is required, and share this information with the patient. Options include: (1) Refer John to a dietitian and/or personal trainer for diet and exercise advice, respectively. (2)  Refer John to a primary care provider for prescription medication for obesity. (3) Counsel John on diet and exercise. (4)  Recommend nonprescription orlistat. (5) Recommend a dietary supplement for weight loss. (6)  Take no action. Plan 6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Because of previous failures with diet and exercise alone, the patient chooses to try orlistat while again trying to diet. 7. Describe the recommended therapeutic approach to the patient. Take orlistat up to 3 times a day before meals that contain fat, as described in the text. 8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. You can anticipate that weight loss may be slightly easier to achieve when combining orlistat with diet and exercise, compared with diet and exercise alone. Patient Education 9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the patient: a. appropriate dose and frequency of administration 60 mg up to 3 times a day b. maximum number of days the therapy should be employed Greatest benefit is usually seen within first 6 months of therapy. c.product administration procedures Take before meals containing fat. Minimizing dietary fat and spreading it out between all meals should help to minimize the gastrointestinal side effects such as flatus and oily discharge associated with orlistat. Taking a multivitamin supplement at bedtime is wise in case fat-soluble vitamin malabsorption occurs with orlistat. d. expected time to onset of relief Weight loss should be detected with the first 2 weeks of initiating orlistat therapy along with diet and exercise regimen. e. degree of relief that can be reasonably expected Many patients lose 5 to 10 pounds during the first 6 months of therapy. f. most common side effects Flatulence, oily spotting, loose and frequent stools, fatty stools, fecal urgency, fecal incontinence g. side effects that warrant medical intervention should they occur None h. patient options in the event that condition worsens or persists Consult a dietitian or personal trainer for diet and exercise advice, respectively, or see a primary care provider for prescription medication for weight loss. i. product storage requirements No special requirements j. specific nondrug measures Continue diet and exercise measures. Find exercise that is enjoyable and thus sustainable. Attempt to reduce stress and thus stress eating. Too little sleep has been associated with increased body weight, so sleep hygiene measures may be helpful. 10. Solicit follow-up questions from patient. Can I double the dose of medication if weight loss slows? 11. Answer patient’s questions. Dosage above 60 mg up to 3 times a day should be attempted only under the supervision of a primary care provider.

Secondary problems: malabsorption of feedings and failure to thrive 4. Identify exclusions for self-treatment. Dehydration and failure to thrive are exclusions for self-care. 5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the parents. Options include:

(1) Refer to the PCP.

(2) Refer to the pediatric emergency department.

(3) Recommend a formula change.

(4) Take no action. Plan 6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Depending on the time of day and availability of the PCP, the parents should be instructed to take Miquel either to the PCP or to the emergency department. This decision should be made prior to allowing the family to leave, if possible. Discussion with the PCP would also be prudent. 7. Describe the recommended therapeutic approach to the parents. Miquel appears to be suffering from dehydration and needs to see a doctor right away. You should take Miquel to see his primary care provider [or go to the emergency department, depending on what was decided] right away. [Be sure Miquel's family understands the directions and the directions to the facility; use an interpreter, if necessary.] 8. Explain to the parents the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Miquel does not appear to be tolerating his formula well. He is hungry all the time, because he is not absorbing the nutrients in the formula. Currently, he needs immediate medical attention to correct his dehydration. After that problem is corrected, the doctors will evaluate him to determine the cause of his malabsorption and failure to thrive. Patient Education 9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the parents. Criterion does not apply in this case. 10. Solicit follow-up questions from parents. Why can’t we just change formulas and see if he does better? 11. Answer parents’ questions. Dehydration can quickly lead to serious problems in small infants including seizures and other complications. He should be evaluated by a medical professional prior to making any interventions related to his feedings.

Secondary problem: increased intestinal gas 4. Identify exclusions for self-treatment. Bloody or bilious emesis Signs of dehydration: sunken fontanelle, dry mucous membranes, decreased wet

diapers, dark urine, decreased oral intake 5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the parents. Options include:

(1) Call Lauren’s PCP to verify the caloric density and volume of feedings desired. Give Lauren’s parents instructions on the proper feeding of the infant.

(2) Refer Lauren’s parents to the PCP.

