Family Medicine

OMS III CLINICAL ROTATION

MODULE 1

Cases:
1) Ophthalmology and Oral Cavity/Acute Pharyngitis

Reading Assignment:

Rakel Textbook of Family Medicine, Chapter 17, pages 274-300; Chapter 18, pages 336-345

Case 1a.

A 4-year-old male presents to the primary care office accompanied by his father with complaint of thick
yellow discharge from his right eye x 1 day. He denies fever or loss of appetite. He does attend daycare.
On physical examination, visual acuity is intact. He’s afebrile. Extraocular muscles are intact. No rashes
are noted. You note crusting of eyelashes, yellow discharge and erythematous conjunctiva.

1. What type of infection is the most likely cause of his symptoms?

Bacterial

2. How did he likely acquire this infection?

From another person or fomite contact like towels or bed sheets)
3. What are the most common specific microorganisms likely to be involved?

Staphylococcus, Streptococcus pneumoniae, group A and B streptococci, Haemophilus,

Escherichia coli, Moraxella and Pseudomonas aeruginosa

4. Select an effective medication to treat his infection.

Bacterial conjunctivitis generally last 1-2 weeks and is usually self-limiting.

Severe cases needing treatment before cultures are treated with topical fluoroquinolones, such
as levofloxacin.

5. What is the optimal route for administration of treatment?

ophthalmic

6. Under what circumstances would systemic administration of medication be indicated?

W/ systemic septicemia, which can be caused by Pseudomonas

Conjunctivitis secondary to STDs, such as chlamydia and gonorrhea.

7. Anticipate one potential complication of management.

 A toxic chemical conjunctivitis may occur if the individual is managed with gentamycin or
neomycin eye drops.

Case 1b.

You note that his father, a 41-year-old otherwise healthy man, is squinting and rubbing his left eye
during the encounter. When questioned, he reports working with some metal in the garage yesterday
evening. He notes that his left eye felt irritated when he went to bed last night and today he feels like he
has sand under his eyelid. He’s given an appointment and also seen, as he is also your patient. On
physical examination, visual acuity and extraocular muscles are intact. You note a superficially
embedded piece of metal at the 1 o’clock position just outside the iris.

1. What are two potential complications of a metallic foreign body in the eye?

Corneal infection or scarring

Rust rings, which are formed from tear production; these can permanently stain the cornea,
cause persistent inflammation

2. After removal of the metallic foreign body, what should be given presumptively?

Topical antibiotic drops or ointment

3. If no improvement is noted in 24-48 hours, what must be obtained?

Ophthalmologist referral

Case 2 Oral Cavity and Acute Pharyngitis

One week later, the man returns with complaint of fever and sore throat x 2 days. He denies otalgia or
cough. No vomiting or diarrhea. He requests an antibiotic. On physical examination, he appears mild-to-
moderately ill, but non-toxic. Temperature is 100.5 degrees orally. TMs are pearly grey bilaterally.
Oropharynx is erythematous. Bilateral anterior cervical lymphadenopathy is noted.

1. What is the likelihood that his sore throat is viral vs bacterial?

Viruses are the most common cause of sore throats

2. What are some diagnostic features to help differentiate viral vs bacterial etiology?

A bacterial etiology would most likely produce white patches in the throat and on the
tonsils; red, swollen tonsils; and pus in the back of the throat.
Obtaining a culture from a throat swab.

3. What is the sensitivity of a rapid strep test?

90-95%, but clinical trials claim 60-80%

 4. What is the specificity?

95-97%, but clinical trials claim 90%

True Result

Positive Negative

Reported Result

Positive 90 95

Negative 10 5

5. What is the gold standard for diagnosis Group A Beta Hemolytic Strep (GABHS) infection?

Throat culture

6. What are the consequences of treating empirically?

Not cost-effective
Studies have shown that children receiving immediate antibiotic therapy are more likely to
have symptomatic recurrences in the months following treatment than are children who
delay the initiation of therapy for 48 hours for the culture results.

7. What are the consequences of failing to diagnose GABHS?

Acute rheumatic fever, peritonsillar abscess, and acute glomerulonephritis

8. What is the most cost effective strategy?

Culture