diagnosis Management*

Ophthalmia

neonatorum

Neonates: Chlamydia

trachomatis, Staphylococcus

aureus, Neisseria

gonorrhoeae, HSV (silver

nitrate reaction occurs in

10% of neonates)

Erythema, chemosis,

purulent exudate

with N. gonorrhoeae

; clear to mucoid

exudate with

chlamydia

Culture (ELISA, PCR),

Gram stain, R/O

N. gonorrhoeae,

 chlamydia

Saline irrigation to eyes until

exudate gone; follow with

erythromycin ointment

For N. gonorrhoeae:

ceftriaxone or IM or IV

For chlamydia: erythromycin

or possibly azithromycin PO

For HSV: antivirals IV or PO

Bacterial

conjunctivitis

In neonates 5 to 14 days old,

preschoolers, and sexually

active teens: Haemophilus

influenzae(nontypeable),

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Streptococcus pneumoniae,

S. aureus, N. gonorrhoeae

Erythema, chemosis,

itching, burning,

mucopurulent

exudate, matter in

eyelashes; ? in winter

Cultures (required in

neonate); Gram stain

(optional); chocolate

agar (for N.

gonorrhoeae

) R/O pharyngitis,

N. gonorrhoeae

, AOM, URI, seborrhea

Neonates: Erythromycin 0.5%

ophthalmic ointment

?1 year old: Fourth-generation

fluoroquinolone

For concurrent AOM: Treat

accordingly for AOM

Warm soaks to eyes three

times a day until clear

No sharing towels, pillows

No school until treatment

begins

Chronic bacterial

conjunctivitis

(unresponsive

conjunctivitis

previously treated

as bacterial in

etiology)

School-age children and

teens: Bacteria, viruses,

C. trachomatis

Same as above;

foreign body

sensation

Cultures, Gram stain;

R/O dacryostenosis,

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blepharitis, corneal

ulcers, trachoma

Depends on prior treatment,

laboratory results, and

differential diagnoses

Review compliance and prior

drug choices of conjunctivitis

treatment

Consult with ophthalmologist

Inclusion

conjunctivitis

Neonates 5 to 14 days old

and sexually active teens:

C. trachomatis

Erythema, chemosis,

clear or mucoid

exudate, palpebral

follicles

Cultures (ELISA,

PCR), R/O sexual

activity

Neonates: Erythromycin or

azithromycin PO

Adolescents: Doxycycline,

azithromycin, EES,

erythromycin base,

levofloxacin PO

Viral conjunctivitis Adenovirus 3, 4, 7; HSV,

herpes zoster, varicella

Erythema, chemosis,

tearing (bilateral);

HSV and herpes

zoster: unilateral

with photophobia,

fever; zoster: nose

lesion; spring and fall

Cultures, R/O corneal

infiltration

Refer to ophthalmologist if

HSV or photophobia present

Cool compresses three or four

times a day

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Allergic and vernal

conjunctivitis Atopy sufferers, seasonal

Stringy, mucoid

exudate, swollen

eyelids and

conjunctivae, itching

(key finding),

tearing, palpebral

follicles, headache,

rhinitis

Eosinophils in

conjunctival scrapings

Naphazoline/pheniramine,

naphazoline/antazoline

ophthalmic solution (see text)

Mast cell stabilizer (see text)

Refer to allergist if needed

*See text for dosages.

Blepharitis

Blepharitis is an acute or chronic inflammation of the eyelash follicles or meibomian

sebaceous glands of the eyelids (or both). It is usually bilateral. There may be a history of

contact lens wear or physical contact with another symptomatic person. It is commonly

caused by contaminated makeup or contact lens solution. Poor hygiene, tear deficiency,

rosacea, and seborrheic dermatitis of the scalp and face are also possible etiologic factors.

The ulcerative form of blepharitis is usually caused by S. aureus. Nonulcerative blepharitis is

occasionally seen in children with psoriasis, seborrhea, eczema, allergies, lice infestation, or

in children with trisomy 21.