(3) Take no action. Plan 6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Lauren’s current feeding schedule, 120 mL every 3 hours of 24 kcal/oz formula, provides 252 mL/kg/day and 202 kcal/kg/day. Both significantly exceed the usual recommended intakes for a healthy, term infant (see Tables 26-2 and 26-14). The most appropriate plan would be to decrease the overall intake. The PCP should be contacted to verify the caloric density of the formula. The family should then be instructed to feed Lauren approximately 2.5 ounces every 3 hours or 3-3.5 ounces every 4 hours. This decreased intake of formula should decrease the episodes of emesis, and decrease fussiness and irritability caused by overfeeding. 7. Describe the recommended therapeutic approach to the parents. The primary care practitioner should be contacted to verify the desired concentration of Enfamil LIPIL The volume of the feedings should be reduced to the volumes listed in step 6. If the symptoms persist after these interventions, Lauren should be taken to the PCP. 8. Explain to the parents the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Because the symptoms started (or acutely worsened) with the change from breast milk to infant formula, and both the caloric density and the volume of the infant formula exceed the usual needs of a healthy term infant, overfeeding is the most likely cause of Lauren’s emesis and irritability. If overfeeding is the major issue, decreasing the caloric density and volume of feedings will have almost immediate results. Patient Education 9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the parents: a. appropriate dose and frequency of administration New feeding regimen: Enfamil LIPIL 2.5 ounces every 3 hours or 3-3.5 ounces every 4 hours. Watch for cures to the baby’s hunger and satiety patterns to avoid under- or overfeeding. b. maximum number of days the therapy should be employed If no improvement is seen in 2-3 days, then the primary care provider should be contacted for a possible change in the formula (see Table 26-6). c. product administration procedures The formula should be mixed per product instruction (e.g., 1 scoop in 2 ounces of water to make 20 kcal/oz formula) per the information given in the box Patient Education for Infant Nutrition. d. expected time to onset of relief Several days e. degree of relief that can be reasonably expected Emesis likely will not be eliminated. All infants have some gastroesophageal reflux and spit or vomit from time to time. Forceful emesis and emesis with every feeding as well as irritability from gas pains should improve. f. most common side effects None g. side effects that warrant medical intervention should they occur Persistent vomiting, especially if severe, bilious, or bloody; weight loss; dehydration h. patient options in the event that condition worsens or persists Contact primary care provider to evaluate for other causes such as cow-milk intolerance, gastroesophageal reflux, or other conditions. i. product storage requirements Infant formula should be used soon after mixing or kept tightly covered in the refrigerator and used within 24 hours of preparation. See product information for any specific storage requirements. 10. Solicit follow-up questions from parents. What if Lauren doesn’t appear to be satisfied with the smaller volume of feedings? 11. Answer parents’ questions. From the history, it sounds like Lauren’s stomach is too full after each feeding, resulting in a forceful emesis to remove the extra volume. If she receives only the amount needed, she should feel satisfied, without an episode of emesis. If she takes the smaller amount and still appears to be hungry, then an additional 0.5 ounces can be given.

problemfe). Dysphagia is of unknown cause but could be related to stroke or esophageal damage related to alendronate. Weight loss of 11% over 2-3 months is significant, and may place the patient at risk of electrolyte and fluid abnormalities associated with refeeding syndrome. 4. Identify exclusions for self-treatment. Significant weight loss 5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the patient. Options include: (1)  Refer Mrs. Quinn to her PCP for evaluation of her dysphagia and assessment

of nutritional status. (2)  Recommend a liquid meal replacement product that can be used without

medical supervision. (3) Take no action. Plan 6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Refer the patient to her PCP for evaluation. 7. Describe the recommended therapeutic approach to the patient. N/A 8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. You need to see your PCP, because the swallowing problem may be related to the alendronate you take to improve your bone strength or to something more serious. Your weight loss also indicates that blood tests might be needed to monitor your electrolytes when you start taking the liquid nutrition product. Patient Education 9. When recommending self-care with nonprescription medications and/or nondrug therapy, convey accurate information to the patient. Criterion does not apply in this case. 10. Solicit follow-up questions from patient. Why is the weight loss so concerning? I thought it was good for me to weigh less. 11. Answer patient’s questions. Many people are overweight and they are encouraged to lose weight. However, your usual weight was considered a healthy weight; you had a body mass index of 22.4, which is considered normal. Any time weight loss is not planned, there are concerns about the cause. Rapid weight loss can cause changes in blood tests (your electrolytes) that could affect your heart and breathing.

Lunch: something from the mall’s food court; often a sandwich with potato chips and soft drink

Afternoon snack: typically a candy bar or granola bar

Dinner: meat (beef, pork, or chicken mostly; fish every once in a while when someone has gone fishing); potatoes or pasta most nights; fresh, frozen, or canned vegetable 4-5 times per week; sweet dessert (cake, pie, baked goods) or ice cream 5-6 times a week; typically has a soft drink with dinner, occasionally an alcoholic drink e. patient’s sleep habits Usually sleeps 7-8 hours per night f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements None; birth control pill and multivitamin g. allergies NKA h. history of other adverse reactions to medications None i. other (describe) Assessment and Triage 3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). Mrs. Romero has no signs/symptoms of disease but wants to follow a preventive strategy with diet. 4. Identify exclusions for self-treatment. None 5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the patient. Options include: (1) Refer Mrs. Romero to her PCP for assessment of heart disease and evaluation of her risk. (2)  Refer Mrs. Romero to a registered dietitian for comprehensive nutritional assessment and counseling. (3) Inform Mrs. Romero of foods that have health claims associated with reduced risk of heart disease. (4) Take no action. Plan 6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Mrs. Romero may require a combination of the options.

