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Snapshot
  • A 24-year-old man presents to his primary care phyisician for discomfort and redness in his eyes. He notes these symptoms began 2 days prior to presentation and is associated with a "sandy" or "gritty" sensation in his eyes. He also notes some discharge that makes his eyes difficult to open in the morning. A few days ago, he developed a cough with fever and pharyngitis that was managed with tea, analgesics, and antipyretics. On physical exam, there is bilateral conjunctival injection with watery discharge. There is no evidence of pus. (Acute viral conjunctivitis)
Introduction
  • Overview
    • inflammation of the conjunctiva
Anatomy
  • Conjunctiva
    • transparent tissue that adheres to the anterior portion of the sclera and lines the eyelids
    • divided into 2 sections
      • bulbar conjunctiva
        • covers the sclera
      • tarsal conjunctiva
        • covers the inner eyelids
    • covers up to the limbus
 
Conjunctivitis
Type
Etiology
Pathophysiology Presentation Diagnosis Management
Bacterial conjunctivitis
  • Staphylococcus aureus
    • most common in adults
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Neisseria gonorrhoeae
    • associated with hyperacute bacterial conjunctivitis
      • this is a sight-treatening organism
  • Direct contact with an infected substance
  • Symptoms 
    • erythema
    • pruritus
    • the eye is "stuck shut" in the morning
  • Physical exam
    • purulent discharge 
      • the discharge is thick and globular
      • found on the lid margins and corners of the eye
  • Clinical diagnosis
  • Medical and pharmacologic 
    • topical erythromycin ointment or trimethoprim-polymyxin B drops
      • indication
        • first-line treatment for bacterial conjunctivitis
Hyperacute bacterial conjunctivitis
  • Neisseria gonorrhoeae
    • this is a sight-treatening organism
  • Microorganism is transmitted from the genitalia to the hands and then to the eyes
  • Symptoms
    • erythema
    • pruritus
  • Physical exam
    • profuse purulent discharge
    • tenderness to palpation of the eye
    • chemosis
    • eyelid swelling
    • periauricular adenopathy
    • patients commonly have a concomitant urethritis
  • Gram stain of the discharge demonstrating gram-negative diplococci
  • Medical and pharmacologic
    • topical and systemic antibiotics
      • indication
        • first-line treatment
Viral conjunctivitis
  • Adenovirus
    • most common cause
  • Direct contact with an infected substance
  • Symptoms 
    • sandy, burning, or gritty sensation in the eye
  • Physical exam 
    • watery or mucoserous discharge
    • patients may have a concomitant upper respiratory tract infection
  • Clinical diagnosis
  • Conservative and lifestyles
    • supportive management 
      • indication
        • initial management
          • viral conjunctivitis self-resolves
Allergic conjunctivitis 
  • Allergen
  • Airborne allergen interacts with IgE within the eye, leading to mast cell degranulation
  • Symptoms  
    • erythema
    • pruritus
  • Physical exam
    • watery or mucoserous discharge
  • Clinical diagnosis
  • Conservative and lifestyle
    • allergen avoidance
      • indication
        • recommended in all types of allergic reactions
  • Medical and pharmacologic
    • eye drops
      • indication
        • first-line treatment
      • medications
        • mast cell stabilizers
          • cromolyn
        • antihistamines 
          • olopatadine
          • alcaftadine
        • dual-action medications
          • pheniramine
          • naphazoline 
 
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.PH.11) A 45-year-old truck driver complains of itchy eyes. He states his symptoms are worse when he goes outside and better when he takes a shower. His past medical history is significant for hypercholesterolemia, type II diabetes mellitus, and hypertension for which he takes atorvastatin, metformin, and lisinopril. His temperature is 98.1°F (36.7°C), blood pressure is 174/104 mmHg, pulse is 82/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man with the findings in Figure A which are seen in both eyes. Which of the following is the most appropriate next step in management? Review Topic

QID: 102610
FIGURES:
Type in at least one full word to see suggestions list
1

Cetirizine

8%

(1/12)

2

Diphenhydramine

25%

(3/12)

3

Olopatadine

8%

(1/12)

4

Reassurance

0%

(0/12)

5

Topical erythromycin

58%

(7/12)

M2

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SUBMIT RESPONSE 3

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(M2.OP.4868) A 22-year-old man presents to his primary care physician with itchy eyes. The patient recently moved to the northern US and states that he has experienced bilateral itching and watering of his eyes. He states that it is very distracting and is making it hard for him to work. The patient denies any recent sick contacts and lives alone. He works as a machinist and is currently struggling with his finances. The patient has a past medical history of asthma, and his current medications include albuterol, fluticasone, fish oil, and whey protein supplements. His temperature is 99.5°F (37.5°C), blood pressure is 100/65 mmHg, pulse is 60/min, respirations are 15/min, and oxygen saturation is 99% on room air. Cardiopulmonary exam is within normal limits. You notice the bilateral findings seen in Figure A. Otoscopy reveals bilateral clear tympanic membranes. The rest of the patient's physical exam is within normal limits. Which of the following is the most likely diagnosis? Review Topic

QID: 109561
FIGURES:
Type in at least one full word to see suggestions list
1

Viral conjunctivitis

14%

(5/36)

2

Bacterial conjunctivitis

0%

(0/36)

3

Allergic conjunctivitis

81%

(29/36)

4

Corneal abrasion

3%

(1/36)

5

Foreign body

3%

(1/36)

M2

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SUBMIT RESPONSE 3

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(M2.OP.3) A 6-year-old boy is brought to the pediatrician complaining of itchy eyes. The mother states that she has noted that he has been tearing and that both of his eyes have been red for the past 4 days. The patient denies any pain but has had a runny nose for the past week. The mother states that he has not had any sick contacts, and he has been home from school for summer vacation. She notices that his symptoms seem to improve in the evening after he showers. His temperature is 97.0°F (36.1°C), blood pressure is 100/66 mmHg, pulse is 90/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Which of the following is the most likely diagnosis?
Review Topic

QID: 105369
FIGURES:
Type in at least one full word to see suggestions list
1

Allergic conjunctivitis

0%

(0/34)

2

Bacterial conjunctivitis

68%

(23/34)

3

Corneal abrasion

0%

(0/34)

4

Endophthalmitis

29%

(10/34)

5

Viral conjunctivitis

0%

(0/34)

M2

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SUBMIT RESPONSE 1
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