Clinical Findings

• Swelling and erythema of the eyelid margins and palpebral conjunctiva

726

• Flaky, scaly debris over eyelid margins on awakening; presence of lice

• Gritty, burning feeling in eyes

• Mild bulbar conjunctival injection

• Ulcerative form: Hard scales at the base of the lashes (if the crust is removed, ulceration is

seen at the hair follicles, the lashes fall out, and an associated conjunctivitis is present)

Differential Diagnosis

Pediculosis of the eyelashes.

Management

Explain to the patient that this may be chronic or relapsing. Instructions for the patient

include:

• Scrub the eyelashes and eyelids with a cotton-tipped applicator containing a weak (50%)

solution of no-tears shampoo to maintain proper hygiene and debride the scales.

• Use warm compresses for 5 to 10 minutes at a time two to four times a day and wipe away

lid debris.

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• At times antistaphylococcal antibiotic (e.g., erythromycin 0.5% ophthalmic ointment) is

used until symptoms subside and for at least 1 week thereafter. Ointment is preferable to eye

drops because of increased duration of contact with the ocular tissue. Azithromycin 1%

ophthalmic solution for 4 weeks may also be used (Shtein, 2014).

• Treat associated seborrhea, psoriasis, eczema, or allergies as indicated.

• Remove contact lenses and wear eyeglasses for the duration of the treatment period.

Sterilize or clean lenses before reinserting.

• Purchase new eye makeup; minimize use of mascara and eyeliner.

• Use artificial tears for patients with inadequate tear pools.

Chronic staphylococcal blepharitis and meibomian keratoconjunctivitis respond to oral

erythromycin. Doxycycline, tetracycline, or minocycline can be used chronically in children

older than 8 years old.

Hand-Foot-Mouth Syndrome

Enteroviruses

Nonpolio Enteroviruses

Of the more than 100 serotypes of nonpolio RNA enteroviruses, 10 to 15 serotypes account

for most diseases. They are grouped into four genomic classifications: human 495

enteroviruses (HEVs) A, B, C, and D. Coxsackieviruses and echoviruses are subgroups of

HEVs. Hand-foot-mouth, herpangina, pleurodynia, acute hemorrhagic conjuncti

vitis, myocarditis, pericarditis, pancreatitis, orchitis, and dermatomyositis-like syndrome are

manifestations of infection. These enteroviruses are the most common cause of aseptic

meningitis and have also been associated with paralysis, neonatal sepsis, encephalitis, and

other respiratory and GI symptoms. The specific serotype may not be unique to any given 

disease (Abzug, 2011).

As evidenced by the name, enteroviruses concentrate on the GI tract as their primary

invasion, replication, and transmission site; they spread by fecal-oral contamination,

especially in diapered infants. They are also transmitted via the respiratory route and

vertically either prenatally, during parturition, or possibly by way of breastfeeding by an

infected mother who lacks antibodies to that particular serotype. Transplacental infection can

lead to serious disseminated disease in the neonate that involves multiorgan systems (liver,

heart, meninges, and adrenal cortex).

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Enteroviruses have worldwide distribution, occurring in temperate climates during the

summer and fall and in tropical climates year round. In known cases, infants younger than 12

months old have the highest prevalence rate (>25%), and HEVs account for 55% to 65% of

hospitalizations for suspected infant sepsis. Illness occurs more frequently in males; those

living in crowded, unsanitary conditions; and in those of lower socioeconomic status (Abzug,

2011). Infection can range from asymptomatic to undifferentiated febrile illness to severe

illness. Young children are more likely to be symptomatic. The incubation period is 3 to 6

days (less for hemorrhagic conjunctivitis). After infection, the virus is shed from the

respiratory tract for up to 3 weeks and from the GI tract for up to 7 to 11 weeks; it is viable

on environmental surfaces for long periods.

Nonpolio enteroviral infection is not a reportable disease, nor is it routinely tested for in the

clinical setting, so the overall incidence rate is not known. The CDC administers the National

Respiratory and Enteric Virus Surveillance System (NREVSS) and the National Enterovirus

496Surveillance System (NESS) to monitor detection patterns of respiratory and enteric

adenoviruses. The 2014 outbreak of an illness in children referred to as acute flaccid myelitis

bears some similarity to infections caused by viruses, including enterovirus; epidemiologic

studies are ongoing (CDC, 2015f).

Clinical Findings

History.