(1)  Provide basic information and counseling related to functional foods with health claims associated with heart disease. Emphasize authorized and authoritative health claims (Table Authorized and Authoritative Health Claims), because these have strong scientific evidence supporting the claim. The limited evidence for qualified claims and structure-function claims can be presented along with a discussion of where they fit, if at all, in the patient’s overall plan. (2)  Refer Mrs. Romero for cholesterol screening (or perform screening in the pharmacy) and assessment for heart disease. (3)  Refer Mrs. Romero to a dietitian if she wants/needs more than basic counseling on nutrition or have her request a referral from her PCP (may be necessary for insurance coverage). 7. Describe the recommended therapeutic approach to the patient. A number of foods with health claims are associated with decreased risk of heart disease. For several foods, there is significant scientific agreement regarding the potential benefits. Using these foods in place of some of your current foods may reduce your risk of heart disease. However, it would also be helpful to know what your risks are, including your cholesterol level. 8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Given your family history, you should have your cholesterol checked periodically and be evaluated for other risk factors for heart disease.

I can provide you basic information on foods that have health claims related to heart disease and may be of benefit in maintaining heart health. Dietitians are the food and nutrition experts; they can do a comprehensive assessment of your diet and provide more in-depth dietary counseling if you want that. Patient Education 9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the patient: a. appropriate dose and frequency of administration (1)  Decreased dietary saturated fat and cholesterol: Recommend not more than 10% of calories from saturated fat and not more than 300 mg cholesterol a day, but less is better. Most people find 1% milk to be more acceptable than nonfat (skim) milk, so you might want to try it in place of 2% milk, or you could try soy milk. (2)  Fruits, vegetables, and grain products that contain fiber, particularly soluble fiber: Recommend replacement of white breads and pasta with whole grain. Total dietary fiber should be at least 25 g/day (Al for women 19-50 years of age). (3)  Soluble fiber from oat bran, rolled oats, or whole oat flour in certain foods, or barley: Incorporate these products into the diet as replacement for breads and cereals that are not whole grain. (4)  Soy protein: 25 g/day is required in conjunction with a diet low in saturated fat and cholesterol. For many people, the major dietary modifications needed to eat this much soy are very difficult to make, especially if all family members are not committed to the changes. (5)  Plant sterol and stanol esters: Total intake is at least 1.3 g/day of sterol esters or 3.4 g/day of stanol esters, as part of a diet low in saturated fat and cholesterol. You usually need to eat the products at least twice a day to get the recommended amount. Some margarines and orange juice have added plant/stanol esters. (6)  Whole-grain foods: This health claim overlaps somewhat with that for “grain products that contain fiber” (#2) but does not specify “particularly soluble fiber.” Insoluble fibers are also important in health. Look for whole grain, such as whole wheat, as the first ingredient on labels. To make these health claims, foods must generally contain a certain amount of the component. Check food labels for these claims and for ingredient amounts.

There are also health claims with less vigorous supporting data for which evidence suggests a benefit but research is not conclusive (does not prove a benefit; therefore, these claims may not be as effective or the claim might be changed if new studies are reported. Because the following foods are otherwise healthy foods when used in moderation, they can still be safely incorporated into your diet. (1)  Walnuts and several other types of nuts: 1.5 ounces a day; remember that nuts are a concentrated source of calories, so use judiciously. (2) Omega-3 fatty acids: specifically eicosapentaenoic acid (EPA) and docosa-hexaenoic acid (DHA), found in salmon, lake trout, herring, and other oily fish. (3)  Monounsaturated fats from olive oil; 23 g/day (2 tablespoons) in place of a similar amount of saturated fat. A number of salad dressings and a few soft margarines now include olive oil. (4) Canola oil, unsaturated fatty acids; 19 g/day (1.5 tablespoons) in place of a similar amount of saturated fat. Some cooking oil, a number of salad dressings, a few soft margarines, and some baked goods include canola oil. b. maximum number of days the therapy should be employed No limit; preferably, these foods will be incorporated as part of an ongoing healthful diet for life. c. product administration procedures These foods can replace other foods in your diet so that the total calories do not increase. The more “healthful” fats must replace saturated fats and not increase the total fat intake. You will need to read food labels carefully to be sure you are getting whole grains, low-saturated fats, low cholesterol, and sterol/stanol esters in the product. Also look for the amount of soy or soluble fiber. d. expected time to onset of relief These steps are preventive at this time; for elevated cholesterol, dietary changes typically are effective within a few weeks. e. degree of relief that can be reasonably       expected Mild-to-moderate decrease in total and low-density lipoprotein cholesterol.You should be able to decrease “borderline” high cholesterol to within an acceptable range, but these foods alone would probably not be enough if you had significantly elevated cholesterol, especially considering the history of heart disease in the family. f. most common side effects Rapid increases in fiber content of the diet can cause gas and bloating, so it is best to gradually increase the fiber in your diet. Replace 1-2 servings of white bread and pasta with whole-grain products every few days until the refined foods are totally replaced. Also add extra fiber by gradually replacing the low-fiber cereals with a whole-grain cereal or oatmeal. Fruits and vegetables can be increased gradually as well to replace snacks and desserts. Be sure to take plenty of water when eating a high-fiber diet. g. side effects that warrant medical intervention should they occur Moderate-to-severe abdominal pain, nausea, vomiting; these side effects may be signs of bowel obstruction or diverticulitis. h. patient options in the event that condition Dietary changes for Mrs. Romero are preventive, unless her cholesterol is worsens or persists                      elevated at the time it is checked. Cholesterol levels should be monitored periodically; if cholesterol increases to an unacceptable level despite these dietary changes, it may be necessary for Mrs. Romero to consider drug (statin) therapy. i. product storage requirements              See food label. j. specific nondrug measures                N/A 10. Solicit follow-up questions from patient. Where can I find more information on dietary changes and diet plans to prevent heart disease? May I use dietary supplements instead of changing to functional foods? Most information on the Internet is advertising for dietary supplements. 11. Answer patient’s questions. The Food and Drug Administration Web site (www.fda.gov) includes information on health claims and food labels that you might find helpful. You could consider making an appointment with a registered dietitian who could help develop some menus that incorporate foods you like and provide more specific plans for substituting healthier foods. Your health plan may contract with a dietitian. If not, the American Dietetic Association can provide the name(s) of private consultants and the contact information for a dietitian. The phone number for referrals is on their Web site (www.eatright.org). In general, foods are better than supplements. Many studies have shown beneficial effects from a diet containing fiber-rich foods and whole grains but not with isolated supplements. Psyllium, found in products like Metamucil, fits criteria for a health claim related to soluble fiber and risk of congestive heart disease, and could be used to increase soluble fiber. It also has the added benefit of reducing constipation, as do fibers from whole grains.

