PAeasy EENT

A 72-year-old man presents with a neck mass. Examination reveals a mass within a multinodular goiter. The patient undergoes a fine needle aspiration, which reveals cancerous cells. Question What is the most aggressive type of thyroid cancer? Answer Choices 1 Papillary carcinoma 2 Follicular carcinoma 3 Medullary carcinoma 4 Anaplastic carcinoma 5 Squamous cell carcinoma

Anaplastic carcinoma Explanation Anaplastic carcinoma is the correct response. Anaplastic carcinoma is the most aggressive form of thyroid cancer. It is associated with gene mutations and early metastasis. Papillary carcinoma, follicular carcinoma, medullary carcinoma, and squamous cell carcinoma are all incorrect responses. Anaplastic carcinoma is the most aggressive type of thyroid cancer.

A 40-year-old man with a past medical history of hepatitis C presents with burning and pain of his oral cavity, which has been associated with a pruritic rash of the flexor aspect of his left wrist. The physical exam is remarkable for violaceous, shiny, and polygonal papules arranged as lines and circles on his wrist. These papules range in size from 1 mm to 1 cm in diameter, and have fine, white lines on them. In the oral cavity, a reticular, white, lacy pattern is visualized, as seen in the image. Question What is the most appropriate first-line pharmacological treatment of this patient's oral lesions? Answer Choices 1 Clobetasol propionate (Temovate) gel 2 Cyclosporine (Sandimmune) capsules 3 Soriatane (Acitretin) 4 Nystatin oral suspension 5 Doxycycline (Vibramycin) oral suspension

Cyclosporine (Sandimmune) capsules Explanation This patient most likely has lichen planus with cutaneous and oral involvement. It is an inflammatory mucocutaneous condition that usually exhibits a distinctive morphology and is associated with hepatitis C. The classic appearance of skin lesions includes violaceous polygonal flat-topped papules and plaques, commonly occurring at the wrist. For lichen planus of the oral mucosa, topical steroids are usually tried first. Treatment with steroids is especially indicated in ulcerative forms of oral lichen planus. Topical and systemic cyclosporin has been tried with some success; however, a randomized double-blind study indicated that topical cyclosporin was a less effective and much more costly regimen than clobetasol.Newer topical calcineurin inhibitors have replaced topical cyclosporin for the treatment of lichen planus. If corticosteroid resistance occurs, other treatment options using oral or topical retinoids are available. One controlled trialdemonstrated efficacy of treatment with a dosage of 30 mg daily of soriatane (acitretin) once daily for 8 weeks. When prescribing any retinoid, however, physicians must be familiar with the risk profile because of the severe teratogenicity associated with this class of drugs. Nystatin and vibramycin suspensions are not indicated, as this patient is not experiencing a fungal or bacterial infectious process.

A 12-year-old boy presents with fatigue and jaundice. History obtained from the patient and his mother is negative for recent illness, fever, infectious exposures, medication, alcohol, or drug use. He denies gastrointestinal (GI) symptoms and a history of GI disease. On physical examination, he appears ill; the liver edge is palpable and slightly tender. Skin and sclera are icteric, and there is corneal discoloration. On eye examination using a slit-lamp, you note brown-yellow rings encircling the iris in the rim of the cornea bilaterally. You order a serum ceruloplasmin level, which is reported as low. What is this diagnostic corneal pigmentation known as? Answer Choices 1 Fleischer's rings 2 Kayser-Fleischer rings 3 Rust rings 4 Arcus juvenilis 5 Pinguecula

Explanation The correct answer is Kayser-Fleischer rings, which are the result of accumulation of copper in the cornea and the most unique sign of Wilson's disease. Wilson's disease is an inherited disorder of copper toxicity due to a genetic defect in copper transport. Beginning at birth, copper is not secreted into the bile or incorporated into the copper protein ceruloplasmin, resulting in low serum levels of ceruloplasmin. Symptoms and signs develop between 5 - 40 years of age as copper accumulates in the liver, brain, cornea, kidney, and reproductive organs. 50% of patients present with hepatitis; 40% present with neurological manifestations (tremor, speech disorders, dysphagia, incoordination), and 5 - 10% first present with Kayser-Fleischer rings (a brown-yellow ring in the cornea around the iris from copper deposits), amenorrhea, miscarriages, or hematuria. Diagnosis in confirmed by Kayser-Fleischer rings on slit-lamp examination in the presence of a low serum ceruloplasmin. AST and ALT levels are often elevated; serum copper is low; 24-hour urinary copper excretion is elevated. Treatment is lifelong chelation or oral zinc and a low copper diet. Keratoconus is a bulging of the cornea to form a cone, and the classic sign is Fleischer's rings, which is an iron colored ring surrounding the cone. This progressive bulge is due to a weakness in the cornea and often occurs bilaterally beginning at 10 - 20 years of age. There are frequent changes in visual acuity necessitating repeated prescription changes, and contacts provide better correction than glasses. Corneal transplant may be necessary if corrective lenses are not adequate. Arcus juvenilis is a gray or white arc around the peripheral cornea similar to arcus senilis in adults. It occurs in younger adults and is often associated with high blood cholesterol. A metallic foreign body lodged in the cornea can quickly result in a single, small diameter rust ring that requires ophthalmologic intervention with a rust ring drill for removal. A pinguecula is a raised, yellowish discoloration on the bulbar conjunctiva at the 3 o'clock or 9 o'clock position of the sclera-corneal junction. It is a benign growth; it is due to an accumulation of conjunctival tissue that can be the result of chronic actinic irritation.

A 12-year-old female presents to the office with an acute sore throat. The patient is experiencing great pain when swallowing. Even the swallowing of her own saliva causes intense pain. An examination of the throat reveals an enlarged and erythematous epiglottis. A special throat culture request was made in consideration to the finding of acute epiglottitis. The patient was discharged and treated with ampicillin. The next day the culture was significant for 4+ of a gram-negative coccobacillus that only grew on chocolate agar media. The cause of this acute epiglottitis is: Answer Choices 1 Streptococcus pneumoniae 2 Staphylococcus aureus 3 Streptococcus pyogenes 4 Haemophilus influenzae 5 Candida albicans

H Influenzae Explanation Streptococcus pyogenes is a gram-positive coccus, catalase negative, beta hemolytic on blood agar, appearing as chains on gram stain. Definitive identification to distinguish it from other beta hemolytic streptococci is the detection of its specific "A" antigen by latex agglutination techniques. It is associated with streptococcal pharyngitis, scarlet fever, streptococcal pyoderma, necrotizing fascitis, and streptococcal toxic shock syndrome. Bacteremia is uncommon. They are universally sensitive to penicillin. Streptococcus pneumoniae is a gram-positive lancet-shaped coccus that is catalase negative and occurs in pairs. It is a common cause of otitis media in children. It is also a major cause of meningitis in elderly people and especially those that have underlying conditions, are malnourished, or are alcoholics. The organism is alpha hemolytic on blood agar. Staphylococcus aureus is a gram-positive coccus, catalase positive, and coagulase positive, predominantly beta hemolytic on blood agar, appearing in characteristic grape clusters on gram stain. Staphylococcus aureus can cause a variety of infections. In children with reactive tonsils, this can be a source of infection, leading to severe tonsillitis. A semisynthetic penicillin is the treatment of choice. Haemophilus influenza is a gram-negative coccobacillus. It is also a major cause of meningitis. It occurs mostly in young infants and children where it can also cause a severe epiglottitis that can necessitate intubation. When it occurs in adults, it is usually due to an underlying condition, such as paranasal sinusitis, remote head trauma, or otitis. The organism will not grow on blood agar and requires the presence of growth factors (hemin and NAD) for growth. Candida albicans is a yeast. Yeast appears on gram stain as large gram-positive organisms approximately 3-5 times larger than gram-positive cocci. They are aerobic and generally grow well on most nonselective agar media. The organism is a major cause of throat infections in the immunocompromised, such as patients with HIV. When causing an infection in the throat, it is called "thrush."

A 42-year-old man presents with a 3-day history of, as he puts it, "not being able to hear in my right ear". He is otherwise healthy, and he is not taking any medications. There is not a history of trauma. On physical exam, the whisper test is decreased on his right; the Weber test lateralizes to the right ear and the Rinne test is as follows: right ear bone conduction is greater (lasts longer) than air conduction; left ear air conduction lasts longer than bone conduction. Question What is the most likely diagnosis? Answer Choices 1 Right ear sensorineural hearing loss, possibly due to Meniere's disease 2 Left ear sensorineural hearing loss, possibly due to Meniere's disease 3 Left ear conductive hearing loss, possibly due to middle ear disease 4 Right ear sensorineural hearing loss, possibly due to acoustic neuroma 5 Right ear conductive hearing loss, possibly due to cerumen impaction

5 Right ear conductive hearing loss, possibly due to cerumen impaction Explanation Hearing loss can be recognized at the bedside as either sensorineural or conductive through the Rinne and Weber tests. In this case, the Rinne test bone conduction (BC) lasts longer than air conduction (AC) in the right ear ( affected ear) and the Weber test lateralizes to the right ear (affected ear). Normally AC lasts longer than BC because of the amplifying effects of the eardrum and middle ear. If BC is longer than AC, the patient is likely to have conductive deafness. Both tests in this patient indicate a conductive hearing loss in the right ear, probably produced by cerumen impaction; there is no apparent evidence of middle-ear disease. In sensorineural hearing loss, both AC and BC are equally diminished. Right ear sensorineural hearing loss due to Meniere's disease is incorrect. The patients Rinne and Weber test results indicate conductive hearing loss confined to the right ear not sensorineural hearing loss. There is no evidence of Meniere's disease. Left ear sensorineural hearing loss due to Meniere's disease is incorrect. This patient's hearing tests indicate a conductive hearing loss in the right ear. In sensorineural hearing loss both AC and BC are equally diminished. Symptoms of Meniere's disease are not present. Left ear conductive hearing loss due to middle-ear disease is incorrect. The patient's hearing tests indicate a conductive hearing loss in the right ear not the left. Right ear sensorineural hearing loss due to acoustic neuroma is incorrect. There is no evidence of sensorineural hearing loss or acoustic neuroma in this patient.

A 28-year-old man presents with diplopia and the inability to move the right eye outwards. He was hit by a ball on the right side of his face while playing volleyball 2 hours ago. His symptoms are non-progressive. On examination, his visual acuity is normal in both eyes. Right eye is medially deviated and cannot be moved laterally; otherwise, there is no abnormality detected. Question What is the most likely nerve injured? Answer Choices 1 Abducens 2 Oculomotor 3 Trochlear 4 Facial 5 Trigeminal

Abducens Explanation The abducens, or cranial nerve VI, is the most common nerve traumatized in head injuries. It is the only supply to the lateral rectus muscle of the eye, which is responsible for external or lateral deviation of the eye. Injury to this nerve results in esotropia (internal deviation) of the eye and failure to move the eye outwards. The oculomotor, or cranial nerve III, supplies most extraocular muscles except the SO (superior oblique) and lateral rectus. Injury results in external deviation, ptosis, and pupil dilatation. The trochlear nerve supplies the SO, and an injury to the nerve alone is rare. It results in defective downward and inward gaze. The facial, or cranial nerve VII, supplies the facial muscles; an injury to the nerve results in facial paralysis (i.e., inability to close the eye, inability to frown with the forehead, and loss of mouth movement with smiling). The trigeminal nerve supplies the muscles of mastication and sensation of the face. An injury to this nerve results in defective facial sensation and mastication.

A 42-year-old man presents with a 3-day history of headache, stuffy nose, greenish nasal discharge, and low-grade fever. He also has body aches, facial pain, and a dry cough. He denies shortness of breath, abdominal pain, nausea, and vomiting. He has no past medical history; he is on OTC meds, including acetaminophen, for his condition. On exam, he has a temperature of 99.9° F and a pulse of 86/min; BP is 120/76 mm Hg, and SPO2 is 92%. Lungs are clear, and the abdomen is normal. Nasal mucosa appears boggy, and there is tenderness over the facial bones (maxillary area). Pharynx is without exudates. Question What is the most likely diagnosis? Answer Choices 1 Acute rhinitis 2 Migraine 3 Acute pharyngitis 4 Acute sinusitis 5 Influenza

Acute Sinusitis Explanation Acute sinusitis is a common condition that is characterized by nasal congestion, purulent nasal discharge, headache, facial pain, cough, teeth pain, myalgias, and low-grade fever. Other symptoms include halitosis, anosmia, and metallic taste in the mouth. Out of these 11 features, presence of 4 or more is diagnostic for bacterial sinusitis. History regarding previous medications (rhinitis medicamentosa), occupational rhinitis, polyps in the nose, or vasomotor rhinitis needs to be taken. Maxillary sinuses are tender, as in this case, along with congested nasal mucosa. Diagnosis is usually clinical. Radiological confirmation may aid in definitive diagnosis and treatment. Transillumination of maxillary sinuses with a torchlight may reveal loss of normal illumination, but doing so is generally not recommended in practice. Plain radiographs in various sinus views may show opacification or air fluid level. The imaging of choice in recent times has been a limited CT scan of sinuses, which is fairly reasonable price wise and has proven to be quite helpful. It can show opacification, mucosal thickening, abscess formation, bone destruction, tumors, and blockage of the osteomeatal complex. Treatment includes a 2-week course of amoxicillin, amoxicillin-clavulanate, cefuroxime, or quinolones, along with an oral decongestant, nasal decongestant, and anti-inflammatory medications. Acute rhinitis is usually viral and characterized by serous nasal discharge, rather than purulent, fever, fatigue, sneezing, scratchy throat, and moderate cough. Examination is not very remarkable. It is self-limiting, and it resolves after 4 - 7 days. There is no response to antibiotics. Symptomatic treatment with decongestants and antitussives is indicated. Migraine headaches are not associated with nasal congestion, fever, cough, or sore throat. Recurrent headaches are common, and patients may get an aura prior to an attack. Acute pharyngitis is associated with severe sore throat, pain on swallowing, erythematous pharynx with or without exudates, and enlarged tonsils. There may be headache and body ache with fever, especially in streptococcal infections. Throat swab can be sent for culture. Office-based rapid streptococcus tests are also available. Sinus pain and tenderness are absent, and nasal congestion is absent or mild. Influenza is a viral illness with high fever and chills, severe myalgias, headache, malaise, and fatigue. It can be debilitating and life threatening in the elderly. Dry hacking cough with sore throat may be present. Examination reveals few positive findings. Mild hyperemia of the pharynx and flushed face may be the only findings other than fever. Diagnosis is clinical. Treatment is supportive.