General symptoms include:

• A mild upper respiratory infection (URI) is common and may include complaints of sore

throat, fever, vomiting, diarrhea, anorexia, coryza, abdominal pain, rash, and headache.

• Nonspecific febrile illness of at least 3 days: In young children, there is an undifferentiated

abrupt-onset febrile illness (101° to 104° F [38.5° to 40° C]) associated with myalgias,

malaise, irritability; fever may wax and wane over several days.

• Onset of viral symptoms within 1 to 2 weeks after delivery for neonates infected

transplacentally.

Physical Examination.

General findings include mild conjunctivitis, pharyngeal infection, and/or cervical

adenopathy. Other findings include:

• Skin: Rash may be macular, macular-papular, urticarial, vesicular, or petechial. May

imitate the rash of meningitis, measles, or rubella.

• Herpangina: There is a sudden onset of high fever (up to 106° F [41° C]) lasting 1 to 4

days. Loss of appetite, sore throat, and dysphagia are common, with vomiting and abdominal

pain in 25% of cases. Small vesicles (from one to more than 15 lesions of 1 to 2?mm each)

appear and enlarge to ulcers (3 to 4?mm) on the anterior pillars of the fauces, tonsils, uvula,

and pharynx and the edge of the soft palate. The vesicles commonly have red areolas up to

10?mm in diameter. This self-limiting infection usually lasts 3 to 7 days.

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• Acute lymphonodular pharyngitis: This manifests as an acute sore throat lasting

approximately 1 week.

• Hand-foot-mouth disease: This is a clinical entity evidenced by fever, vesicular eruptions in

the oropharynx that may ulcerate, and a maculopapular rash involving the hands and feet.

The rash evolves to vesicles, especially on the dorsa of the hands and the soles of the feet,

and lasts 1 to 2 weeks (Fig. 24-1).

Pharyngitis

Pharyngitis, Tonsillitis, and Tonsillopharyngitis

Pharyngitis is an inflammation of the mucosa lining the structures of the throat, including the

tonsils, pharynx, uvula, soft palate, and nasopharynx. It can be due to infectious agents or

noninfectious causes, such as smoke or other air irritants. The illness is generally acute and

involves an inflammatory response, including erythema, exudate, or ulceration.

The etiology could include a number of viruses and bacteria. If there are nasal symptoms, it

is called nasopharyngitis, but if there are no nasal symptoms, the disease is called pharyngitis

or tonsillopharyngitis. Most cases of pharyngitis are caused by viruses (Gereige and Cunill-De

Sautu, 2011). Adenovirus is the most common cause of nasopharyngitis (Cherry, 2009c

). Other viruses include Epstein-Barr virus (EBV), herpes simplex virus (HSV),

cytomegalovirus (CMV), enterovirus, influenza virus, parainfluenza, and human

immunodeficiency virus (HIV). The viral organisms generally present with upper nasal

symptoms. The common bacterial etiology is GABHS in children between 5 and 11 years

old, whereas 40% of reported cases of gonococcal infections occur in females 15 to 19 years

old. Other organisms include Corynebacterium diphtheriae, Arcanobacterium haemolyticum,

Neisseria gonorrhoeae, group C and group G streptococci, Chlamydia trachomatis,

Francisella tularensis, and Mycoplasma pneumonia (Gereige and Cunill-De Sautu, 2011).

Acute Viral Pharyngitis, Tonsillitis, or Tonsillopharyngitis

Adenoviruses are more likely to cause pharyngitis as a prominent symptom. Other viruses

(e.g., rhinovirus) are associated with pharyngitis as a minor symptom and rhinorrhea or

cough as predominant features. The enterovirus (coxsackievirus, echovirus), herpesvirus, and

EBV are also common. Viral infections occur year-round, but adenovirus presenting as

pharyngoconjunctival fever occurs in outbreaks during the summer due to contaminated

swimming pools (Gereige and Cunill-De Sautu, 2011). It is helpful to know what agents are currently

infecting children in the community. However, when a patient only has a sore throat, it is

difficult to differentiate viral from bacterial causes. Hoarseness, cough, coryza,

conjunctivitis, and diarrhea are classic features of a viral infection (

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