(1)  Focus on only potential drug-nutrient interactions.

(2)  Discuss the role of balanced nutrition as the ideal route of taking vitamins and minerals. Identify nutritional needs unique to this geriatric client and where supplementation may be recommended.

(3) Take no action. Plan 6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Assess the client’s perceived need for the nutrient supplements.

Evaluate dietary intake from food groups, encouraging at least 5 servings of produce daily, 3 servings of low-fat dairy products, 2 servings of protein, and 6 servings of whole grain food sources daily.

Discuss the vitamin and mineral content of the various supplements and the total intake in comparison with the dietary reference intakes. Conversion of units of measure for vitamin A may be necessary to assess total intake. For example, if the multivitamin provides 3500 IU of vitamin A and the antioxidant supplement plus beta-carotene provides 25,000 IU of beta-carotene, the patient’s intake of vitamin A is likely excessive. The dietary reference intake for this client is 700 meg as RAE (2330 IU) with a UL of 3 mg (9990 IU) daily.

To convert the client’s supplemented intake to micrograms of RAE per day, you note that 1 meg as RAE = 10 IU vitamin A activity as beta-carotene = 3.33 IU vitamin A activity as retinol. This calculates to 3551 meg as RAE daily in supplements alone.

Suggest limiting vitamin supplementation to a U.S. Pharmacopeia-approved multivitamin with no more than 100% of dietary reference intake for vitamins and minerals. 7. Describe the recommended therapeutic approach to the patient. Unless specifically recommended by your primary care provider or ophthalmologist, reconsider taking the supplement for vision if you are taking a U.S. Pharmacopeia-approved multivitamin with minerals. Take the multivitamin and the calcium supplement at different times. Separate both of these supplements from the levothyroxine. 8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Your current supplemental intake for vitamin A well exceeds the dietary reference intake. Instead of taking multiple supplements, optimize your nutrient intake by eating whole grains, fruits, and vegetables. In addition to fiber and many commonly recognized vitamins and minerals, fruits and vegetables provide lutein, a carotenoid associated with reduced risk of age-related macular degeneration when consumed regularly. Also choose low-fat dairy products and protein sources daily. Complementing a balanced diet with a daily multivitamin with minerals is reasonable to ensure adequate nutrient intake when the regular intake of healthy meals becomes difficult. If vitamin D intake is not sufficient between dietary sources and the multivitamin, a calcium product with vitamin D may be recommended. Patient Education 9. When recommending self-care with nonpre-scription medications and/or nondrug therapy, convey accurate information to the patient. Criterion does not apply in this case.

(1) Assess the client’s perceived need for the nutrient supplements. (2) Evaluate dietary intake from food groups, encouraging at least 5 servings of produce daily, 3 servings of low-fat dairy products, 2 servings of protein, and 6 servings of whole-grain food sources daily. (3) Discuss which nutrients may need supplementation, on the basis of the patient’s patterns of dietary intake. Evaluate Centrum Silver for adequacy, while avoiding intakes above the UL. (4) Discuss the lack of data and potential harm associated with megadoses of vitamin. (5) Take no action. Plan 6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Encourage a well-balanced diet, emphasizing that studies repeatedly demonstrate that good nutrition is associated with multiple health benefits, including a lower risk of some cancers and other age-related diseases. Evaluate the Centrum Silver multi-vitamin with the client, comparing the level of supplementation of each nutrient compared with the dietary reference intake. Point out that the product contains gingko biloba and vitamin C; therefore, additional supplementation of these substances is not necessary. 7. Describe the recommended therapeutic approach to the patient. See step 6. 8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. See step 6. Patient Education 9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the patient: a. appropriate dose and frequency of administration Consider one U.S. Pharmacopeia-approved multivitamin daily that contains no more than 100% of dietary reference intake for nutrients. b. maximum number of days the therapy should be employed N/A c. product administration procedures You may take your multivitamin with your current medications in the morning. However, check with your pharmacist on coadministration of any newly prescribed medications. 10. Solicit follow-up questions from patient. What about antioxidant vitamins? 11. Answer patient’s questions. Data from well-designed trials do not support antioxidant supplementation for the prevention or treatment of cancer. In fact, some trials have suggested potential harm is associated with supplementation of vitamins A, E, and C, selenium, and other nutrients in relation to cancer risk. Therefore, dosing of these nutrients above the dietary reference intake cannot be recommended at this time.