A 64-year-old Asian man presents with a 1-hour history of severe right eye pain that started while he was watching a movie at the theater. He notes blurred vision and seeing halos around lights when using his right eye. He denies loss of vision, trauma, discharge, and any symptoms in the left eye. Last eye exam was 6 months ago, which resulted in new glasses. Past medical history is negative, and the patient denies any allergies. On physical exam, visual acuity is OS 20/25, OD is 20/70, and OU is 20/40. Pupil on right eye is 7 mm, and left eye is 3 mm. Right pupil is non-reactive to light; left pupil is reactive to light. Right cornea is steamy in appearance, and left cornea is clear. Question What is the most likely diagnosis? Answer Choices 1 Acute angle-closure glaucoma 2 Chronic glaucoma 3 Cataract 4 Acute uveitis 5 Acute conjunctivitis

Acute closed angle glaucoma Explanation Acute angle-closure glaucoma is frequent among the older age group and in Asians. Essential for diagnosis is rapid onset of severe pain and profound vision loss/blurring with halos around lights. On physical exam, a fixed and dilated pupil as well as red eye with a steamy cornea is the hallmark. Chronic glaucoma is usually an insidious onset of bilateral loss of peripheral vision. Cataracts usually present as gradually progressive and non-painful; there are clear corneas, normal pupil size, and normal light reaction. Acute uveitis presents with blurred vision; the cornea is clear, and the affected pupil is small with poor papillary light response. Acute conjunctivitis presents with copious discharge; it does not impact vision. There is a clear cornea, normal pupil size, and normal papillary light reaction.

During a routine physical exam, a 16-year-old boy notes a painful lesion on the inside of his cheek. A round whitish-gray ulcer with an erythematous surrounding halo is noted on exam. The lesion is tender to the touch. The patient denies any medical, surgical, sexual, or social history. What is the primary diagnosis? Answer Choices 1 Mucous patch due to syphilis 2 Tori mandibulares 3 Caviar lesions 4 Aphthous ulcer 5 Leukoplakia

Aphthous ulcer Explanation This lesion is likely an aphthous ulcer, also known as a canker sore. An aphthous ulcer is a painful, round whitish-gray ulcer that has a classic red surrounding halo. It is self-limiting, and it will heal within 1 - 1.5 weeks. Second-stage syphilis presents as a mucous patch that is gray in color, raised, oval-shaped, and may be distributed in multiple areas in the oral cavity. Syphilis needs to be treated by penicillin. Caviar lesions are varicosities found on the dorsal side of the tongue only. This type of lesion does not have any significance clinically, and no intervention is needed. Tori mandibulares are benign, painless bony projections found on the inner side of the lower teeth. The mucosa covering these tori are of normal color and appearance. Leukoplakia is characterized by non-tender white patches found in the inside of the mouth. Biopsy is necessary to determine malignancy.

A 19-year-old woman with asthma presents with a decreased sense of smell and a feeling of obstruction in her nasal cavity. Her asthma has been well controlled, and she denies any wheezing or shortness of breath. On exam, her lung sounds are normal, but there is the presence of multiple pale swollen masses in her nares. Question In addition to treatment of her condition, which medication should be avoided? Answer Choices 1 Acetaminophen 2 Ibuprofen 3 Aspirin 4 Prednisone 5 Oxycodone

Aspirin Explanation Aspirin should be avoided in this patient. Given the description of pale swollen masses, it is likely that the patient has nasal polyps. Patients with a history of asthma and nasal polyps may also have a sensitivity to aspirin that causes bronchospasm. The combination of asthma, nasal polyps, and aspirin sensitivity is known as the Samter triad. Due to this potential reaction, aspirin should be avoided in this individual. Acetaminophen, ibuprofen, and oxycodone are not contraindicated in patients with asthma and nasal polyps. Prednisone is not contraindicated in patients with nasal polyps. In fact, a short course of nasal or oral steroids may actually treat nasal polyps. For those refractory to medical management, surgical removal of nasal polyps may be necessary.

A 50-year-old man with a past medical history of hypertension, asthma, hyperthyroidism, tachyarrhythmia, and aspirin allergy presents with chronic "nasal congestion," nasopharyngeal itching, sneezing, and diminished sense of smell. His physical examination reveals normal vital signs, no lymphadenopathy, and normal eye, mouth, throat, and pulmonary exams. His nasal exam was noteworthy for reduced patency, diminished sense of smell, and for the findings on internal speculum exam in the image below. Question What is the most effective pharmacological treatment of this patient's condition? Answer Choices 1 Ipratropium bromide (Atrovent) nasal spray 2 Beclomethasone (Beconase) nasal spray 3 Fexofenadine (Allegra) tablets 4 Clindamycin (Cleocin) tablets 5 Pseudoephedrine (Sudafed) tablets

Beclomethasone (Beconase) nasal spray xplanation This patient is demonstrating signs and symptoms consistent with a nasal polyp and contributory allergic rhinitis. They present as yellowish boggy masses of hypertrophic mucosa and are associated with long-standing allergic rhinitis. Intranasal corticosteroids are the mainstay of treatment of allergic rhinitis. Intranasal corticosteroid sprays have revolutionized the treatment of allergic rhinitis. Evidence-based literature reviews show that these are more effective (and frequently less expensive) than nonsedating antihistamines. Patients should be reminded that there may be a delay in onset of relief of 2 or more weeks. Corticosteroid sprays may also shrink hypertrophic nasal mucosa and nasal polyps, thereby providing an improved nasal airway and osteomeatal complex drainage. Because of this effect, intranasal corticosteroids are critical in treating allergy in patients prone to recurrent acute bacterial rhinosinusitis or chronic rhinosinusitis. Intranasal anticholinergic agents, such as ipratropium bromide 0.03% or 0.06% sprays (42-84 mcg per nostril 3 times daily), may be helpful adjuncts when rhinorrhea is a major symptom. Ipratropium nasal sprays are not as effective as intranasal corticosteroids for treating allergic rhinitis but are useful for treating vasomotor rhinitis. In general, first- and second-generation antihistamines have been shown to be effective at relieving the histamine-mediated symptoms associated with allergic rhinitis (e.g., sneezing, pruritus, rhinorrhea, ocular symptoms), but are less effective than intranasal corticosteroids at treating nasal congestion. Antihistamines offer temporary, but immediate, control of many of the most troubling symptoms of allergic rhinitis. Over-the-counter antihistamines include nonsedating loratadine (10 mg orally once daily), fexofenadine (60 mg twice daily or 120 mg once daily), and minimally sedating cetirizine (10 mg orally once daily). Clindamycin is an antibiotic and not appropriate for non-infections conditions. Oral and topical decongestants (such as Sudafed) improve the nasal congestion associated with allergic rhinitis by acting on adrenergic receptors, which causes vasoconstriction in the nasal mucosa, resulting in decreased inflammation. The abuse potential for pseudoephedrine should be weighed against its benefits. Common adverse effects that occur with the use of intranasal decongestants are sneezing and nasal dryness. Duration of use for more than 3 to 5 days is not usually recommended, because patients may develop rhinitis medicamentosa or have rebound or recurring congestion. Because oral decongestants may cause headache, elevated blood pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia, patients with underlying cardiovascular conditions, glaucoma, or hyperthyroidism should only use these medications with close monitoring.

A 61-year-old woman presents a 1-week history of intermittent episodes of feeling like she was spinning. She states the episodes are brief; however, they occur 2 - 3 times per day. It is worse when she turns to her right side while lying in bed. Even when she is not dizzy, she feels off balance. She denies tinnitus, decreased hearing, fever, syncope, nausea, vomiting, diplopia, or any other related symptoms. During the Dix-Hallpike maneuver, the patient exhibits nystagmus, with her eyes beating upward and torsionally when the right ear is turned downward. The nystagmus diminished with each time the maneuver was performed. Question Based on the above description, what is the most likely diagnosis? Answer Choices 1 Benign Paroxysmal Positional Vertigo 2 Labyrinthitis 3 Meniere's Disease 4 Vestibular Schwannoma 5 Brainstem Infarction

Benign Paroxysmal Positional Vertigo Explanation Benign Paroxysmal Positional Vertigo (BPPV) is the correct answer; episodes of BPPV are brief in nature and occur with change in position. People often feel off balance even when an episode is not occurring. BPPV does not typically cause hearing loss. The Dix-Hallpike maneuver elicits an episode of vertigo, with nystagmus being noted during the exam. The nystagmus diminishes with each maneuver due to fatiguability. Labyrinthitis is incorrect; labyrinthitis is usually caused by an infection, which the patient did not have. Labyrinthitis often includes hearing loss and or tinnitus. Episodes often last days or weeks. Meniere's disease is incorrect; vertigo with Meniere's disease usually lasts from 20 minutes to 24 hours in duration. Sensorineural hearing loss and tinnitus are also common features. Typical onset is usually between 20 - 40 years old. Vestibular schwannoma is incorrect; most people with this have hearing loss and or tinnitus. True spinning vertigo is uncommon with this disorder. People do have unsteadiness with walking. Some other symptoms can include paresthesia, hypesthesia, facial paresis, and taste disturbances. Symptoms are slow onset. Brainstem infarction is incorrect; patients present with sudden onset of symptoms, and the symptoms persist for days to weeks. Nystagmus has central characteristics versus the above patient, which showed peripheral characteristics. This would also have associated neurological signs and symptoms.

A 74-year-old man presents with a 1 ½-hour history of severe pain and blurred vision in his left eye. Upon examination, his left eye is erythematous with a steamy cornea and a nonreactive, dilated pupil. An ophthalmologic consult is ordered, and tonometry is completed, revealing an elevated intraocular pressure and a confirmed diagnosis of acute angle-closure glaucoma. Question What will be the definitive treatment for this patient? Answer Choices 1 Left laser peripheral iridotomy 2 Bilateral laser peripheral iridotomy 3 IV acetazolamide 4 Oral glycerol 5 Topical timolol 0.25%

Bilateral laser peripheral iridotomy Explanation The correct answer is bilateral laser peripheral iridotomy. This is a procedure during which a puncture-like opening is made near the base of the iris in order to decrease intraocular pressure in patients with angle-closure glaucoma. While there are various medications used to treat acute episodes, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. If this occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally. Left laser peripheral iridotomy is not the correct answer. While there are various medications used to treat acute episodes of angle-closure glaucoma, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. Narrow anterior chambers always occur bilaterally. If acute angle-closure glaucoma occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally as opposed to being done in JUST the affected eye. IV acetazolamide is not the correct answer. This medication is given in episodes of acute angle-closure glaucoma in order to decrease the intraocular pressure. It is typically given in a single 500mg IV dose followed by 250mg orally 4 times daily. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient's underlying issue is narrow anterior chambers. Oral glycerol is not the correct answer. This medication is an osmotic diuretic that can be given 1-2 g/kg in order to decrease a patient's intraocular pressure during an acute episode of angle-closure glaucoma. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient's underlying issue is narrow anterior chambers. Topical timolol 0.25% is not the correct answer. This medication is a topical β-adrenergic blocking agent used twice daily chronically in patients who have chronic glaucoma. The disorder does not require the acute lowering of intraocular pressure such as angle-closure glaucoma. Topical timolol would not be effective in lowering intraocular pressure in patients with angle-closure glaucoma.

A 3-year-old boy presents after waking up with his eyelids glued together. His mother states that he has been rubbing his eyes constantly. The medical history is unremarkable, and the patient had not been sick before. Upon examination, redness of the lid margin, edema, conjunctival irritation, and loss of lashes can be seen. There are also some scales on the lid margin that can be removed easily. What is the most likely diagnosis? Answer Choices 1 Hordeolum 2 Bacterial conjunctivitis 3 Trachoma 4 Blepharitis 5 Viral conjunctivitis

Blepharitis The symptoms described above are typical for blepharitis, an inflammation of the lid margins. There are 2 types of blepharitis: Ulcerative blepharitis: it is caused by bacterial infection (mostly staphylococci) of follicles and meibomian glands. Adherent crusts develop that result in bleeding if removed. Pustules form in the lash follicles and turn into small ulcers. Repeated episodes can lead to permanent loss of lashes, scarring of the lids, and sometimes even corneal ulceration. Treatment consists of application of antibiotic ointment for 7 to 10 days. Seborrheic blepharitis: the cause is not known. Sometimes it is associated with seborrhea of scalp and face. The scales are easily removable. Treatment is usually to just keep the eyelids clean. If it does not clear, antibiotic ointment is needed. Hordeolum is a localized infection of the Zeis, Moll, or meibomian glands; it is usually caused by staphylococci. It can be associated with blepharitis or follow it. The internal hordeolum (affecting the meibomian glands) involve pain, redness, and localized edema with an elevated yellow area near the affected gland that turns into an abscess, which rarely ruptures spontaneously. The external hordeolum (affecting the glands of Zeis or Moll) starts with pain, redness, and tenderness, which turns into an induration with a yellowish spot in the center. The abscess soon ruptures and emits pus. Acute conjunctivitis is an inflammation of the conjunctiva that can be bacterial, viral, or allergic. The most common pathogens for bacterial infection in adults are Staphylococci, Streptococcus pneumoniae, and Haemophilus influenzae. In children, bacterial conjunctivitis is more common than viral conjunctivitis and is caused by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Symptoms are itching, irritation, foreign body sensation, tearing, and in bacterial infection, mucopurulent discharge. Small bumps with fibrovascular cores on the palpebral conjunctiva that look like a velvety surface are a typical papillary reaction. Bacterial conjunctivitis is usually self-limiting but can also cause corneal or systemic complications (like meningitis in primary meningococcal meningitis) and should therefore be treated with topical antibiotics (e.g., polymyxin-bacitracin, ciprofloxacin, or ofloxacin). Viral conjunctivitis is more common than bacterial conjunctivitis in adults; it is caused by herpes virus or during the course of systemic or cutaneous infections, such as rubella, measles, cytomegaly, syphilis, or systemic adenovirus infections. Occasionally permanent vision loss can occur, as well as cataract, microphthalmos, retinal involvement, interstitial keratitis, and optic neuritis. Trachoma is a chronic conjunctivitis caused by chlamydia trachomatis. It is transmitted via contact (hands, towels, etc.), and it is a major cause of blindness in developing countries due to poor hygiene and economic conditions. In the United States, only mild forms are typically seen, usually in immigrants from endemic areas. The disease presents as conjunctivitis with small lymphoid follicles. Cultures are often false negative; therefore, PCR to prove the presence of chlamydial DNA in ocular secretions should be performed. Treatment consists of topical or systemic tetracycline or erythromycin.

A 66-year-old man presents with sudden onset of brief episodes of blindness in his right eye, with complete recovery of vision within 24 hours. The event is described as a shade coming down across his field of vision, and it is not painful. Question What is the most common underlying condition leading to the event described above? Answer Choices 1 Migraine headaches 2 Lower extremity deep venous thrombosis 3 Carotid stenosis 4 Sickle cell disease 5 Acute angle-closure glaucoma

Carotid stenosis Explanation The diagnosis for this case is amaurosis fugax. The most common cause of amaurosis fugax is ipsilateral carotid stenosis, leading to carotid emboli that lodge in the retinal arteries, causing temporary blindness until the emboli dissolves. Screening is performed through carotid Doppler ultrasonography, CT, or MR angiography. Treatment includes low-dose aspirin or other anti-platelet therapy, along with treatment of underlying cause. Migraine headaches, sickle cell disease, and acute angle-closure glaucoma are all less common causes of amaurosis fugax. Lower extremity deep venous thrombosis is not a likely source for emboli causing amaurosis fugax.

