NR 602 Midterm -Chalazion Soap Note

NR 602 Midterm -Chalazion Soap Note Sample

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

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.

NR 602 Midterm -Chalazion Soap Note

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), 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, 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
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.

NR 602 Midterm -Chalazion Soap Note

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

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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.
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.

NR 602 Midterm -Chalazion Soap Note

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 495enteroviruses (HEVs) A, B, C, and D. Coxsackieviruses and echoviruses are subgroups of HEVs. Hand-foot-mouth, herpangina, pleurodynia, acute hemorrhagic conjunctivitis, 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).

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.

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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.
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).

NR 602 Midterm -Chalazion Soap Note