Inflammation of the bulbarand/ or palpebral conjunctiva of less than 4 weeks duration

System(s) affected: Nervous, Skin/Exocrine

Genetics: N/A

Incidence/Prevalence in USA: Variable, but accounts for 1 -2% of all ambulatory office visits

Predominant age: Depends on cause

Predominant sex: Male = Female

Medical Symptoms and Signs of Disease

• General: for viral, bacterial, allergic, atopicand nonspecific

– Red eye, conjunctival injection

– Discharge

– Foreign body sensation

– Eyelid sticking or crusting

– Normal visual acuity and papillary reactivity, otherwise, see Differential Diagnosis

• Viral, adenoviral or enteroviral most common sporadically in children, or may be associated with influenza, measles or mumps

– History of upper respiratory infection or systemic viral symptoms

– May start with 1 eye, then progresses to both eyes in 1-2 days

– Watery mucous discharge

– Inferior palpebral conjunctival follicles

– Palpable preauricular lymphadenopathy

• Viral, herpes simplex or zoster

– May have history of recurrent ocular herpes simplex

– Burning sensation, rarely itching

– Unilateral, with concurrent herpetic skin vesicles on eyelid or in distribution of ophthalmic branch of trigeminal nerve if herpes zoster

– Palpable preauricular node

• Bacterial, gonococcal hyperacute infection

– Rapid onset 12-24 hours

– Severe purulent discharge

– Chemosis-conjunctival edema

– May have rapid growth of superior corneal ulceration

– Eyelid swelling

– Preauricular adenopathy

– ? History or signs of other sexually transmitted diseases (chlamydia, HIV, etc.)

• Bacterial, nongonococcal: may be epidemic

– Mild pruritus

– Mild purulent discharge

– Conjunctival chemosisedema

– No preauricular adenopathy

– If contact lens user, must rule out pseudomonal keratitis

• Allergic

– Itching most dominant symptom

– Watery discharge

– History of seasonal or dander allergies

– Chemosis-conjunctival edema

– Eyelids edematous and red

– No preauricular adenopathy

• Atopic/vernal recurrent

– History of atopy

– Itching

– Thick sticky discharge

– Seasonal recurrences

– Large conjunctival papillae (bumps) under upper eyelid

– Sometimes superior corneal “shield” ulcer (sterile gray-white infiltrate)

– Sometimes raised white dots on inner lids or limbus

– Sometimes superficial punctate keratopathy on fluorescein staining

• Nonspecific irritative

– Dry eyes with intermittent redness and mucus

– Irritation after a chemical exposure or drug reaction

– Foreign body: may still have redness and discharge 24 hours after removal

What Causes Disease?

• Viral

– Adenovirus (common cold)

– Coxsackie

– Enterovirus (acute hemorrhagic conjunctivitis)

– Herpes simplex, primary and recurrent

– Herpes zoster or varicella

– Molluscum contagiosum

– Measles, mumps or influenza

• Bacterial

– Staphylococcus aureus

– S. epidermidis

– Streptococcus pneumoniae

– Haemophilus influenzae (especially in children)

– Pseudomonas species (must rule out in contact lens users; frequently progresses to corneal ulcers)

Oneisseria gonorrhoeae

Oneisseria meningitidis

– Chlamydia trachomatis causes a chronic conjunctivitis — gradual onset over 4 weeks

• Allergic

– Hay fever, seasonal allergies

– Vernal conjunctivitis/atopy

• Nonspecific

– Irritative: topical medications, wind, or dry eye ultraviolet light exposure, smoke

– Autoimmune: Sjogren’s, pemphigoid, Wegener granulomatosis

– Rare: Rickettsial, fungal, parasitic, tuberculosis, syphilis, Kawasaki disease, Grave disease, gout carcinoid, sarcoid, psoriasis, Stevens-Johnson,

Reiter syndrome

Risk Factors

• History of contact with infected persons; epidemic bacterial or viral conjunctivitis

• Sexually transmitted disease contact: gonococcal chlamydial, syphilis, herpes

• Use of contact lenses: pseudomonal

Diagnosis of Disease

Differential Diagnosis

• Uveitis (iritis, iridocyclitis, choroiditis): limbal flush (red band at corneal margin, less on other areas of conjunctiva) hazy anterior chamber, decreased visual acuity

• Penetrating ocular trauma: ophthalmologic emergency; hospitalize

• Acute glaucoma (ophthalmologic emergency) headache, corneal clouding, decreased visual acuity

• Corneal ulcer(s) or foreign body: abnormal fluorescein exam

• Dacryocystitis: tenderness and swelling over tear sac (near nasal bridge)

• Scleritis and episcieritis: red injected vessels are radially oriented, sectoral (pie wedge) inflammation, sometimes with nodularity of sclera

• Ophthalmia neonatorum: neonates in first 2 days of life — gonococcal; 5-12 days of life — chlamydial, consider HSV if maternal cultures were positive for herpes simplex. Consider specialty consultation. All of these require systemic therapy as well as topical.