An 84-year-old man presents to the emergency room with 2.5-hour history of painless, progressive vision loss in his right eye, which began while he was reading. He denies any other symptoms. Past medical history is positive for hypertension and a cardiac dysrhythmia. Physical exam findings include a BP of 180/110; other vital signs are normal, and the left eye non-reactive to light. Marcus Gunn pupil (afferent pupillary defect) is seen; funduscopic exam reveals a pale retina with a red spot. The rest of the physical exam is normal. What is the most likely cause of vision loss in this patient? Answer Choices 1 Retinal vein occlusion 2 Retinal detachment 3 Angle closure glaucoma 4 Central retinal artery occlusion 5 Branch retinal artery occlusion

Central Retinal artery occlusion Explanation Central retinal artery occlusion (CRAO) interferes with the major supply of blood to the retina, causing vision loss. In 25% of individuals, the macula is supplied by the cilioretinal arteries, sparing some central vision in the event of CRAO. The occlusion is principally caused by thrombus, thromboembolia, cholesterol plaques, calcium, or vasospasm. The patient notes a sudden, painless, monocular vision loss; the physical examination reveals a problem in the visual afferent way, and the funduscopic examination shows the red spot, which is the pigment of the choroid showing through the macula. Treatment consists of decreasing intraocular pressure in order to increase the pressure gradient in the artery and force the embolus to dislodge, restoring vision. Application of digital pressure, carbonic anhydrase inhibitors, beta-blockers, and paracentesis of the anterior chamber are some of the methods used for this purpose. Retinal vein occlusion should be considered in the differential; it is characterized by preservation of some vision, and it rarely shows a red spot in the retina at the funduscopic examination. Retinal detachments often cause prodromal symptoms, such as flashing lights, floating 'spider webs', and the sensation of 'having a curtain drawn up or down' over the visual field. The funduscopic exam reveals an undulating, pale, detached retina. Acute angle-closure glaucoma is characterized by severe ocular pain and blurred vision, rather than loss of vision.

A 24-year-old man presents with a painless, localized swelling of his left lower eyelid; it has developed over a period of weeks. He is seeking medical attention because it is now producing a foreign body sensation in his left eye; it is also hindering his path of vision. On physical examination, his visual acuity is normal; there is no evidence of injection or discharge. You palpate, and you observe a nontender, localized nodule on the lower eyelid. Question What is the most likely diagnosis? Answer Choices 1 Keratitis 2 Chalazion 3 Malignant melanoma 4 Blepharitis 5 Ectropion

Chalazion Explanation Chalazion is the correct response. Chalazion is a granulomatous inflammation of the meibomian gland, and it has the typical presentation of being a hard, nontender swelling of either the upper or lower lid. It is sometimes accompanied by redness and swelling of the adjacent conjunctiva. Blepharitis is the incorrect choice; typically, blepharitis is a bilateral condition of general inflammation of the eyelid skin, eyelashes, and associated glands. Characteristics of blepharitis include red-rimmed eyes as well as scales on the eyelashes. Tears may even have a greasy distinction to them. Ectropion is also an incorrect choice. Ectropion is the outward turning of the lower lid. This is not what was described in this case. Keratitis is also incorrect; it produces a painful eye, a hazy-appearing cornea as well as evidence of an ulcer or even an abscess in this area; hypopyon is also possible in patients who have keratitis. Malignant melanoma can have a presentation in the ocular area that is somewhat like the one described in this case; however, it is not a common presentation.

A 38-year-old man presents with a firm, painless bump on his left eyelid. On examination, you note a 5 mm mass within the tarsus of the left eye. The skin is freely movable over the mass. The remainder of the eye exam is unremarkable. What is most likely diagnosis? Answer Choices 1 Pterygium 2 Ectropion 3 Internal hordeolum 4 Chalazion 5 External hordeolum

Chalazion Explanation The clinical picture is an example of a chalazion. A chalazion is a painless chronic mass in the eyelid. Chalazions differ from hordeolums in that they are usually painless apart from the tenderness caused when they swell up, and are generally larger in size than styes. Ectropion is when the eyelid sags outwardly and the lid does not close well. Hordeolum are acute, red, and painful. Pterygium involves the sclera.

A 10-day-old male infant presents with bilateral conjunctivitis with moderate white discharge. He is acting normally, has no fever, and is feeding well. He was born full term via vaginal delivery without any complications. His mother had prenatal care starting at 12 weeks. He has been gaining weight well. On exam, he is alert and active. Question What is the most likely cause of this infant's conjunctivitis? Answer Choices 1 Chlamydia trachomatis 2 Herpes simplex 3 Neisseria gonorrhoeae 4 Silver nitrate 5 Coxsackievirus

Chlamydia Explanation Ophthalmia neonatorum is a form of conjunctivitis occurring in infants younger than 4 weeks. The usual incubation period for C. trachomatis is 5 - 14 days and 2 - 5 days for N. gonorrhoeae. Conjunctivitis due to silver nitrate drops usually occurs within 6 - 12 hours after birth. Staphylococcus aureus can also cause ophthalmia neonatorum. Since this infant's mother had appropriate prenatal care, she most likely would have had a c-section if she had active herpes lesions. Coxsackievirus is not a common cause of conjunctivitis in neonates.

A 73-year-old African-American man presents for a routine follow-up since being diagnosed with glaucoma. His ophthalmologist has started him on a topical carbonic anhydrase inhibitor (dorzolamide) in order to lower eye pressure by decreasing aqueous humor production. What is the site of action of this drug? Answer Choices 1 Trabecular meshwork 2 Canal of Schlemm 3 Corneal endothelium 4 Ciliary body epithelium 5 Retinal pigment epithelium

Ciliary body epithelium Explanation The correct response is the ciliary body epithelium. Aqueous humor is produced in the epithelium of the ciliary body; it travels through the pupil into the anterior chamber and drains through the trabecular meshwork into the canal of Schlemm. A topical drug which decreases aqueous humor production would be expected to act at the ciliary body epithelium. The trabecular meshwork and canal of Schlemm are part of the outflow pathway of aqueous humor; they are not involved in aqueous humor production. The corneal endothelium and retinal pigment epithelium are not involved in aqueous humor production.

A 66-year-old woman presents with an acute closed-angle glaucoma attack. She is experiencing excruciating pain in her left eye, vision loss, vision field defect, nausea, and vomiting. She is given 4% pilocarpine. What is the primary purpose of pilocarpine administration? Answer Choices 1 Antiemetic effect 2 Control of increased intraocular pressure 3 Restoration of peripheral vision 4 Improvement of vision 5 Pain relief

Control of increased intraocular pressure Explanation In the long run, therapy with pilocarpine has all the stated effects; however, the primary purpose is the control of increased intraocular pressure. Pilocarpine is a cholinomimetic alkaloid extracted from Pilocarpus pennatifollus plants and has muscarinic effect. It is applied to the eye, where it contracts the pupil and lowers the intraocular pressure. Another usage of the drug is in the sweat chlorine test to diagnose cystic fibrosis; it administered via iontophoresis to produce sweating. Antiemetic drugs are a derivative from the following drug groups: cholinolytics (scopolamine), antihistamines (promethazine), dopamine-antagonists (metoclopramide, domperidone), and neuroleptics (chlorpromazine). Analgesics can be inhibitors of the prostaglandin synthesis (acetylsalicylic acid and derivatives), local anesthetics (lidocaine), or opioids (morphine). Some neuroleptics, antidepressants, ethanol, and ketamine influence the pain impulses as well.

A 32-year-old woman presents with a 3-day history of irritation, burning, itching, and redness of both eyelids. She denies fever, visual changes, and photophobia. On physical examination, you note the presence of scales clinging to the eyelids bilaterally. Question What is the proper management in this case? Answer Choices 1 Daily cleaning with a damp cotton applicator and baby shampoo 2 Short-term oral antibiotic therapy for 7 days 3 Short-term oral corticosteroid therapy for 14 days 4 Topical corticosteroid eye drops for 10 days 5 Prompt ophthalmologist referral

Daily cleaning with a damp cotton applicator and baby shampoo Explanation The scenario presented above depicts a patient with anterior blepharitis, which is a common disorder seen in primary care; it typically consists of a recurrent bilateral inflammation of the lid margins that involves the eyelid skin, eyelashes, and associated glands. Commonly, the underlying cause is seborrhea, which usually originates in the scalp, eyebrows, or ears. Sometimes, anterior blepharitis can be ulcerative, and the origin in the presented case is staphylococci. Anterior blepharitis can typically be resolved and controlled by cleaning the affected areas daily using a damp cotton applicator, warm water, and a baby shampoo mixture. The object of the daily cleaning is to remove the visible scales as efficiently as possible. None of the other listed options are an appropriate treatment plan for anterior blepharitis. Patients can also be diagnosed with what is known as posterior blepharitis, which is an inflammation of the meibomian glands of the eyes. It is usually staphylococcal in origin, and it typically presents with significantly worse signs and symptoms, such as hyperemic lids, the presence of telangiectasias, inflammation of the gland or their orifices, or even abnormal secretions; tears may be described as being frothy or greasy. More significant cases of posterior blepharitis can lead to conjunctivitis, hordeola, chalazions, eyelash trichiasis, or even corneal vascularization and thinning. Treatments for posterior blepharitis may consist of long-term oral antibiotic therapy, short-term topical steroids, or short-term topical antibiotics eye drops; if significant complications are evident, an ophthalmologist referral is indicated.

A 27-year-old woman presents with a 3-day history of left eye pain. The patient notes sensitivity to light, and she comments that her eye throbs in pain at night. On physical examination, you note a redness and loss of visual acuity. Question What would be an appropriate treatment for this patient? Answer Choices 1 Cool compresses and artificial tears 2 Cortisporin ointment 3 Dexamethasone and homatropine ophthalmic drops 4 Oral acyclovir 5 IV acetazolamide

Dexamethasone and homatropine ophthalmic drops Explanation The correct response is dexamethasone and homatropine ophthalmic drops. The clinical picture is suggestive of uveitis. Patients with uveitis usually note redness, pain, photophobia, and visual loss. Treatment is with topical steroids and a dilating agent to relieve the discomfort. There are multiple causes of uveitis, but it is primarily immunogenic. Cool compresses and artificial tears are not effective treatment for uveitis. Cortisporin is effective against bacterial conjunctivitis. Patients typically present with a copious discharge in the affected eye with mild discomfort. There is no loss of visual acuity. Oral acyclovir is used in the treatment of herpes simplex keratitis. Dendritic ulcer is seen on staining with fluorescein, which is not seen in this patient. IV acetazolamide is used in the treatment of acute angle-closure glaucoma. Patients typically present with rapid onset of severe eye pain, profound visual loss, and halos around lights. The symptoms of severe eye pain, profound vision loss, and halos around lights are not seen in this patient.

What description of "red eye" is caused by acute glaucoma? Answer Choices 1 Homogeneous bright red patch between conjunctiva and sclera, normal pupil size, and unaffected vision 2 Diffuse flush and dilatation of central vessels around the iris, pupils anisocoric, decreased vision 3 Inflamed eyelids, normal vessels, normal pupil size, and unaffected vision 4 Dilated conjunctival vessels, normal pupil size, and unaffected vision 5 Dilated central and conjunctival vessels, dilated pupil, and decreased vision

Dilated central and conjunctival vessels, dilated pupil, and decreased vision Explanation Acute glaucoma is the sudden increase in intraocular pressure secondary to blocked drainage from the anterior chamber. It manifests as dilatation of both the central and conjunctival vessels. Pupil size is often dilated, and vision is decreased. It is considered an ocular emergency. Conjunctival injection is the dilatation of the conjunctival vessels. Pupil size and vision are unaffected. It is a result of superficial processes, such as infection, allergies, irritation, and vasodilators. Ciliary injection is the dilatation of the branches of the anterior ciliary artery, and it manifests as a diffuse flush and dilatation of the central vessels around the iris. The pupil may be normal, but it is usually small and anisocoric. Vision is decreased. It is a result of disorders of the cornea or inner eye, and requires immediate attention. A subconjunctival hemorrhage is a patch of blood that appears outside the vessels between he conjunctiva and sclera. Pupil size and vision are unaffected. It may be the result of trauma, bleeding disorders, or sudden increases in venous pressure, such as from coughing. It is usually not of clinical significance. Blepharitis is inflammation of the eyelid margins. Vessels, pupil size, and vision are all normal. Seborrhea and staphylococcal infections are common causes.

A 12-year-old girl does not want to eat and appears to have a fever. She has an inflamed throat, and you decide to treat her with 7 days of penicillin, but her mother tells you that her daughter is allergic to penicillin. What antibiotic should you prescribe to this child? Answer Choices 1 Cefaclor 2 Ampicillin 3 Amoxicillin 4 Cephalexin 5 Doxycycline

Doxycycline Explanation Tetracyclic antibiotics, such as doxycycline or tetracycline, would be the antibiotics of choice for a patient allergic to penicillin. Tetracyclics reversibly bind to the ribosome and inhibit protein synthesis. Doxycycline is contraindicated in children less than 8 years of age, pregnant women, and breastfeeding women. The major classes of antibiotics used today include penicillins, cephalosporins, aminoglycosides, macrolides, and tetracyclines. A patient who is allergic to 1 type of penicillin (ampicillin, amoxicillin) is allergic to all types. Often, these patients are also allergic to the cephalosporins (cephalexin, cefaclor).

Which of the following drugs used in glaucoma therapy has a prolonged duration of action and can be administered relatively infrequently? Answer Choices 1 Timolol 2 Tropicamide 3 Echothiophate 4 Albuterol 5 Epinephrine

Ecothiophate Cholinomimetics are front-line drugs in the treatment of open-angle glaucoma. The cholinomimetics (or cholinergic agonists) include direct-acting choline esters with M3-muscarinic activity such as pilocarpine and carbachol, and indirect-acting cholinesterase inhibitors such as physostigmine and echothiophate (an ultra-long-acting organophosphate). Cholinesterase inhibitors are nonspecific cholinergic agonists that bind available cholinesterase enzymes such as acetylcholinesterase and plasma cholinesterase. Compared to acetylcholine, these drugs are more slowly hydrolyzed from the enzyme. More importantly, cholinesterase is prevented from inactivating acetylcholine while cholinesterase inhibitor molecules are attached. Physostigmine exhibits reversible cholinesterase inhibition whereas anticholinesterases such as the organophosphates, echothiophate and isoflurophate, produce extended action in glaucoma therapy. The prolonged duration of effect of these cholinergic drugs aids in patient compliance in the treatment of glaucoma. The extended effect is due to the irreversible nature of the cholinesterase enzyme inhibition and the time required to synthesize new enzyme to replace that which has been hydrolyzed. (It should be noted that the risk of cataract development is higher with the organophosphate derivatives than with other drugs used in glaucoma therapy.) The cholinomimetics produce miosis and contraction of the ciliary muscle which increases tension on the trabecular meshwork, opens pores, and improves the drainage of aqueous humor into the canal of Schlemm. Alpha agonists such as epinephrine cause an increased outflow of aqueous humor through the trabecular meshwork at the anterior chamber angle.

