1000-2000 5 ьшò

ONGOING CARE

DIET

Salt and fluid restriction

PATIENT EDUCATION

Smoking cessation and avoidance of exposure to secondary smoke is strongly recommended.

Level of physical activity should be discussed with physician.

Pregnancy should be avoided.

PROGNOSIS

Patients with cor pulmonale resulting from COPD have a greater likelihood of dying than do similar patients with COPD alone. In patients with COPD and mild disease (PAP20 to 35 mm Hg), 5-year survival is 50%.

REFERENCES

1.Seeger W, Adir Y, Barberà JA, et al. Pulmonary hypertension in chronic lung diseases. J Am Coll Cardiol. 2013;62(25 Suppl):D109–D116.

2.Simonneau G, Gatzoulis M, Adiata I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D34–D41.

3.Galiè N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67–119.

4.Taichman DB, Ornelas J, Chung L, et al. Pharmacologic therapy for pulmonary arterial hypertension in adults: CHEST guideline and expert panel report. Chest. 2014;146(2):449–475.

SEE ALSO

Chronic Obstructive Pulmonary Disease and Emphysema; Congestive Heart

Failure: Differential Diagnosis; Pulmonary Arterial Hypertension; Pulmonary

Embolism

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CODES

ICD10

I27.81 Cor pulmonale (chronic)

I26.09 Other pulmonary embolism with acute cor pulmonale

CLINICALPEARLS

Treatment of cor pulmonale requires treatment of the underlying disease. Therefore, accurate diagnosis of primary pulmonary disease is critical to clinical management and treatment therapy.

Continuous, long-term oxygen therapy improves life expectancy and quality of life in cor pulmonale.

Referral of patients with cor pulmonale to a specialized center is strongly recommended.

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CORNEALABRASION AND ULCERATION

Patrick F. Cleary, DO Christine S. Persaud, MD

BASICS

DESCRIPTION

Corneal abrasions: result from cutting, scratching, or abrading the thin, protective, clear coat of the exposed anterior portion of the ocular epithelium. These injuries cause pain, tearing, photophobia, foreign body sensation, and a gritty feeling (1).

Corneal ulceration: break in the epithelial layer of the cornea leading to exposure of the underlying corneal stroma, which results in a corneal ulcer. Superficial ulcers, limited to loss of the corneal epithelium, are the most common form of ulceration (2).

Corneal abrasion and ulceration can both lead to impaired vision from scarring.

EPIDEMIOLOGY

Incidence

Corneal abrasions are commonly seen in primary care. Eye-related diagnoses make up 8% of total ER visits. Of those eye-related visits, 45% are corneal abrasions. Abrasions are the third leading cause of red eye, following conjunctivitis and subconjunctival hemorrhage (3).

Associated with significant morbidity and loss of productivity

ETIOLOGYAND PATHOPHYSIOLOGY

Corneal abrasions are most often caused by mechanical trauma but may also result from foreign bodies, contact lenses wear, or chemical and flash burns.

Corneal ulceration: Contact lenses use, HIV, trauma, ocular surface disease, and ocular surgery increase the incidence. Edema plays a major role in epithelial defect. Edema can lead to trauma, ischemia, and increased intraocular pressure. Excessive fluid disrupts the normal architecture of the epithelial layer (4).

Causes of ulcerations include the following:

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–Infection with gram-positive organisms ~29–53% (Staphylococcus aureus and coagulase-negative Streptococcus are common ones)

–Infection with gram-negative organisms ~47–50% (Pseudomonas being

most common, followed by Serratia marcescens, Proteus mirabilis, and gram-negative enteric bacilli)

Increased risk of corneal ulceration in HIV and diabetes mellitus (DM) patients and immunocompromised

RISK FACTORS

History of trauma (direct blunt trauma, chemical burn, radiation exposure, etc.)

Contact lenses wear

Male gender

Age: 20 to 34 years old

Job (construction, manufacturing)

Lack of eye protection

GENERALPREVENTION

Protective eyewear during work (automechanics, metal workers, miners, etc.) and during sports

COMMONLYASSOCIATED CONDITIONS

Vitamin Adeficiency is associated with corneal ulcers.