Laboratory

• Usually not needed initially for the most common causes of conjunctivitis

• Culture swab if thought to be bacterial or if contact lens user

• Gram stain of discharge if thought to be gonococcal

Drugs that may alter lab results: N/A

Disorders that may alter lab results: N/A

Pathological Findings

N/A

Special Tests

• Pap stain for giant cells of herpes simplex.

• Viral culture or immunofluorescence for herpes simplex

Diagnostic Procedures

• Document visual acuity/Snellen Chart

• Fluorescein staining to detect foreign bodies, corneal ulcers or punctate keratitis, and look for dendritic lesions of herpes simplex or zoster

• Examine eyelid skin also for herpetic vesicles, lice or nits, blepharitis or styes

Treatment (Medical Therapy)

Appropriate Health Care

Outpatient

General Measures

• Cool compresses and eyelid cleansing with wet cloth up to 4 times per day

• Discontinue use of contact lenses for duration of inflammation

• Patching of eye not beneficial

• Try to avoid irritants such as smoke, dry wind, prolonged sun exposure

Activity

No restrictions

Diet

No restrictions

Patient Education

• Discuss handwashing techniques to decrease transmission of disease

• Do not re-use eye cosmetics after an infection. They should be discarded.

• Demonstrate eye dropper techniques: while eye is closed, and head tipped back, drop several drops in a lake at nasal margin then patient can open eyes to allow liquid to enter. Never touch tip of applicator to skin or eye.

• Demonstrate ointment techniques; apply 1/2 inch to edqe of lower lid

Medications (Drugs, Medicines)

Drug(s) of Choice

• Viral: nonherpetic

– Artificial tears for symptomatic relief

– Vasoconstrictor/antihistamine (e.g. naphazoline/pheniramine) qid for severe itching

– Consider bland, inexpensive, topical antibiotic ointments in an empiric approach “in case” a viral infection is complicated by skin flora:

– Erythromycin ophthalmic ointment 1/2 inch twice a day for 5 days, or

– 10% sodium sulfacetamide ophthalmic drops 2 gtts every 4 hours for 5 days.

• Viral: herpetic

– Trifluorothymidine 1% drops one drop 5 times a day or vidarabine 3% ointment 5 times per day.

– Acyclovir oral, consult drug reference

– If corneal lesions seen, consider ophthalmologist referral

• Bacterial: gonorrheal

– If ulceration visible, or can not be ruled out consider emergent ophthalmologic consultation and hospitalization for IV ceftriaxone

– If no corneal lesions, ceftriaxone 1 gm IM, as single dose and topical bacitracin ophthalmic ointment ½ inch, 4 times per day.

• Bacterial: non-gonococcal

– Bacitracin ophthalmic 1/2 inch 2-4 times per day for 5 days or

– Erythromycin ophthalmic ointment, 1/2 inch 2-4 times per day for 5 days, or

– Sodium sulfacetamide 10% solution, 2 drops every 4 hours (while awake) for 5 days

– Fluoroquinolone eye drops (such as ciprofloxacin) are more expensive but also are acceptable

– Avoid aminoglycoside drops and neomycin ointments as they can cause a reactive keratoconjunctivitis after a few days of use

• Allergic and atopic

– Artificial tears 4 to 8 times per day

– Vasoconstrictor/antihistamine qid

– azelastine (Optivar) 0.05% bid

– epinastine (Elestat) 0.05% bid

– NSAID (anti-inflammatories)

– Ketorolac (Acular) 0.5%

– levocabastine (Livostin) qid

– Mast cell stabilizers:

– ketotifen (Zatidor) 0.025% bid

– cromolyn (Opticrom) 4% qid

– olopatadine (Patanol) tid

– Oral antihistamine (e.g., diphenhydramine 25 mgtid) in severe cases

Contraindications: Avoid use of topical steroids unless in ophthalmologic setting and able to monitor intraocular pressure

Precautions:

• Do not allow dropper to touch eye or skin to avoid contamination. Do not re-use same eye cosmetics after an infection — they should be discarded

• Vasoconstrictor/antihistamine — rebound vasodilation after prolonged use

• Avoid topical steroids in non-ophthalmologic setting as patients must be monitored for development of steroid related cataracts and glaucoma. If superior shield ulcer of vernal conjunctivitis is present, refer to ophthalmology for steroids.