A 7-year-old boy presents to his pediatricians office with a 3-week history of clear nasal discharge, itchy eyes, and excessive sneezing. The family recently took in a stray cat, which sleeps with the boy. On examination of the nasal passage, you note swelling of the turbinates with clear drainage from the nares bilateral. On examination of the oral cavity, you note slight pharyngeal erythema, post-nasal drip, and no tonsillar edema. Question Based on your suspected diagnosis, if you were to microscopically exam the nasal secretions, you would expect to see an excess amount of which of the following? Answer Choices 1 Eosinophils 2 Neutrophils 3 Lymphocytes 4 Monocytes 5 Histiocytes

Eosinophils Explanation This patient is presenting with allergic rhinitis. This condition typically exhibits nasal secretions that are rich in eosinophils, which are the specific type of leukocytes that are involved in allergic reactions. Neutrophila would be seen in excess in the case of infection. Lymphocytes would be seen in excess in the case of an immune reaction. Monocytes and histiocytes would be seen in excess if bacteria were present, requiring their phagocytic activity.

A 9-year-old girl presents with a sore throat. The mother states that she began to run a fever a few days ago, and she complained that her throat hurt. On physical exam, you note a red throat, a red, beefy tongue, tonsillar exudates, and swollen anterior cervical lymph nodes. You order a rapid strep test which comes back positive. It is noted in the patient's records that she has had a severe anaphylactic reaction to penicillin. What antibiotic would treat this infection while minimizing the risk of invoking an allergic reaction? Answer Choices 1 Augmentin 2 Cephalexin (Keflex) 3 Ciprofloxacin 4 Mupirocin (Bactroban) 5 Erythromycin

Erythromycin Explanation The clinical picture is suggestive of a streptococcal bacterial infection. Penicillins are the 1st-line antibiotics in the treatment of strep pharyngitis. Since the patient is allergic to penicillins, erythromycin is an effective alternative and has no allergic cross-reactivity with the penicillins. Augmentin contains amoxicillin, a member of the penicillin family with allergic cross-reactivity; it is contraindicated for patients allergic to penicillin. Cephalexin, a cephalosporin, can be used to treat strep throat. However, approximately 7% of patients who are allergic to penicillin are also allergic to cephalosporins. Therefore, compared to erythromycin, use of this agent poses a slightly higher risk of causing an allergic reaction in this patient. Ciprofloxacin is effective against Gram-negative organisms. Since streptococcal species are Gram-positive, it would not be an appropriate treatment in this scenario. Mupirocin is a topical antibiotic and is not indicated in the treatment of strep throat.

A 35-year-old woman presents with slowly progressive right-sided hearing loss, tinnitus, and continuous vertigo. Patient's Weber test reveals lateralization to the left ear. Question What is the most likely cause of this patient's symptoms? Answer Choices 1 Vestibular neuronitis 2 Meniere's disease 3 Acoustic neuroma 4 Labyrinthitis 5 Benign paroxysmal positional vertigo

Explanation Acoustic neuroma is a benign tumor of the VIII cranial nerve. While these tumors are benign, their growth can lead to sensorineural hearing loss, vertigo, and tinnitus. Because the tumor is slow growing, symptoms typically have a gradual onset. Diagnosis is made by MRI. In vestibular neuronitis, patients present with paroxysmal episodes of vertigo without hearing loss. The patient may also have nystagmus. Meniere's disease also presents with vertigo, sensorineural hearing loss, and tinnitus; however, these symptoms are typically episodic in nature, whereas the symptoms of acoustic neuroma are continuous. Labyrinthitis presents with an acute onset of continuous vertigo, hearing loss, and tinnitus. Symptoms gradually improve over several weeks, though hearing may remain impaired following recovery. Acoustic neuroma has a gradual onset, and symptoms will not improve until the tumor is treated. Patients with benign paroxysmal positional vertigo have recurrent episodes of brief vertigo without hearing loss; the vertigo is related to changes in head position. There is no associated hearing loss.

A 28-year-old woman presents with an itchy throat, prolonged sneezing episodes, watery red eyes, and inflamed nasal membranes. Her temperature is normal and a throat culture is negative. She is most likely suffering from allergic rhinitis. Her physician will most likely prescribe diphenhydramine. To what class of compounds does the drug of choice belong? Answer Choices 1 Antihistamine (H1) 2 Cathartic 3 Opioid analgesic 4 Prostaglandin 5 Antihypertensive

Explanation Antihistamines are drugs that have major applications in treating the symptoms of allergic rhinitis and urticaria. They may also be used in treating motion sickness and nausea. Some antihistamines, because of their strong sedative properties, are used in the treatment of insomnia; therefore, they also find their way into many over-the-counter sleep aids. The most common adverse effect observed with H1 receptor blockers is sedation. Other effects seen are tremors, blurred vision, lassitude, dizziness, fatigue, drying of the nasal passages, and dry mouth. Antihistamines can interact with other drugs, leading to serious consequences such as the potentiation of the effects of CNS depressants (alcohol, etc.). Monoamine oxidase (MAO) inhibitors can potentiate the anticholinergic effects of antihistamines. In spite of this, H1 receptor blockers are relatively safe. Chronic toxicity is rare; however, acute poisoning is common, especially among children, and leads to dangerous effects such as hallucinations, ataxia, convulsions, and (if untreated) coma and cardiorespiratory collapse.

A 4-year-old boy accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The child is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Pulse is 94/min; BP is 110/70 mm Hg, and temperature is 101 F. Question What is the next best step to confirm the diagnosis? Answer Choices 1 Direct fiberoptic laryngoscopy in the operating room 2 Indirect laryngoscopy 3 Examination with tongue depressor 4 Lateral neck radiograph 5 Complete blood count (CBC) and blood culture

Explanation Direct fiberoptic laryngoscopy is the correct answer. The patient has symptoms of acute epiglottitis, a diagnosis that can be made on clinical grounds. The next step is direct fiberoptic laryngoscopy performed in a controlled environment - usually the operation theater - in order to visualize and culture the edematous larynx, as well as to secure the airway through placement of an endotracheal tube1. Direct visualization in the examination room with tongue depressor or indirect laryngoscopy is not recommended because of the high risk of immediate laryngospasm and complete airway obstruction1. Lateral neck radiograph usually reveals an enlarged edematous epiglottis (thumbprint sign). Laboratory investigations like complete blood count (CBC) typically reveal elevated leukocytes with neutrophil predominance, and blood cultures are usually positive1. These investigations assist the diagnosis but may delay the critical step of placing the endotracheal tube1.

A 16-year-old girl presents with throat pain. Her sore throat was first noticed when she woke up this morning. The patient has a temperature 102 degrees F. On examination, the pharyngeal mucosa is erythematous, with yellow exudate. She has tender anterior cervical lymphadenopathy. Question What organism is the most likely cause of her condition? Answer Choices 1 Group A streptococcus 2 Corynebacterium diphtheriae 3 Adenovirus 4 Rhinovirus 5 Candida albicans

Explanation Group A streptococcus is the correct response. Group A streptococcus is the most common cause of bacterial pharyngitis. The patient has presence of fever, exudate and tender anterior cervical adenopathy, which are all highly suggestive of bacterial pharyngitis Corynebacterium diphtheriae is an incorrect response. Corynebacterium diphtheriae is an uncommon cause of sore throat. It would present with a gray pseudomembrane on examination of the throat. Adenovirus and rhinovirus are incorrect responses. Viral pharyngitis does not typically present with exudate or tender anterior cervical adenopathy. Candida albicans is an incorrect response. Candida albicans of the throat typically presents with thin exudate, but it is not common unless a patient is immunocompromised or has had recent antibiotic treatment.

A 44-year-old man presents for follow-up of poorly controlled type I diabetes mellitus, which was diagnosed 32 years ago. What change on his funduscopic examination would indicate a need for urgent referral to an ophthalmologist? Answer Choices 1 Blot hemorrhages 2 Cotton wool spots 3 Microaneurysms 4 Neovascularization 5 Flame-shaped hemorrhages

Explanation Neovascularization is the hallmark of proliferative diabetic retinopathy. New vessels can appear at the optic nerve and the macula as a result of retinal hypoxia. They are susceptible to rupture, resulting in vitreous hemorrhage, retinal detachment, and blindness. Proliferative retinopathy requires urgent referral to an ophthalmologist and is usually treated with pan retinal laser photocoagulation. The risk of developing diabetic retinopathy is related to the extent of glycemic control and the duration of diabetes. It is classified as nonproliferative and proliferative. Blot hemorrhages, cotton wool spots, and microaneurysms are indicative of nonproliferative diabetic retinopathy, which is usually seen 10 to 20 years after the onset of diabetes. Nonproliferative retinopathy does not always progress to proliferative retinopathy, but if it becomes extensive, it can result in retinal ischemia, which increases the likelihood of proliferative disease. Flame-shaped hemorrhages are indicative of hypertensive retinopathy.

A 69-year-old man presents to his physician with a 3-month history of white oral lesion. Exam findings are suspicious for oropharyngeal cancer. Question What is the most common type of oropharyngeal cancer? Answer Choices 1 Adenocarcinoma 2 Basal cell carcinoma 3 Squamous cell carcinoma 4 Papillary carcinoma 5 Medullary carcinoma

Explanation Squamous cell carcinoma is the most common form of oropharyngeal cancer, accounting for 90% of cases. Adenocarcinoma, basal cell carcinoma, papillary carcinoma, and medullary carcinoma are all incorrect.

A 36-year-old woman presents with a small and irregular right pupil. On exam, you note that the pupil does not respond to direct or consensual light stimuli; however, it becomes smaller during an accommodation testing. What is the most likely diagnosis? Answer Choices 1 Transient ischemic attack (TIA) 2 Retinal artery occlusion 3 Retinal vein occlusion 4 Tertiary syphilis 5 Herpes simplex keratitis

Explanation The clinical picture is suggestive of tertiary syphilis; more specifically, it is likely tabes dorsalis. The pupil describe here is the Argyll Robertson pupil. The pupil reacts poorly to light, but it reacts well to accommodation. Signs and symptoms seen in a TIA include temporary weakness and heaviness of the contralateral arm, leg, or face. There may be monocular vision loss in the eye contralateral to the affected limbs, which are not described in this patient. Retinal vein or artery occlusion will produce sudden vision loss, which is not described in this patient. Herpes simplex can involve the eyes, but the patient will develop keratitis (cornea inflammation) with impaired vision, and dendritic ulcers can be seen with fluorescein stain.

A 22-year-old woman presents with a 1-day history of foreign body sensation in her right eye. She woke up with pain in the right eye, and she immediately had trouble opening her eye. She wears soft contact lenses and does not remember how long the last pair was in for. She removed her contact lenses the night before the pain started. There was no trauma. Visual acuity was 20/40 O.U. without corrective lenses, and extraocular movements were within normal limits. With fluorescein stain, a defect is noted; it is round and found at the center of the cornea. No foreign bodies are noted. Question What intervention is indicated? Answer Choices 1 Pressure patch 2 Trifluridine drops 3 Ketorolac 0.5% solution 4 Ciprofloxacin 0.3% solution 5 Sulfacetamide 10% solution

Explanation The correct answer is ciprofloxacin 0.3%; the patient has a corneal abrasion due to contact lenses. Ciprofloxacin covers pseudomonas, and pseudomonas should always be covered when someone gets a corneal abrasion from contact lenses. A pressure patch is never used in someone who gets a corneal abrasion from contact lenses because of the risk of developing infectious keratitis. Trifluridine drops are used as an antiviral for Herpes Simplex keratitis; they are not used for corneal abrasions. Ketorolac solution is used to help pain in a corneal abrasion, but it is not the mainstay of treatment. Sulfacetamide solution is not used for corneal abrasions caused by contact lenses because it does not cover pseudomonas adequately.

A 42-year-old man presents with a 24-hour history of severe vertigo, tinnitus, hearing loss, nausea, and vomiting intermittently; episodes last at least 30 minutes at a time. After a thorough history and examination, the patient is diagnosed with Ménière's disease. Question What medication is he most likely to be given to treat the acute symptoms? Answer Choices 1 Hydrochlorothiazide/triamterene (Dyazide/Maxzide) 2 Meclizine (Antivert) 3 Diazepam (Valium) 4 Acetazolamide (Diamox) 5 Dimenhydrinate (Dramamine)

Explanation The correct answer is diazepam (Valium), as this is a benzodiazepine medication that can be given 5-10mg IV in order to treat an acute attack during a severe episode of Ménière's disease. Other medications that are fast-acting and can effectively treat an acute attack are atropine and transdermal scopolamine. A few second-line choices for acute treatment are droperidol, promethazine (Phenergan), and diphenhydramine (Benadryl). With the exception of the transdermal scopolamine, all of the listed medications are given by IV or IV push in a controlled setting. Hydrochlorothiazide/triamterene (Dyazide/Maxzide) is not the correct answer, as this combination medication is not used for an acute attack but is the first line treatment for maintenance in patients who have had recurrent attacks. The goal of treating patients with Ménière's disease is to prevent the number of disabling spells of vertigo that they experience. Along with a low sodium diet, diuretics are the mainstay of long-term treatment. Patients should be instructed about a low sodium diet and are to restrict their sodium intake to 1500 mg per day. Other lifestyle changes, such as smoking cessation, caffeine restriction, and alcohol restriction, should also be followed when applicable. If the sodium restriction and diuretic are not effective, then patients should be counseled on an even more restrictive diet of 1000mg sodium per day and have their diuretic dose increased (if not contraindicated) before considering another treatment option. Meclizine (Antivert) is not the correct answer, as this is an antihistamine medication that can be used for maintenance and long-term prevention of recurrent attacks. Acetazolamide (Diamox) is not the correct answer, as this is another diuretic medication choice that can be used for maintenance and long-term prevention of recurrent attacks. Dimenhydrinate (Dramamine) is not the correct answer, as this is another antihistamine medication that can be used for maintenance and long-term prevention of recurrent attacks.