Neuropathy of cranial nerve (CN) V

DM, thyroid dysfunction, immunocompromised states, connective tissue disease

DIAGNOSIS

HISTORY

Corneal abrasion is a clinical diagnosis. It includes a history of recent ocular trauma and acute pain. Other symptoms include photophobia, pain with extraocular muscle movement, excessive tearing, blepharospasm, foreign body sensation, gritty feeling, blurred vision, and headache.

PHYSICALEXAM

Gross examination of the anatomy: eyelids, surface of the eye, pupils, and

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extraocular muscles

Snellen chart

Tonometry

Penlight

Blepharospasm: fluorescein stain

Wood lamp (5)

DIFFERENTIALDIAGNOSIS

Corneal abrasion

–Acute angle-closure glaucoma Conjunctivitis

–Infective keratitis

Uveitis

Keratoconjunctivitis (3,5)

Corneal ulceration

–Herpes zoster

Herpes zoster ophthalmicus

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Ulcer culture

Pretreatment with topical antibiotics may alter culture results.

Diagnostic Procedures/Other

Slit lamp and fluorescein dye to identify and evaluate corneal abrasions

Trauma/foreign body has geographic shape; if due to contact lenses, several punctate lesions (5)

Document visual acuity.

Test Interpretation

Scraping culture/staining identifies bacteria, yeast, or intranuclear inclusions to help narrow diagnosis.

TREATMENT

GENERALMEASURES

Most uncomplicated corneal abrasions heal in 24 to 48 hours.

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May not require follow-up if lesion is >4 mm, uncomplicated abrasion, normal vision, and resolving symptoms

Patching not recommended

–Does not reduce pain

–Delays healing (4)[A]

MEDICATION

Treatment guidelines: pain control, infection prevention, and daily symptom monitoring

Oral analgesic: narcotics, acetaminophen, NSAIDs

Topical anesthetics include proparacaine hydrochloride 0.1–0.5%, tetracaine hydrochloride 1%.

– Proparacaine may be less cytotoxic than tetracaine (4)[B].

First Line

Ophthalmic NSAIDs: Diclofenac 0.1% QID helps relieve moderate pain:

–Alternatives include ketorolac 0.5% and bromfenac 0.09%.

–Caution: Ophthalmic NSAIDs may rarely cause corneal melting and perforation.

Ophthalmic antibiotics may help prevent further infection and ulceration of corneal abrasions (6)[C].

Some ophthalmic antibiotics include ciprofloxacin 0.3%, ofloxacin 0.3%, gentamicin 0.3%, erythromycin 0.5%, polymyxin B/trimethoprim (Polytrim), and tobramycin 0.3%.

Large corneal abrasions (>4 mm) or very painful abrasions should be treated with a combination of topical antibiotic and topical NSAID.

Fungal keratitis is treated with a protracted course of topical antifungal agents (by ophthalmologist).

Herpetic keratitis should be referred promptly to ophthalmologist and treated initially with trifluridine:

– Vidarabine and acyclovir are alternatives.

ISSUES FOR REFERRAL

Indications for referral include:

–Chemical burn

–Evidence of corneal ulcer or infiltrate

–Failure to heal after 3 to 4 days

–Inability to remove a foreign body

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–Increase size of abrasion after 24 hours

–Penetrating injury

–Presence of hyphema (blood) or hypopyon (pus)

–Rust ring

–Vision loss of >20/40

Worsening symptoms or improvement after 24 hours (5)

–Immediate ophthalmology consultation for corneal ulceration for culture and initiation of treatment

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Most uncomplicated corneal abrasions heal in 24 to 48 hours.

Follow-up not necessary for small (<4 mm), uncomplicated abrasions, normal vision, and resolving symptoms

Lesions >4 mm, decreased vision, and abrasions due to contact lenses need follow-up within 24 hours (3)[C].

PATIENT EDUCATION

Prevention of abrasions and proper handling of contact lenses can prevent recurrence of corneal ulcers.

PROGNOSIS

Corneal abrasions heal within 24 to 48 hours.

Ophthalmology consult with penetrating eye injury

COMPLICATIONS

Recurrence

Scarring of the cornea

Loss of vision

REFERENCES

1.Wilson SA, Last A. Management of corneal abrasion. Am Fam Physician. 2004;70(1):123–128.

2.Belknap EB. Corneal emergencies. Top Companion Anim Med.