Significant possible interactions: N/A

Alternative Drugs

• Viral — numerous over-the-counter and prescription topical vasoconstrictors and antihistamines

• Bacterial

– Polymyxin-gramicidin

Oneomycin-polymyxin b-bacitracin (Neosporin) (15% of people have reaction to neomycin)

– Ciprofloxacin

– Norfloxacin

– Chloramphenicol (warning: slight hematological adverse effect risk)

– Oral erythromycin for chlamydia in neonate (see drug reference for dosing)

• Allergic

– Numerous topical vasoconstrictors and antihistamines

– Numerous oral antihistamines

Patient Monitoring

Referral if worse in 24 hours. Bacterial: expect improvement in 24 hours and resolution in 2-5 days.

Prevention / Avoidance

• Avoid listed causes when possible

• Wash hands frequently

Possible Complications

• Viral

– Corneal scars with herpes simplex

Oneonatal herpes simplex could include encephalitis

– Lid scars or entropion with Varicella zoster

– Bacterial superinfection

• Bacterial

– Chronic marginal blepharitis

– Conjunctival scar if membrane develops.

– Corneal ulcers or perforation, very rapid with gonococcal

– Hypopyon: pus in anterior chamber

– Chlamydial neonatal ophthalmia: could have concomitant pneumonia

• Allergic, chemical or nonspecific

– Bacterial superinfection

Expected Course / Prognosis

• Viral

10 days for pharyngitis with conjunctivitis

– Several weeks for epidemic keratoconjunctivitis

– 2-3 weeks for herpes simplex

• Bacterial

2-4 days with treatment 010-14 days if untreated

Miscellaneous

Associated Conditions

• Viral infection (e.g., common cold)

• Sexually transmitted diseases

Age-Related Factors

Pediatric: Neonatal conjunctivitis may be gonococcal, chlamydial, irritative or related to dacryocystitis. Gonococcal ophthalmia neonatorum is an emergency.

Geriatric: More likely to have autoimmune, systemic or irritative conditions

Others: Epidemic bacterial (streptococcal) conjunctivitis reported on college campuses

Pregnancy

N/A

Synonyms

Pinkeye

International Classification of Diseases

077.99 Unspecified diseases of conjunctiva due to viruses

372.50 Conjunctival degeneration, unspecified

372.14 Other chronic allergic conjunctivitis

See Also

Rhinitis, allergic

Vernal keratoconjunctivitis

Sjogren syndrome

A sensation of functionally impairing muscle fatigue, cramps and/or pain of the lower extremities brought on by exertion and relieved with rest. Less than 10% of patients with known lower extremity atherosclerosis develop claudication. Approximately 90% of all patients with claudication are cigarette smokers.

System(s) affected: Cardiovascular, Musculoskeletal

Genetics: Geni loci unidentified

Incidence/Prevalence in USA:

• Biennial incidence (Framingham study): 0.07% in men aged 35-44 years and 1.4% in men older than 65 years; diabetic patients 4-6 times that of nondiabetics

• Prevalence: approximately 1.7-2.2% among older patients

Predominant age: Common in males > 55, females > 60

Predominant sex: Male > Female (by a less than 2:1 ratio)

Medical Symptoms and Signs of Disease

• Cold feet are an early warning symptom

• Sudden or gradual onset

• Restricted walking distance due to symptom onset

• Symptom continuum from calf muscle fatigue to severe cramps/pain

• Dependent rubor

• Hairless lower extremities

• Leg color may be normal when horizontal, but may appear dusky crimson hue when in lowered position

• Marked blanching on evaluation

• Poorly palpable or absent lower extremity pulses (may not be true for patients with blood vessel calcifications i.e. diabetic patients)

• Paresthesias or numbness are later symptoms

• Symptoms of pain may not be detected in a diabetic patient

• Nonhealing ulcer associated with poor circulation

What Causes Disease?

• Sites affected depends on involved vasculature:

• Aortoiliac disease — pain may extend from buttocks to thigh

• Femoropoliteal disease — pain may extend from calves to feet

• Superficial femoral artery occlusion accounts for most cases of lower extremity claudication symptoms.

• Subclavian, axillary and/or brachial artery blockages may lead to upper extremity claudication symptoms.

• Other causes of arterial occlusion to consider: emboli. popliteal entrapment, adventitious cystic disease of the popliteal arteries, and thromboangiitis obliterans (Buerger disease)

Risk Factors

(Cigarette smoking and hypertension are most closely linked with worsening claudication symptoms)

• Smoking

• Diabetes mellitus

• Hypertension

• Hypercholesterolemia

• Family history

• Obesity

• Preexisting heart disease

Diagnosis of Disease

Differential Diagnosis

[Neither pseudoclaudication nor osteoarthritis affects ankle brachial indices (see below)]

• Pseudoclaudication: attributed to spinal cord impingement or spinal stenosis. Sitting or squatting helps relieve symptoms.

• Osteoarthritis: pain made worse by weight bearing

Drugs that may alter lab results: None

Disorders that may alter lab results: Calcified, non-compressible vessels would affect ankle brachial indices (see below).