A 30-year-old man presents with recurrent vertigo. He gives a history of attacks when rising from bed in the morning and rolling over in bed. He does not have headache, earache, hearing loss, nausea, or vomiting. On examination, external auditory canals are normal. Hearing tests are within normal limits. Pulse is 72/min, and blood pressure is 120/78 mm Hg. Central nervous system examination, including higher functions and mental status, is within normal limits. Question What is most likely to be useful in treating the patient's condition? Answer Choices 1 Diuretics 2 Methylprednisolone 3 Selective serotonin reuptake inhibitors (SSRIs) 4 Repositioning maneuvers 5 Scopolamine patch

Explanation The correct answer is repositioning maneuvers. The patient gives a classic history of benign paroxysmal positional vertigo, which most often responds to treatment with repositioning maneuvers that utilize gravity to remove the otoconia (calcium carbonate crystals) from the semicircular canals that are thought to be responsible for causing the condition1. Diuretics are used in cases of vertigo in Meniere's disease caused by increased endolymphatic pressure1. This patient does not have symptoms of Meniere's disease, which usually include hearing loss, nausea, and vomiting. Methylprednisolone is used to treat vertigo caused by vestibular neuritis which is associated with nausea, vomiting, and upper respiratory infections1. Selective serotonin reuptake inhibitors (SSRIs) are used to treat vertigo in psychosomatic disorders like major depression, anxiety, and panic disorders1. This patient does not have symptoms associated with any of these disorders. Scopolamine is an anticholinergic medication used to treat vertigo caused by motion sickness1. It causes symptomatic relief, but is not a treatment for vertigo.

A 20-year-old man with no significant past medical history presents with a severe sore throat for the last hour. He reports associated fever, difficulty swallowing, difficulty in opening his mouth, excessive salivation, and a self-described "raspy, harsh voice." He denies chills, sick contacts, otalgia, myalgias, malaise, rashes, wheezing, shortness of breath, and cough. He also denies smoking, drinking, drug use, or recent sexual activity. His physical exam is notable for a toxic-appearing young male patient with tonsillar hyperemia, swelling of the anterior pillar and soft palate, tender cervical lymphadenopathy, and a small, left-tonsillar abscess. The primary care provider performs an oropharyngeal culture and refers the patient immediately to the emergency room for further treatment. Question What is the most likely agent isolated from the oropharyngeal culture performed by the provider? Answer Choices 1 Corynebacterium diphtheriae 2 Staphylococcus aureus 3 Haemophilus influenzae 4 Streptococcus pyogenes 5 Fusobacterium necrophorium

Explanation The correct response is Steptococcus pyogenes. This patient's presentation is significant of a peritonsillar abscess. Group A hemolytic streptococci (often as part of a mixed flora containing anaerobes) are most commonly isolated.

A 30-year-old African-American man is admitted to the hospital to undergo stapedectomy for the treatment of otosclerosis. He had been experiencing increased hearing loss in the right ear over the past few years. His mother had suffered from the same condition when she was in her 40's and had been successfully operated upon. You do an assessment using the Weber and Rinne tests. Question What do you expect to find? Answer Choices 1 Bone conduction of the affected side is greater than air conduction 2 Bone conduction of the affected side is equal to air conduction 3 Air conduction of the affected side is greater than bone conduction 4 Sound lateralizes to the unaffected ear 5 Bone conduction of the unaffected ear is greater than air conduction

Explanation The correct response is bone conduction of the affected side is greater than air conduction. Otosclerosis is a pathological condition of the middle-ear in which there is a formation of spongy bone near the footplate of the stapes. As it advances, it causes progressive fixation of the stapes footplate. Therefore, the sound transmission by air conduction from the stapes via the oval window to the perilymph of the inner ear is reduced. Weber tuning fork test is performed by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone is heard. The fork stimulates both inner ears equally. A patient with a unilateral conductive hearing loss hears the tone louder in the affected ear and a patient with a sensorineural loss hears the tone louder in the unaffected ear. In otosclerosis the sound lateralizes to the affected ear. The Rinne tuning fork test compares air to bone conduction. The stem of the vibrating tuning fork is placed on the mastoid process first and then the tines of the tuning fork are held in front of the ear and the patient is asked which stimulus is perceived better. In a healthy individual, the tone is heard longer and louder by air conduction, whereas with a conductive hearing loss, it is the other way around. Therefore, in otosclerosis the bone conduction is better than air conduction (BC>AC). With a sensorineural hearing loss, both receptions are reduced, but in the same ratio.

A 40-year-old man presents with a painless, circular, 7-millimeter spot inside his mouth; he noticed it 2 days ago. His medication list includes propranolol for hypertension. He is a known alcoholic. The diagnosis of leukoplakia of the buccal mucosa is made. The physician adopts a 'watch-and-wait' attitude; however, after 2 weeks the lesion is still present and unchanged. Question What is the best course of management? Answer Choices 1 Continue to observe and reassure the patient 2 Discontinue propranolol 3 Order a fluorescent antinuclear antibody test (FANA) 4 Perform a biopsy of the lesion 5 Treat with oral nystatin

Explanation The correct response is that you should perform a biopsy of the lesion. Leukoplakia is a white keratotic lesion seen on mucous membranes. Irritation from various mechanical and chemical stimuli, including alcohol, favors development of the lesion. Leukoplakia can occur in any area of the mouth, and it usually exhibits benign hyperkeratosis on biopsy. On long term-term follow-up, 2% to 6% of these lesions will have undergone malignant transformation into squamous cell carcinomas. Oral nystatin would not be appropriate treatment because this lesion is not typical of oral candidiasis. Candidal lesions usually are multiple and spread quickly when left untreated. A fluorescent antinuclear antibody test is also not indicated, as the oral lesions of lupus erythematosus are typically irregular, erosive, and necrotic. An idiosyncratic reaction to propranolol is unlikely in this patient.

A 78-year-old Caucasian man presents with unilateral painless loss of vision in the right eye of 3 hours duration. Examination reveals an elderly gentleman who is anxious but in no acute distress. Visual acuity is light perception only in the right eye and 20/30 in the left eye. Pupillary examination is significant for an afferent pupillary defect on the right side. Penlight examination of the eyes is otherwise unremarkable. Retinal examination of the right eye reveals a cherry-red spot. Retinal examination of the left eye is unremarkable. Question What disease process most likely accounts for the patient's presentation? Answer Choices 1 Adult-onset Tay-Sach's disease 2 Open angle glaucoma 3 Central retinal artery occlusion 4 Trauma 5 Cataract

Explanation This case represents the classic presentation of a central retinal artery occlusion, namely acute, unilateral, painless, loss of vision as well as a cherry-red spot on fundus examination. Tay-Sach's disease is a lysosomal storage disease found predominantly in Ashkenazi Jews. Infants with this fatal neurodegenerative disease do have a cherry red spot on retinal examination. An adult-onset form of Tay-Sach's disease is rare but does exist. Onset of symptoms is in the 3rd or 4th decade of life; however, it is characterized by neurologic deterioration and cherry-red spots would be bilateral. Although this patient does have a cherry-red spot, there is nothing in the presentation to suggest Tay-Sach's disease. Open angle glaucoma is a chronic, slowly progressive condition that would not be expected to cause acute visual loss. The patient gives no history of trauma and no evidence of trauma is seen on examination. A cataract, or opacification of the lens, would not be expected to cause acute visual loss.

A 17-year-old boy was in your clinic 4 days ago for evaluation of a 101.8° F fever and was diagnosed with acute pharyngitis. You prescribed penicillin VK 250 mg TID for 10 days. The patient returns today because his sore throat is now worse. He has not been able to drink fluids, and he has excruciatingly severe pain with swallowing. You recognize the muffled "hot potato" voice. On re-examination, you identify a right medial deviation of the soft palate with a 4+ right tonsillar swelling. Question What is the most likely diagnosis? Answer Choices 1 Oral candidiasis 2 Peritonsillar abscess 3 Laryngitis 4 Mononucleosis 5 Dental abscess

Explanation This patient is clearly suffering from a peritonsillar abscess. This occurs when an active infection penetrates the tonsillar capsule and then involves the surrounding tissue. These patients will have a severe sore throat, odynophagia, trismus, deviation of the soft palate, and an abnormally muffled voice (i.e., a 'hot potato voice'). Oral candidiasis (or thrush) does not present with the symptoms described in the scenario. Typically, oral candidiasis is painful and appears as creamy-white, curd-like patches; overlying erythematous mucosa can be found virtually anywhere in the oral cavity. The white patches can easily be wiped off when attempted. Laryngitis is lower on the differential diagnosis list because it usually presents with the primary symptom of hoarseness. Laryngitis frequently occurs approximately 1 week after the occurrence of an upper respiratory viral infection that has since resolved. A dental abscess would cause severe, persistent, throbbing toothache, sensitivity to hot and cold temperatures, sensitivity to biting or chewing, fever, possibly noticeable swelling in the face or cheek, or even lymphadenopathy relating back to the site of the abscess. The symptoms of a dental abscess do not match the clinical scenario presented. Mononucleosis also presents somewhat differently than the scenario above, making it a less likely diagnosis. Malaise, fever, sore throat (sometimes exudative), lymphadenopathy, palatal petechiae, and even splenomegaly are found in patients with mononucleosis.

A 34-year-old man presents due to something being "wrong" with his left ear. He reports his hearing has been gradually declining, but he recently noticed some discomfort and malodorous discharge draining from this ear. He denies any trauma to the ear and any symptoms in his right ear. Upon further questioning, he admits to some tinnitus and mild vertigo. He otherwise feels well. He denies nasal symptoms, headache, sore throat, and fevers. His past medical history is unremarkable; he has no known medical conditions or history of surgery; he takes no medications and has no allergies. He lives with his wife and 2 children; he works as an office manager, and he denies the use of alcohol, tobacco, and drugs. On physical exam, his vitals are normal. Examination of the left ear reveals mucopurulent drainage within the external auditory canal. The tympanic membrane is disrupted by a retraction pocket within the upper portion, with some thick yellow debris and a polyp protruding from the pocket. Hearing tests are not performed. The right ear reveals mild tympanosclerosis on the tympanic membrane, but it is otherwise normal. The remainder of the patient's exam is normal. Question What is the most likely diagnosis? Answer Choices 1 Cholesteatoma 2 Contact dermatitis of the ear canal 3 Labyrinthitis 4 Otitis externa 5 Psoriasis

Explanation This patient is presenting with a cholesteatoma, which a benign neoplasm of the tympanic membrane. It is considered a complication of chronic otitis media, so this patient could be expected to report a history of frequent otitis media. (The tympanosclerosis on the right is another clue.) The cholesteatoma is an epidermal inclusion cyst. Complications can include infection, and more significantly, erosion into bone and nerve damage. Contact dermatitis of the ear canal can produce local irritation with pain and/or pruritus, and if the inflammation is severe enough, discharge. The hearing loss and the physical exam findings of the pocket and polyp are not associated with contact dermatitis. Labyrinthitis is a condition that can cause hearing loss, tinnitus, and nausea. The cause is not well understood, but it involves the inner ear, not the tympanic membrane. Ear discharge is not associated with labyrinthitis. Otitis externa is an inflammatory condition of the ear canal, and can be most commonly caused by fungal or bacterial organisms. It can lead to ear pain and discharge. Typically, it should not causing hearing loss and tinnitus; furthermore, it would not cause the findings on this patient's tympanic membrane. Psoriasis is a dermatologic condition that affects skin all over the body. It is typically described as silvery scale over bright red plaques. It can affect the ear canals, causing pain and pruritus, but it does not typically the affect the tympanic membrane.

A 9-year-old boy presents to the emergency department with acute onset of 90 minutes of fever, sore throat, and labored breathing. IV access and oxygen therapy are both initiated in preparation for diagnostic testing. The physician assistant in the emergency department is concerned that he might have epiglottitis. Question What finding on lateral neck radiograph would support this diagnosis? Answer Choices 1 Narrowing of the trachea 2 Foreign body in the trachea 3 Soft tissue mass in the nasal cavity 4 Narrowing of the esophagus 5 Thumb-like projection superior to the larynx

Explanation Thumb-like projection superior to the larynx is the correct answer, as this is the description that is often used for an edematous epiglottis seen with epiglottitis. The epiglottis is a flap of tissue at the entrance of the larynx that points upwards while a person is breathing and folds down while swallowing. This mechanism prevents food from entering the trachea rather than the esophagus while eating. Epiglottitis can be life threatening and is an infection of the epiglottis that can lead to obstruction of the airway. It is commonly caused by H. influenza type B, group A Streptococcus, pneumococcus, or staphylococci. The classic thumb sign is usually seen on a lateral neck radiograph, which is essentially a swollen epiglottis seen on X-ray. Narrowing of the trachea is not the correct answer, as this is not typically seen on the neck radiograph of a patient with epiglottitis. A patient with croup (an upper respiratory viral illness characterized by a barking cough, stridor, and fever) can have narrowing of the trachea on a lateral neck radiograph. Foreign body in the trachea is not the correct answer. A lateral neck radiograph would show a foreign body in the trachea if one was lodged there, and this would not be associated with epiglottitis. Soft tissue mass in the nasal cavity is not the correct answer. The epiglottitis is soft tissue, but is not located in or near the nasal cavity. A patient with a nasal polyp may have a soft tissue mass in their nasal cavity on lateral neck radiograph. Narrowing of the esophagus is not the correct answer. Narrowing of the esophagus can occur with an esophageal stricture, but is more commonly diagnosed with a barium swallow or endoscopy. Narrowing of the esophagus can be seen on a neck radiograph in a patient with esophageal cancer, as well.

A 62-year-old woman presents to the Emergency Department with acute unilateral loss of vision for 1 hour. Fundoscopic examination demonstrates vein dilation, intraretinal hemorrhages, and cotton-wool spots with optic disc swelling. Which of the following is the most likely diagnosis? Answer Choices 1 Macular degeneration 2 Retinal artery occlusion 3 Retinal vein occlusion 4 Diabetic retinopathy 5 Retinal detachment

Explanation Retinal vein occlusion results in acute vision loss with retinal vein dilation, intraretinal hemorrhages, cotton-wool spots, and optic disc swelling on fundus examination. Macular degeneration does not cause acute vision loss but progressive loss over time and does not result in the findings above. Retinal artery occlusion does not cause retinal vein dilation and causes a classic cherry-red spot at the fovea. Diabetic retinopathy does not cause the constellation of signs noted above. Retinal detachment was not found on fundoscopic examination.

A 10-year-old boy presents to your office with chronic otitis media with accompanying purulent discharge occurring over the past 6 months. He is very irritable, and his mother has been increasingly frustrated that he has not completely responded to the treatments. Question Which of the following organisms is most likely associated with this patient's condition? Answer Choices 1 Haemophilus influenzae 2 Pseudomonas aeruginosa 3 Streptococcus pneumoniae 4 Mycoplasma pneumoniae 5 Enterococcus faecalis

Explanation The correct answer is Pseudomonas aeruginosa as it is one of the most common organisms causing chronic otitis media. Other common organisms include Proteus sp. and Staphylococcus aureus. The hallmark sign of chronic otitis media is purulent discharge from the ear. The condition is most often resolved by tympanoplasty. Haemophilus influenza, Streptococcus pneumonia, and Moraxella catarrhalis are common organisms found in acute otitis media, but Enteroccoccus faecalis is not typically found in chronic or acute otitis media.