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2015;30(3):74–80.

3.Wipperman JL, Dorsch JN. Evaluation and management of corneal abrasions. Am Fam Physician. 2013;87(2):114–120.

4.Malafa MM, Coleman JE, Bowman RW, et al. Perioperative corneal abrasion: updated guidelines for prevention and management. Plast Reconstr Surg. 2016;137(5):790e–798e.

5.Pflipsen M, Massaquoi M, Wolf S. Evaluation of the painful eye. Am Fam Physician. 2016;93(12):991–998.

6.Fraser S. Corneal abrasion. Clin Ophthalmol. 2010;4:387–390.

CODES

ICD10

S05.00XAInj conjunctiva and corneal abrasion w/o fb, unsp eye, init

H16.009 Unspecified corneal ulcer, unspecified eye H16.049 Marginal corneal ulcer, unspecified eye

CLINICALPEARLS

Contact lenses use should be discontinued until corneal abrasion or ulcer is healed and pain is fully resolved.

Eye patching is not recommended.

Prescribe topical and/or oral analgesic medication for symptom relief and consider ophthalmic antibiotics.

Prompt referral to an ophthalmologist should be made with suspicion of an ulcer, recurrence of abrasion, retained foreign body, viral keratitis, significant visual loss, or lack of improvement despite therapy.

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CORNS AND CALLUSES

Sangili Chandran, MD Valerie Rygiel, DO

BASICS

DESCRIPTION

Acallus (tyloma) is a diffuse area of hyperkeratosis, usually without a distinct border.

–Typically, the result of exposure to repetitive forces, including friction and mechanical pressure; tend to occur on the palms of hands and soles of feet (1)

Acorn (heloma) is a circumscribed hyperkeratotic lesion with a central conical core of keratin that causes pain and inflammation. The conical core in a corn is a thickening of the stratum corneum.

Hard corn or heloma durum (more common): often on toe surfaces, especially 5th toe (proximal interphalangeal [PIP]) joint

Soft corn or heloma molle: commonly in the interdigital space (1)

Digital corns are also known as clavi or heloma durum.

Intractable plantar keratosis is usually located under a metatarsal head (1st and 5th most common), is typically more difficult to resolve, and often is resistant to usual conservative treatments.

EPIDEMIOLOGY

Corns and calluses have the largest prevalence of all foot disorders.

Incidence

Incidence of corns and calluses increases with age.

Less common in pediatric patients

Women affected more often than men

Blacks report corns and calluses 30% more often than whites.

Prevalence

9.2 million Americans

~38/1,000 people affected

ETIOLOGYAND PATHOPHYSIOLOGY

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Increased activity of keratinocytes in superficial layer of skin leads to hyperkeratosis. This is a normal response to excess friction, pressure, or stress.

Calluses typically arise from repetitive friction, motion, or pressure to skin. The increased pressure is often secondary to a metatarsal deformity (long metatarsal or plantarflexed metatarsal) or another bone spur or deformity.

Hard corns are an extreme form of callus with a keratin-based core. Often found on the digital surfaces and commonly linked to bony protrusions, causing skin to rub against shoe surfaces.

Soft corns arise from increased moisture from perspiration leading to skin maceration, along with mechanical irritation, especially between toes.

Genetics

No true genetic basis was identified because most corns and calluses are due to mechanical stressors on the foot/hands.

RISK FACTORS

Extrinsic factors producing pressure, friction, and local stress

–Ill-fitting shoes or walking barefoot

–Not using socks/gloves

–Activities that increase stress applied to skin of hands or feet (manual labor,

running, walking, sports) Intrinsic factors

–Bony prominences: bunions, hammertoes, mallet deformities, deformed metatarsals

–Motor or sensory neuropathy such as secondary to diabetes

GENERALPREVENTION

External irritation and pressure are by far the most common cause of calluses and corns. General measures to reduce friction or pressure on the skin are recommended to reduce incidence of callus formation. Examples include wearing shoes that fit well and using socks and gloves.

Geriatric Considerations

In elderly patients, especially those with neurologic or vascular compromise, skin breakdown from calluses/corns may lead to increased risk of infection/ulceration. 30% of foot ulcers in the elderly arise from eroded hyperkeratosis. Regular foot exams are emphasized for these patients as well as diabetic patients (2).

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