Pathological Findings

N/A

Special Tests

• The ankle brachial index (ABI) = systolic blood pressure at the ankle -f systolic blood pressure of the brachial artery. Normal indices are minimally greater than or equal to 1. The ABI provides information on proximal arterial disease extent and a general idea concerning functional compromise. For example, an ABI greater than 0.5 suggests stenosis of a single arterial segment An ABI less than 0.5 suggests multisegmental arterial stenoses. Claudicants tend to have ABIs ranging from 0.5 to 0.8. Probable tissue death and or rest pain is usually found at ABIs less than 0.3.

• Since calcified vasculature impairs compressibility and ABIs cannot be conventionally measured, photoplethys-mography is another option to evaluate toe pressures. Normal toe pressures are 80-90% of brachial artery systolic blood pressures.

• Two claudication screening tools are the Rose and Edinburgh questionnaires.

– The Rose queries if calf pain while walking is relieved by 10 minutes of rest or if pain exacerbated by an increased pace (or walking uphill) is relieved by tapering or stopping the activity. Other items include persistent pain if walking continues and absence of calf pain while sedentary. If physicians’ diagnosis ot claudication is the gold standard, the Rose questionnaire has a specificity of approximately 99% and a sensitivity of 66%.

– The Edinburgh is a modified Rose questionnaire taking into account that some patients might continue to walk through calf pain. This questionnaire has a sensitivity of approximately 91 % for the detection ot claudicants.

Imaging

• Duplex ultrasound

• Angiography

• Role of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) in comparison to conventional angiography remains to be determined.

Diagnostic Procedures

• Arteriography — when surgical correction is anticipated

• Noninvasive vascular tests

Treatment (Medical Therapy)

Appropriate Health Care

Outpatient. An exception is those patients with severe disease who may require inpatient evaluation

General Measures

• Medical treatment

• Elimination of risk factors whenever possible

• Smoking cessation

• Dietary optimization (low fat and low cholesterol diet)

• Exercise (however, approximately 70% of claudicants will require medication for symptom control)

Surgical Measures

(Note: Most patients do not require surgical management.)

• Angioplasty

• Arterial bypass surgery

Activity

Ambulatory

Diet

Low fat, low cholesterol diet for avoidance and control of hyperlipidemia

Patient Education

• Primary prevention: Encourage an exercise program, no smoking, healthy dietary choices, management of blood glucose in diabetic patients, hypertension control

• Secondary prevention: As above. Emphasize smoking cessation and hypertension control.

Medications (Drugs, Medicines)

Drug(s) of Choice

• Aspirin — 80 mg qd to reduce platelet aggregation

• Pentoxifylline (Trental) — to decrease internal configuration of red cells — 400-800 mg bid-tid. Administer for at least 6-8 weeks to determine if therapy is effective.

• Cilostazol (Pletal) 50-100 mg bid

Contraindications:

• Cilostazol is contraindicated in patients with congestive heart failure

• Pentoxifylline is contraindicated in patients with recent cerebral and/or retinal hemorrhage

Precautions:

• Headache occurs frequently (>30%) in patients taking cilostazol

Significant possible interactions:

• Cilostazol: Metabolized via the cytochrome P-450 isoenzymes. Use caution during coadministration of other inhibitors of CYP3A4 (e.g., grapefruit juice, ketoconazole, itraconazole, erythromycin and diltiazem), and during coadministration of inhibitors of CYP2C19 (e.g. omeprazole).

• Pentoxifylline: theophylline levels may rise

• Concurrent use of beta blockers in patients with coexisting cardiovascular disease does not appear to worsen claudication symptoms in affected patients

Alternative Drugs

• Ticlopidine (Ticlid)

• Vasodilators

• Calcium channel blockers

• Anticoagulants

• Role of PGE1 and PGI2 analogues and stimulants (i.e. AS-103, iloprost, beraprost, defibrotide) continues to be investigated

Patient Monitoring

Peripheral non invasive vascular studies every 6 months. If worsening, would be indication for surgery.

Prevention / Avoidance

• Walking program

• Avoid smoking

Possible Complications

• Tissue/ limb loss- predominantly affects diabetic patients as disease progresses

• Complications of reperfusion

– Compartmental syndrome

– Venous thrombosis induced by low flow state which may flush to right side of heart to pulmonary circulation

Expected Course / Prognosis

• Gradual improvement with use of medical therapy/walking program and diminution/elimination of risk factors. Some patients may require revascularization. Disease progression may include rest pain, tissue loss and gangrene.

• Chronic intermittent ischemia may cause lasting defects in muscle function resulting in weakness which could be an early sign of peripheral arterial disease

Miscellaneous

Associated Conditions

– Other mani festations of arteriosclerotic vascular disease — myocardial infarction(s), carotid artery occlusive disease, renovascular occlusive disease, and hypertension

Age-Related Factors

Pediatric: N/A

Geriatric: More common with advancing age

Pregnancy

N/A

International Classification of Diseases

443.9 Peripheral vascular disease, unspecified

See Also

Thromboangiitis obliterans (Buerger disease)