A 17-year-old boy presents with a 1-day history of an extremely painful and pruritic left ear after returning from a trip to the beach over the weekend. Physical examination of the left ear reveals an erythematous external canal without clear visualization of the tympanic membrane. The patient grimaces and expresses a painful sensation when the left pinna is manipulated. Physical examination of the right ear is benign. Question What is the most appropriate treatment for the above condition? Answer Choices 1 Oral ciprofloxacin 2 Fluoroquinolone ear drops 3 Anti-pseudomonal IV antibiotics for 6 weeks 4 Acyclovir in combination with oral corticosteroids 5 Saline flushes of the ear canal

Fluoroquinolone ear drops Explanation Otitis externa is an inflammation of the external ear canal, usually caused by organisms such as Pseudomonas aeruginosa, S. epidermidis, and S. aureus. In uncomplicated cases, treatment is with oral antianalgesics (e.g., ibuprofen) plus topical agents aimed at cleaning and drying the ear canal and treating the infection. These include 2% acetic acid and fluoroquinolone ear drops. In addition, topical corticosteroids, such as hydrocortisone, can be used to reduce inflammation. Oral antibiotics are generally used for otitis media, not otitis externa. IV antibiotics covering Pseudomonas are used for malignant otitis externa, as it is a life-threatening condition. An anti-viral agent, such as acyclovir, can be used in combination with oral corticosteroids for Ramsey-Hunt Syndrome (herpes zoster affecting the geniculate ganglion). Saline flushes are not helpful in the treatment of otitis externa.

A 3-year-old girl presents with a 5-day history of purulent, foul-smelling nasal discharge. She is otherwise well-appearing, and her mother reports that she has not had any cough, fever, or other illness symptoms recently. She has been eating and sleeping normally. She is playful and "acting like herself". She stays with a babysitter during the day. Her mother also mentions that the discharge seems to only come from one nare. Question What is the most likely diagnosis? Answer Choices 1 Foreign body 2 Seasonal allergies 3 Sinusitis 4 Trauma (nose-picking) 5 Viral URI

Foreign body Explanation This young patient has most likely inserted a foreign body into her nose. It is worth noting that the majority of foreign body insertions (71 to 88%) are completely asymptomatic. However, a child with sinusitis would appear more systemically ill than this child does (would probably have a low-grade fever and some appetite loss), while a child with a viral upper respiratory infection (while often well-appearing) would likely have a reported history of cough and congestion, in addition to bilateral nasal discharge (not unilateral). A child with seasonal allergies would have a history similar to that of a viral URI, but might also mention itchy watery eyes and sneezing. Nose-picking is more likely to lead to epistaxis than to purulent discharge.

A 48-year-old Caucasian woman with multiple comorbidities presents with worsening hearing loss and tinnitus in her right ear. She states this first began about 3 months ago and was initially bearable; it has now progressed to where she cannot hear anything out of her right ear, and the tinnitus is unrelenting and constant. The patient is worried because she is now experiencing balance and coordination issues. An MRI is ordered on the patient, and it reveals the following results. Question Considering the diagnosis, as well as the fact that this patient is a poor surgical candidate, what would be a reasonable treatment option at this time? Answer Choices 1 Gamma knife radiosurgery 2 Chemotherapy 3 Linear accelerator radiation therapy 4 Proton beam therapy 5 Observation only

Gamma knife radiosurgery Explanation Vestibular schwannoma, which also sometimes is referred to as an acoustic neuroma, are one of the most common intracranial tumors encountered in clinical practice. More than likely these occur as unilateral lesions; only rarely can these occur as bilateral masses. Although growth of these lesions is overall slow, the increased size can eventually cause such symptoms as unilateral hearing loss and deterioration of speech discrimination. Tinnitus will also be seen in these patients and as the tumor increases in size more central nervous system components are affected. This will cause loss of balance, coordination, vertigo, facial numbness, facial weakness, or even dysphagia. Typically these lesions are diagnosed via MRI or even a CT scan. Treatment options usually are initially centered on surgical removal; however, our patient is not a candidate for a surgical procedure at this time. Other options would be radiosurgery, or specifically Gamma Knife radiosurgery is recommended. Gamma Knife radiosurgery is seen as an acceptable alternative for microsurgery for non-surgical candidates with similar tumor control rates to those having the surgical intervention. Linear accelerator radiation therapy is another type of radiotherapy used to treat cancers; however, this type is not indicated in the treatment of a vestibular schwannomas. Proton therapy, or proton beam therapy, is yet another type of radiotherapy; however, it is not a type that is specifically used in the treatment of schwannomas. Observation only would not be appropriate for this patient currently as she is having significant symptoms currently that are interfering with her every day and quality of life. Chemotherapy is not used for treating schwannomas.

A 37-year-old man presents with headache, malaise, and nasal congestion. He reports his symptoms started with what he believed to be a common cold, which occurred about 2 weeks ago. However, he has begun feeling much worse over the last 5 days. He describes severe facial pain when he bends to tie his shoes. He admits a very mild nonproductive cough, but he denies shortness of breath, fever, and chills. He has tried multiple over-the-counter cold remedies without relief. His past medical history is unremarkable, with no known medical conditions, no history of surgery, no regular medications and no allergies. He works as a welder, but denies known occupational respiratory exposures. He denies use of alcohol, tobacco, and drugs. On physical exam, his temperature is mildly elevated at 99.9 °F (37.7 °C), and other vitals are normal. His voice has a nasal quality and an occasional mild cough is noted throughout the exam. On HEENT exam, he demonstrates some tenderness over the left frontal region. Green nasal discharge with boggy nasal mucosa is present bilaterally. Mild injection is seen in the posterior nasopharynx. The remainder of his exam is unremarkable. Question What organism is most likely implicated with this patient's current condition? Answer Choices 1 Candida albicans 2 Clostridium difficile 3 Escherichia coli 4 Francisella tularensis 5 Haemophilus influenzae 6 Pseudomonas aeruginosa

Haemophilus Influenzae Explanation This patient presents with a classic acute bacterial rhinosinusitis (sinus infection). The most common causative organisms are Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis. Viruses and anaerobes can also be implicated as causes. Haemophilus influenzae is a Gram-negative bacterium. It is important for clinicians to understand the basic underlying etiology of common infections in order to select appropriate empiric antibiotic therapy. Because of difficulty in obtaining sinus cultures without nasal contamination, culture and identification of sinusitis-causing organisms is rarely done in clinical settings. Candida albicans is a common fungal organism. It is typically responsible for vaginal yeast infections and thrush. It does not usually cause sinusitis. Clostridium difficile is a Gram-positive, anaerobic bacillus. It can be a causative organism in diarrheal illnesses and colitis, and it is often considered a nosocomial (hospital-acquired) infection. It is not linked with sinusitis. Escherichia coli is a Gram-negative bacterium commonly found in the gastrointestinal tract. It is part of the normal GI flora, but can contribute to infection in other systems, such as the urinary tract. It is not usually found in the sinuses. Francisella tularensis is a Gram-negative bacterium that causes tularemia (also known as "rabbit fever"). It is carried by various vectors (ticks, rabbits, and rodents). Tularemia can cause various systemic symptoms, such as fever, malaise, fatigue, aches, and swollen lymph nodes. Pseudomonas aeruginosa is a Gram-negative bacterium that can be found in infections throughout several body systems. It can cause pneumonia, skin infections, as well as gastrointestinal and urinary tract infections. However, it is typically associated with some type of inoculation or immunocompromising condition (e.g., burns, post-catheter, puncture wounds, neutropenia, ventilator use, etc.). This patient history does not suggest any unusual etiology for his sinusitis. Pseudomonas aeruginosa is an unusual and rare cause of sinus infection.

An 8-year-old boy in the 3rd grade is referred to you by his school doctor to be evaluated for poor speaking and reading ability, failure to follow directions in class, and classroom disruptiveness. Despite these problems, he appears to be alert and interactive with other children and there is no demonstration of aggressive behavior or rage. He does not appear to be preoccupied with internal stimuli, and IQ testing results are within normal range. Question What is the most likely cause of his symptoms? Answer Choices 1 Autism 2 Childhood schizophrenia 3 Hearing impairment 4 Learning disability (reading disorder) 5 Seizure disorder (Epilepsy)

Hearing Impairment Explanation Hearing impairment is the most likely cause for this boy's poor communication and reading ability and his classroom problems. Children with hearing impairment appear to learn more slowly because they miss many important cues and information. They often become frustrated and develop other behavioral disturbances such as classroom disruptiveness. Thus, sensory impairment is an important consideration in the differential diagnosis of any child with symptoms that might suggest MR/ID or learning and communication disabilities. The 4 most common causes of speech or language delay are developmental language disabilities (i.e., normal cognition (IQ), impaired intelligibility, and delayed emergence of phrases, sentences, and grammatical markers), mental retardation/intellectual disability (MR/ID), hearing impairment, and autistic spectrum disorders. That being said, research has shown that approximately one third of hearing impaired children will also be found to have at least 1 other disability that affects development of speech and language (e.g., mental retardation, cerebral palsy, craniofacial anomalies). Any child who shows developmental warning signs of a speech or language problem should have a hearing assessment by an audiologist and an examination by a geneticist as part of a comprehensive evaluation. Autism is unlikely in this case because the boy is interactive with classmates and his environment. Reading disorder (or "Developmental Dyslexia") is the most common learning disability. The clinical picture is consistent with a learning disability in that the IQ score is higher than academic performance would suggest (poor speaking and reading ability, failure to follow directions). However, before this boy can be given a diagnosis of a learning disability, hearing impairment must be ruled out with audiometric studies. Childhood schizophrenia is a rare condition that can cause learning disabilities and is characterized by inattention and disruptive behavior; however, it is unlikely in this case, as there appears to be no impairment in social skills, no preoccupations with internal stimuli, and no aggression or rage behavior. Seizure disorders (epilepsy) can cause cognitive disturbances, but these should be detectable with IQ testing. The boy in this case has a normal IQ. Although a topic of much discussion and debate, it is well known that chronic epilepsy has an association with neuropsychological impairment.

A 2-year-old girl is brought to an otolaryngologist by her mother for chronic ear infections. The patient is otherwise healthy, with the exception of recurrent episodes of otitis media (OM). Examination and history show that the child has had average growth and development; she has not had invasive infections, skin disorders, or hospitalization. The child's mother is concerned about the risk of hearing loss and its effects on development. What statement about hearing loss and OM is most accurate? Answer Choices 1 Hearing loss does not result from OM, except in rare cases 2 Sensorineural, but not conductive hearing loss, is associated with OM 3 Hearing loss during OM may adversely affect cognition and language 4 Van der Hoeve syndrome, a sequela of OM, can cause hearing loss 5 Hearing loss associated with OM is always conductive and temporary

Hearing loss during OM may adversely affect cognition and language Explanation Conductive and sensorineural hearing loss are complications of chronic otitis media (OM). Acute and chronic suppurative OM usually results in conductive hearing loss. Chronic infection may result in conductive hearing loss from a perforation of the tympanic membrane; however, sensorineural hearing loss can occur, especially when herpes zoster is the etiologic agent. Cholesteatoma increases the probability of labyrinthitis, which carries a high risk for sensorineural hearing loss. Van der Hoeve syndrome is a constellation of symptoms including hearing loss, but is unrelated to OM. Hearing impairment is a risk factor for impaired speech and language development, particularly if it occurs early in life. In cases where hearing loss due to chronic OM is reversed surgically, it is likely that young children will compensate and catch up to peers. In cases where OM is either undiagnosed or untreated, long-term developmental and social problems may result. Because otitis media is often associated with hearing loss, most clinicians have been eager to treat the condition to restore hearing to normal, thereby preventing any long-term problems.

A 20-month-old boy presents with a 1-week history of fever up to 104oF and irritability. 4 days prior to his visit, his mother noted sores in his mouth; she states that she has noted him to be drooling and that his appetite is quite diminished. His past medical history is unremarkable. He has no medical allergies and his only current medication is acetaminophen. He is current on his immunizations. His physical exam reveals normal vital signs except for a temperature of 103.5oF. On examination of his oral cavity you note swollen, erythematous gingiva with ulcerations present. The ulcerations appear yellowish-white and friable. White-gray lesions approximately 3 mm in diameter are seen on the anterior tongue. The tonsils appear erythematous without exudates. His lips are slightly cracked, and his mucous membranes are slightly tacky. Neck examination reveals bilateral anterial cervical adenopathy. He has no skin lesions. The remainder of his exam is normal. Question What is the most likely cause of this patient's condition? Answer Choices 1 Oral candidiasis 2 Herpetic gingivostomatitis 3 Herpangina 4 Nursing bottle caries 5 Foreign body impaction

Herpetic gingivostomatitis Explanation Herpetic gingivostomatitis, caused by herpes simplex virus type 1, is the most common cause of stomatitis in children 1 - 3 years of age. Symptoms may appear abruptly, with high fever, drooling, fetid breath, and refusal to eat, as noted in the above vignette. However, the fever may precede the oral lesions by 2 - 3 days and presage to a more insidious onset of the disease. The tongue, cheeks, and gingiva are most commonly affected, but the entire oral cavity may be involved. These areas can present with ulcers that are yellowish-gray in color, and the gingiva may be quite friable. Drooling may be present secondary to the pain associated with chewing and swallowing, and dehydration is a real concern in the management of the patient. Cervical and submaxillary adenitis is common. The acute phase may last up to 1 - 2 weeks. Treatment consists of measures to relieve the pain and facilitate the intake of fluids for adequate hydration. Oral candidiasis (thrush) typically presents in the infant period and is usually caused by the yeast Candida albicans. This common affliction presents with white curd-like plaques on the oropharyngeal mucosa and tongue. Scraping the plaques may reveal an erythematous base. Treatment is usually accomplished with oral nystatin. It may be seen in older infants and children on antibiotic treatment or with immunodeficiencies. Herpangina is usually associated with a prodrome of fever, headache, and occasional emesis. Lesions are characteristically 1 - 3 mm in diameter, present as vesicles and ulcers, and are yellow-white in color. Each lesion is surrounded by an erythematous halo up to 10 mm in diameter. The lesions are most always found on the anterior tonsillar pillars, as well as the uvula, soft palate, and tonsils. The anterior mouth is rarely affected. The illness is caused by members of the Enterovirus family and the affected children do not appear as toxic as those that have herpes gingivostomatitis. Treatment is supportive and the acute phase lasts 3 - 6 days. Nursing bottle caries is relatively common, and it is seen in patients that sleep with a bottle in their mouth. These children present with significant erosion of the enamel of the anterior dentition. Treatment typically consists of extraction of severely affected teeth to prevent pain and spread of infection of contiguous tissues. Impaction of a foreign body would lead to pain, edema, and erythema of only a localized portion of the gingivae and not the widespread inflammation noted in the vignette. Difficult cases should be referred to a dentist for further treatment.

An 8-year-old child is brought to your office because of swelling of the left upper eyelid; the swelling is associated with redness and tolerable pain. No fever is noted. Physical examination shows a localized swelling and redness on the upper middle lid of the left eye; there is slight tenderness on palpation. Vital signs are within normal limits. What is the most likely diagnosis? Answer Choices 1 Blepharitis 2 Chalazion 3 Entropion 4 Hordeolum 5 Ectropion

Hordeolum Explanation The clinical picture is suggestive of hordeolum, which is an infection of the lid glands. The most common causative agent is staphylococcus aureus, which may either be acute or subacute. When the Meibomian glands are infected it is referred to as internal hordeolum, wherein the lesion tends to be large and extend to the skin or conjunctival surface. If it affects the glands of Zeis and Moll, it is referred to as an external hordeolum or stye. It is smaller, more superficial, and points to the lid margins. Treatment, like any abscess, is warm compresses and surgical drainage (if needed). Topical antibiotics are also used. If left untreated, it may progress to cellulitis of the lid or orbit, which requires systemic antibiotics. Recurrence is also frequent, and children with recurrent styes should be evaluated for an immunologic problem. Blepharitis is an inflammation of the lid margins, which is characterized by redness and a scaling or crusting lesion. It is initially manifested by itching, irritation and burning sensation. It is recurrent, chronic, and usually bilateral. In cases of the seborrheic type, the scales are greasy, erythema is less, and ulceration seldom occurs. In cases of the staphylococcal type, ulceration is common; lashes may fall out, and it is often accompanied by conjunctivitis and superficial keratitis. Most of the blepharitis is of mixed type. Application of antistaphylococcal agent or sulfonamides directly to the lids daily is the treatment of choice. Daily cleaning of the lid with moist cotton applicator to remove scales and crusts is very helpful. Chalazion is an inflammation of the meibomian glands characterized by a firm nodule on the upper eyelid, which is non-tender. It differs from hordeolum because it does not have the presence of inflammatory signs. Excision is recommended if the nodule is large enough to cause astigmatism by exerting pressure on the globe. Some cases subside spontaneously. Entropion is a condition in which the lid margin is directed inwards. It usually causes discomfort and corneal damage because the eyelashes are also turned inwards. It is most commonly caused by scarring due to inflammation seen in trachoma; it may also result from Steven-Johnson-syndrome. Surgery is effective. Ectropion is the opposite of entropion, in which the lid margin is turned outwards or everted; it is associated with an overflow of tears, maceration of the lid skin, inflammation of exposed conjunctiva, and/or superficial exposure keratopathy. Scarring from inflammation, burns, trauma, or orbicularis muscle weakness from facial palsy are the common causes. Surgical correction is necessary to protect the cornea.

A 17-year-old baseball player presents to the clinic after being struck in the eye with a baseball. On examination, you note bright red blood in the anterior chamber. Question What is your initial diagnosis? Answer Choices 1 Corneal abrasion 2 Pinguecula 3 Retinal detachment 4 Hyphema 5 Hypopyon

Hyphema Explanation The clinical picture is suggestive of a hyphema. Hyphema is defined as hemorrhage into the anterior chamber. Patients with a corneal abrasion note severe pain and photophobia following a history of a traumatic event to the affected eye. Pinguecula is a yellow, elevated conjunctival nodule; it is commonly located on the nasal side of the eye. Most retinal detachments occur spontaneously, and blood in the anterior chamber is not found. Hypopyon is described as pus (white and cloudy fluid) in the anterior chamber; it usually follows a fungal infection.

A 25-year-old woman presents due to constant sneezing episodes that have progressively worsened over the last few months. Further questioning reveals she also suffers from severe bilateral eye irritation, excessive tearing, and pruritus. On physical examination, you note hypertrophic nasal mucosa that is boggy in appearance, with the turbinates appearing pale. The patient states that this is especially bothersome during spring months; however, it also occurs to some degree during the fall. Question Based on the history and physical examination findings, what is the most appropriate first-line clinical intervention at this time? Answer Choices 1 Oral antihistamines 2 Oral decongestants 3 Intranasal decongestants 4 Intranasal corticosteroids 5 Oral steroids

Intranasal corticosteroids Explanation The scenario above is describing a common presentation of allergic rhinitis, most likely leaning more towards the seasonal rhinitis. Based on this diagnosis, the most appropriate first-line treatment is intranasal corticosteroids (ICS). The use of ICS for treatment of allergic rhinitis has essentially been a revolution; evidence-based reviews have found ICS to be much more effective and much less expensive than oral antihistamines. They are also less sedating. Key components of ICS therapy that must be addressed with all patients when prescribing them include appropriate training on usage as well as educating the patient that it will typically take 2 or more weeks to note any improvement. Oral antihistamines are a viable alternative for treatment of allergic rhinitis, but they should not be considered first line. If the patient is unable to tolerate ICS or proper usage cannot be executed, oral antihistamines could potentially be initiated. Oral steroids and oral decongestants are not indicated for the treatment of allergic rhinitis. Intranasal decongestants should not be prescribed to any patients who are diagnosed with allergic rhinitis, and they should be discouraged in general. These over the counter nasal sprays will lead to a condition known as rhinitis medicamentosa after around 5 - 7 days of treatment; a characteristic of this condition is severe rebound nasal congestion. Increased and longer use of intranasal decongestants will further worsen this condition, creating a viscous and endless cycle.

A previously healthy 13-year-old boy presents with a 2-day history of sore throat and fever. On examination, his temperature is 102.4°F. He demonstrates a 'hot potato voice', and he is drooling. Examination of the throat is initially difficult because of trismus, but reveals a fluctuant left tonsil that is displaced medially, with erythema and edema of the soft palate. The uvula is deviated to the right. Tender cervical adenopathy is noted on the left. What is the most appropriate treatment option? Answer Choices 1 Oral penicillin 2 Throat culture and treat if positive for Group A streptococcus 3 Intravenous antibiotics and surgical consultation 4 Intravenous antibiotics alone 5 Intramuscular penicillin

Intravenous antibiotics and surgical consultation Explanation A peritonsillar abscess results from a complication of acute tonsillitis. Usual etiologic agents include group A streptococci, Staphylococcus aureus, Streptococcus pneumoniae, and oral anaerobes. The infections have a rapid onset, and they are accompanied by fever, severe sore throat, trismus, drooling, alterations in speech and dysphagia. The tonsil is unilaterally displaced medially with erythema and edema of the soft palate. Uvular deviation may be deviated to the opposite side. The infection is usually unilateral, but can be seen bilaterally in up to 10% of cases. Therapy consists of intravenous antibiotics and surgical drainage of the abscess. Some surgeons may opt for serial aspirations of the abscess. Occasionally the infection may be seen early in the course and intravenous antibiotics are all that is required. However, this patient has frank abscess formation and, therefore, would require surgery. Oral or intramuscular antibiotics are not indicated initially. Throat culture may help guide therapy, but should never be a replacement for hospitalization and surgical consultation. Complications include upper airway obstruction, aspiration pneumonia due to rupture of the abscess, and spread to the retropharyngeal or mediastinal spaces. Tonsillectomy may be done in an elective basis 3 to 4 weeks after the inflammation resolves. Acute tonsillectomy may be performed for significant airway obstruction or other complications.

A 40-year-old man presents with burning and pain of his oral cavity; the burning and pain have been associated with a pruritic rash of the flexor aspect of his left wrist. He denies a history of smoking, drinking, or illicit drug use. The physical exam is remarkable for violaceous, shiny, and polygonal papules that are arranged as lines and circles on his wrist. These papules range in size from 1 mm to 1 cm in diameter, and they have fine, white lines on them. In the oral cavity, a reticular, white, lacy pattern is visualized, as seen in the image. Question What is correct regarding this condition? Answer Choices 1 The use of imaging study modalities are required for diagnosis 2 Systemic antifungal pharmacotherapy is curative in a majority of patients 3 The patient's oral lesion is a premalignant mucosal finding caused by carcinogen exposure 4 It is a cell-mediated immune response that is associated with hepatitis C and primary biliary cirrhosis 5 The most common causes are iron, folic acid, vitamin B12, and riboflavin deficiencies

It is a cell-mediated immune response that is associated with hepatitis C and primary biliary cirrhosis Explanation This patient most likely has lichen planus with cutaneous and oral involvement. It is an inflammatory mucocutaneous condition that usually exhibits a distinctive morphology; it is associated with hepatitis C virus infection, chronic active hepatitis, and primary biliary cirrhosis. The classic appearance of skin lesions includes violaceous polygonal flat-topped papules and plaques, commonly occurring at t the wrist. Wickham's striae may also be found; these are white lines found within papules. No imaging studies are necessary for lichen planus. Lichen planus is not a fungal disease process; therefore, antifungal agents are not appropriate treatment. Unlike leukoplakia or erythroplakia, the oral finding in this patient is not a premalignant finding. Nutritional deficiencies commonly contribute to angular chelitis and atrophic glossitis, not lichen planus.

A 56-year-old man presents to his GP with a history of persistent and progressive unrelenting hoarseness for the last few months. He used to be a 50-pack-per-year smoker but quit 1 year ago. Physical examination demonstrated a 2 cm firm, non-tender right anterior cervical lymph node. Question Which of the following is the most likely diagnosis? Answer Choices 1 Laryngitis 2 Thyroid cancer 3 Vocal cord nodule 4 Laryngeal cancer 5 Streptococcal tonsillitis

Laryngeal cancer Explanation The correct answer is laryngeal cancer. Tobacco abuse is a common predisposing factor in laryngeal cancer and affects men more often than women. Persistent hoarseness in this population should cause suspicion of cancer. Many patients with laryngeal cancer present with palpable anterior cervical lymphadenopathy. Acute laryngitis lasts for about 1 week and typically follows a viral infection. Chronic laryngitis often due to irritants, vocal abuse, or gastroesophageal reflux does not typically have accompanying non-tender lymphadenopathy. Thyroid cancer may present with anterior cervical lymphadenopathy but is rarely seen with progressive hoarseness. Vocal cord nodules are typically found in patients who overuse their voices and are not related to tobacco abuse. Streptococcal pharyngitis typically causes tender cervical lymphadenopathy unrelated to tobacco abuse and does not cause progressive laryngitis.

A 70-year-old man presents with paralytic strabismus with maximal esotropia as he gazes to the left. Question Which of the following nerves is most likely affected in this case? Answer Choices 1 Left fourth cranial nerve 2 Left sixth cranial nerve 3 Right fourth cranial nerve 4 Right sixth cranial nerve 5 Right third cranial nerve

Left sixth cranial nerve Explanation The correct answer is the left sixth cranial nerve. This nerve abducts the eyeball and paralysis of this nerve results in the inability of the left eye to gaze laterally causing maximal esotropia with left gaze. The right sixth cranial nerve will cause the same symptoms but as the patient gazes to the right. Cranial nerves III and IV are responsible for other movements of the eyeball such as the ability to gaze upward and downward as well as pupil reaction to light and accomodation which will not result in the defects noted in this patient.

A 66-year-old male presents to the clinic with a complaint of not being able to hear the beeping of his microwave oven when it signals completion of it's heating cycle. Knowing that the "beeping" is high pitched and the age of the individual, you suspect hearing loss in this patient that is typically associated with aging. This type of hearing loss is related to which one of the following alterations in the ear? Answer Choices 1 Fibrosis of the tympanic membrane 2 Hypersecretion of cerumen in the external auditory meatus 3 Ankylosis of the stapes at the oval window 4 Loss of cochlear hair cells 5 Loss of otoconia in the otolithic membrane

Loss of cochlear hair cells Explanation Hearing loss may be the result of one of two basic problems. Auditory disorders may be related to either conductive disorders, or sensorineural disorders. Conductive disorders are those that result from the mechanical impedance of sound waves from reaching the auditory sensory receptors. Sensorineural disorders are those that result from the loss of the ability to transduce or convey the mechanical signal into the neural signal. Fibrosis of the tympanic membrane, excessive secretion of cerumen in the external auditory meatus or ankylosis (bone deposition) of the stapes at the oval window are all examples of conductive disorders leading to hearing loss.Furthermore, conductive disorders such as these would result in a clinical situation with the loss of sound at all frequencies, rather than only a high frequency or selected frequency. Loss of the cochlear hair cells, particularly at the beginning of the basal turn of the cochlea, typically result in the loss of high frequency sounds. This is due to a sensorineural disorder which results in the loss of a specific frequency due to inability to transduce or convey the mechanical signal to a neural signal. This selective hearing loss of high frequency sounds, such as that of a beeping microwave oven, can be associated with hearing disorders during the process of aging.Loss of neurons from the spiral ganglion would be another example of a sensorineural disorder. The loss of otoconia in the otolithic membrane would probably have little effect on auditory responses.

A 55-year-old woman comes to your clinic presenting with episodic vertigo, tinnitus, hearing loss, and ear fullness. Her ear and eye physical examination are unremarkable. You perform a Dix-Hallpike maneuver which is negative. There are no carotid bruits noted on auscultation. Which of the following is the best initial treatment for this patient? Answer Choices 1 Restrict water intake 2 Diazepam10 mg BID 3 Antibiotics 4 Fluticasone propionate 5 Low sodium diet

Low sodium diet Explanation The clinical picture is suggestive of Meniere's disease. The classic syndrome consists of episodic vertigo lasting 20 minutes to several hours associated with fluctuating low-frequency sensorineural hearing loss, tinnitus, and a sensation of aural pressure. The Dix-Hallpike maneuver is a diagnostic maneuver for benign paroxymal positional vertigo. Treatment involves a low sodium diet and diuretics. Restricting water intake will lead to dehydration and an increase in sodium levels, worsening the symptoms of Meniere's disease. Diazepam can be used for Meniere's disease but is usually used for severe vertigo. The question is indicating initial treatment. Diazepam is used in the treatment of vestibular neuronitis. In vestibular neuronitis, a paroxymal, usually single attack of vertigo occurs without accompanying impairment of auditory functions and will persist for several days to weeks before clearing. Examination reveals nystagmus. These symptoms are not present in this patient. Antibiotics are not indicated for Meniere's disease. Fluticasone propionate is an anti-inflammatory nasal spray used to treat the nasal symptoms of indoor and outdoor nasal allergies and year-round nonallergic nasal symptoms. Fluticasone helps reduce the inflammation that leads to nasal symptoms that include congestion, sneezing, and itchy, runny nose which are not indicated in this patient.

A 29-year-old woman presents with slowly progressive right-sided hearing loss, tinnitus, and continuous vertigo. Her Weber test reveals lateralization to the left ear. Question What is the recommended next step? Answer Choices 1 Observation 2 Tympanostomy tube placement 3 MRI 4 Angiography 5 Referral for hearing aid

MRI Explanation MRI is the correct response. The presentation of slowly progressive sensorineural hearing loss, vertigo, and tinnitus is suggestive of acoustic neuroma, which is a benign tumor on the 8th cranial nerve. Diagnosis is made through MRI. Observation is an incorrect response. While acoustic neuroma is a benign tumor, its growth can impinge on vital structures. MRI should be obtained in this patient. Tympanostomy tube placement is an incorrect response. Tympanostomy tubes are placed for recurrent otitis media. Angiography is an incorrect response. Angiography has no role in this patient's diagnosis. Referral for hearing aid is an incorrect response. While the patient is suffering from hearing loss, the cause should be investigated before referring her for a hearing aid.

A man cannot hear any normal voice sounds spoken from more than 3 feet away. This is consistent with what type of hearing? Answer Choices 1 Normal hearing. 2 Profound hearing loss. 3 Slight hearing loss. 4 Severe hearing loss. 5 Moderate hearing loss.

Moderate hearing loss Explanation The correct response is moderate hearing loss. Using a normal voice for testing, someone with normal hearing should hear sounds from at least 18 feet away. Someone with slight hearing loss will not generally hear sounds from more than 12 feet away. An individual with moderate hearing loss is limited to approximately 3 feet of hearing. Severe hearing loss is associated with sound perception only immediately around the meatus. Profound hearing loss is near-total or complete loss of one's hearing.

An 8-year-old boy presents with his father on a Sunday afternoon with left ear pain. His father reports that he had 2 ear infections as a baby, but he cannot remember in which ear. The visit occurs during the summer months, and the patient's father says that the boy has been swimming almost daily in a neighbor's pool. Physical examination of the ears bilaterally reveals left ear canal erythema and edema, and pain with manipulation of the left pinna. No other physical examination findings are abnormal. Question What is the most likely treatment? Answer Choices 1 Neomycin/polymyxin B/hydrocortisone topical solution 2 Clotrimazole 1% topical solution 3 Ciprofloxacin oral suspension 4 Triamcinolone 0.1% topical solution 5 Amoxicillin oral suspension

Neomycin/polymyxin B/hydrocortisone topical solution Explanation Neomycin/polymyxin B/hydrocortisone (Cortisporin) solution is the correct answer. In this case, the patient has the diagnosis of acute left bacterial otitis externa. Initially, removal of any desquamated epithelium and moist cerumen should be performed. Topical solutions are usually adequate to treat the infection and should be chosen based on the most likely causative organism. Bacterial cases of otitis externa are usually caused by Pseudomonas aeruginosa or Staphylococcal species. Cortisporin has broad spectrum coverage, including a steroid to reduce inflammation. It is usually given 3-4 times daily for 7-10 days. This is not the first choice, however, if the patient has a perforation of the tympanic membrane in the infected ear. Clotrimazole 1% solution is not the correct answer for treatment of bacterial otitis externa. However, it would be adequate for treatment of fungal otitis externa, as clotrimazole is an antifungal rather than an antibacterial medication. Ciprofloxacin oral suspension is not the correct answer. Topical treatments are usually enough to resolve episodes of acute otitis externa. However, should it become recurrent or if signs of invasive infection (such as fever or cellulitis) are present, then oral antibiotics may be necessary. In those cases, fluoroquinolones are often chosen. Triamcinolone 0.1% solution is not the correct answer. Some children suffer from eczematous otitis externa, and this should be treated differently from acute bacterial otitis externa. Topical therapy is still effective, but acetic acid 2%, aluminum acetate, or various steroid preparations (such as triamcinolone 0.1% solution) are used. Amoxicillin oral solution is not the correct answer. Topical treatments are usually enough to resolve episodes of acute otitis externa. However, should it become recurrent or if signs of invasive infection (such as fever or cellulitis) are present, then oral antibiotics may be necessary. Amoxicillin would likely not be chosen over an oral fluoroquinolone and is more likely to be chosen as treatment for acute otitis media.

A 64-year-old African-American man presents to the emergency department after he went blind in his right eye "out of the blue" 20 minutes ago. There is no pain associated with his symptoms and he is not nauseated. Past medical history is positive for DMII for the past ten years. The pupil reaction on the left side is normal with pressure of 17mmHg. Right pupil evaluation reveals no reaction to light or accommodation with pressure of 20mmHg. Right eye ophthalmoscopy reveals arteriolar narrowing, vascular stasis, and "boxcar" pattern. Question What is the most likely diagnosis? Answer Choices 1 Occlusion of the central retinal artery 2 Acute glaucoma attack 3 Subconjunctival hemorrhage 4 Retinal detachment 5 Macular degeneration

Occlusion of the central retinal artery Explanation The symptoms described above are typical for occlusion of the central retinal artery, which is a branch of the ophthalmic artery, in turn a branch of the internal carotid artery. The "boxcar" pattern is segmentation of the venous blood column, bilateral boxcar ring is a useful sign of circulatory arrest and death. Acute central artery occlusion is an emergency, since it results in permanent blindness if circulation is not restored within 30-60 minutes. An acute glaucoma attack is accompanied by severe pain with decreased vision. The patient usually reports seeing halos around light. The pupil is fixed in a mid-dilated position, and the eyeball is firm to pressure since the intraocular pressure is elevated. Subconjunctival hemorrhage onsets spontaneously and shows a painless, bright red patch on the sclera. It usually is caused by overexertion, is benign, self-limited and has no influence on the visus. Retinal detachment starts with the patient seeing dark, vitreous floaters, light flashes, and blurred vision, which progresses to blindness if not treated. Macular degeneration causes painless loss of visual acuity. There is altered pigmentation in the macula.

A 42-year-old man presents for evaluation of a growth on his tongue. He thinks that the lesion has been present for a few months, and it has not changed; however, he generally prefers to avoid health care, and he has not been concerned. He is only here at the urging of his family member. The patient denies oral symptoms and changes in taste sensation; he states that he generally feels fine. The patient denies the use of chew tobacco and cigarettes. On physical exam, there is a white patch of tissue, which does not scrape off; there is a 'shaggy' appearance on the left lateral tongue. No erythema is noted. No other lesions are identified. The remainder of his exam is normal. A biopsy of the lesion is obtained. The pathology shows hyperkeratosis, "balloon" cells in the upper cell layer, and Epstein-Barr virus (EBV) in the basal epithelial cells. Question What is the most likely diagnosis? Answer Choices 1 Geographic tongue 2 Oral candidiasis 3 Oral hairy leukoplakia 4 Oral lichen planus 5 Squamous cell carcinoma

Oral Hairy Leukoplakia Explanation This patient has oral hairy leukoplakia, which is often associated with HIV-infection or other immunocompromised states (such as post-transplant). It is rare in immunocompetent individuals. The oral hairy leukoplakia is a benign neoplasm of the tongue; in and of itself, it is not of great significance. However, due to its association with an immunocompromised state, it can be a harbinger of a more significant condition. Geographic tongue is a benign condition of the tongue; it affects the epithelium. It typically presents with erythematous patches, with white, rounded borders. Lesions can change size, patterns, and locations. Patients may be asymptomatic or experience burning or oral discomfort. Oral candidiasis (thrush) is a fungal infection of the oral mucosa. Typically, affected individuals note oral pain or discomfort. There may be white plaque with surrounding or underlying erythematous tissue. Biopsy is not typically necessary for diagnosis; this patient's biopsy would have indicated fungal organisms if he had thrush. Oral lichen planus can present with white 'lace-like' patches, but it typically presents with oral pain. Squamous cell carcinoma can present in a variety of lesions (plaques, ulcerations, erosions, papules). Any persistent oral lesion should be biopsied to evaluate for possible malignancy. This patient's biopsy did not indicate malignancy.

A 5-year-old boy presents with a sudden high fever and severe pain in the right ear. He vomited 1 time this morning, and he has been very irritable since the initial onset of symptoms. He also seems to have some difficulty in hearing. The child has been suffering from a cough and cold for the last 2 weeks. He recently returned to the United States after visiting family abroad with his mother, where they spent time with an ill relative. The mother notes that he exhibited no irritability or signs of ear pain during the plane ride home. What would the management of this boy's condition include? Answer Choices 1 Oral amoxicillin 2 Intramuscular amoxicillin 3 Intramuscular ampicillin 4 Oral ampicillin 5 Needle aspiration

Oral amoxicillin for otitis media Explanation The correct response is oral amoxicillin. The diagnosis in this case is acute otitis media (inflammation of the middle ear), which is a common childhood infection. Infants and children are at highest risk for otitis media; incidence rates are 15 - 20%, with peaks occurring from 6 - 36 months and 4 - 6 years of age. Children who develop otitis media in the 1st year of life have an increased risk of recurrent acute infection or chronic disease. In the usual course, a child suffering an upper respiratory infection for several days suddenly develops otalgia, fever, and hearing loss. The characteristic features include a bulging, opaque, erythematous tympanic membrane with impaired mobility. Purulent otorrhea may be present, but earache and fever are not always present. Any child with a 'fever of undetermined origin' must also be evaluated for a middle ear infection. Bacteria are the primary agents of otitis media. The most common causes in all age groups are Streptococcus pneumoniae (25 - 40% of cases), followed by Haemophilus influenzae (15 - 25% of cases). In addition, Gram-negative bacilli cause about 20% of otitis media in neonates; however, these bacteria are rarely found in older children with otitis media. Less common causes include group A Streptococci and Branhamella catarrhalis. Staphylococcus is a less common cause of chronic otitis media. Normally, children will improve clinically within 48 hours after antimicrobial therapy. If there is no improvement, the possibility of a resistant organism must be suspected; trimethoprim-sulfamethoxazole, or erythromycin and sulfonamides may be given. The antibiotic of choice is amoxicillin orally; it is effective for both S. pneumoniae and H. influenzae. There is no added advantage of intramuscular injection over oral amoxicillin. An increasing percentage of H. influenzae and Moraxella catarrhalis strains have now become beta-lactamase producing and, therefore, ampicillin-resistant. Some resistant cases may benefit from a change of antibiotics to erythromycin or sulfonamides. Needle aspiration of the middle ear is only rarely necessary, as in the case of a critically ill child or a child who fails to respond to standard antimicrobial therapy.

A 37-year-old Caucasian woman swims regularly for exercise. She swims 100 laps 4 to 6 times per week. She starts to notice severe right ear pain. She also notes that her right ear is very itchy. She sees her family doctor and mentions her symptoms. When he goes to insert the otoscope, he gently pulls on her ear. This causes her quite a bit of pain. He notes an inflamed external ear canal, but the tympanic membrane is normal. Question What is the most likely pathogen? Answer Choices 1 Pseudomonas aeruginosa 2 Streptococcus pneumoniae 3 Haemophilus influenzae 4 Branhamella catarrhalis 5 Corynebacterium diphtheriae

Pseudomonas Explanation This patient has signs and symptoms of otitis externa, specifically "swimmer's ear." An infection of the external auditory canal, usually due to bacteria, is called otitis externa. Symptoms include ear pain and itching. The finding of an inflamed external ear canal is consistent with otitis externa. The most likely pathogen for swimmer's ear is Pseudomonas aeruginosa. Pseudomonas aeruginosa is a Gram-negative aerobic rod. Other pathogens that can cause otitis externa include Peptostreptococcus, Staphylococcus aureus, Bacteroides, Proteus, and fungi. Streptococcus pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis are all causes of otitis media. Corynebacterium diphtheriae does not infect the ear. The image included here is a photomicrograph of Pseudomonas aeruginosa. The image is courtesy of the CDC.

A 34-year-old woman presents to your office to establish care. Her past medical history is significant for gastritis. She has no other medical problems. As part of your new patient assessment, you perform a neurological examination. On confrontation with visual field testing, you note bilateral temporal field defects, specifically a bitemporal non-homonymous hemianopsia. The remainder of your neurological evaluation is unremarkable. What would be your next step in the management of this patient? Answer Choices 1 Refer the patient to the emergency room for evaluation of a possible stroke 2 Order an outpatient MRI of the brain 3 Check thyroid function tests 4 Check an EKG in your office 5 Consult with ophthalmologist for possible glaucoma

Order an outpatient MRI Explanation Bitemporal visual field loss localizes to the optic chiasm. In a 34-year-old patient, the most likely cause is a pituitary tumor. The next step in management would be to obtain brain imaging to verify the presence of a lesion and to evaluate its extent. An urgent referral to the emergency room is not indicated; at the patient's age, there is nothing to indicate a stroke. Thyroid function tests may be abnormal with a pituitary lesion. Evaluating thyroid hormone levels may be important in characterizing a pituitary lesion if one is present. The first step in management is to obtain brain imaging. Checking an EKG in the office is not indicated based on the information presented. While glaucoma can cause visual field defects, a bitemporal hemianopsia suggests a chiasmal lesion. Glaucoma would be unlikely in this setting and with a patient of this age.

A 67-year-old woman presents saying her husband says she doesn't listen to anything he says. The patient states that occasionally she has to ask people to repeat themselves when sitting to her right. She denies any dizziness, headaches, or visual disturbances. Her current medication is furosemide. On physical examination, the Weber test reveals lateralization to the left ear. Air conduction lasted for 15 seconds and bone conduction lasted 10 seconds. What do you suspect as the cause of this hearing loss? Answer Choices 1 Cerumen impaction 2 Otosclerosis 3 Ototoxicity 4 Meniere's disease 5 Middle ear effusion

Ototoxicity Explanation Ototoxicity secondary to furosemide is the correct answer. Loop diuretics can cause sensory hearing loss, as evidenced by this patient's physical exam finding of lateralization to the good ear and air conduction slightly longer than bone conduction. The Rinne test should reveal an air:bone conduction ratio of 2:1. Cerumen impaction will cause a conductive hearing loss with the lateralization to the affected ear and a negative Rinne test. Otosclerosis typically will result in conductive hearing loss. Meniere's Disease is incorrect because the patient does not exhibit any vertigo or tinnitus. Middle ear effusion is incorrect because it would cause a conductive hearing loss.

A 28-year-old woman with a past medical history of well-controlled asthma presents with recurrent sneezing episodes, nasal itching, congestion, and headache. Her physical exam reveals post-nasal drip, a transverse nasal crease, and bilateral infraorbital cyanosis. Question What additional findings support an allergic etiology of this patient's presentation? Answer Choices 1 Associated manifestations, including malaise, body aches, and cough 2 Pale, bluish nasal mucosa upon speculum examination 3 Provocation by changes in temperature or exposure to odors and chemicals 4 An erythematous and edematous nasal septum and turbinates 5 The presence of fever and copious, purulent green nasal discharge

Pale, Bluish nasal mucosal upon nasal speculum examination Explanation This patient's past medical history and current presentation are remarkable for allergic rhinitis. Signs and symptoms include sneezing paroxysms, nasal, ocular, or palatal itching, clear rhinorrhea, nasal congestion, pale, bluish nasal mucosa, transverse nasal crease, infraorbital cyanosis (allergic shiners), and serous otitis media. Viral rhinitis is often associated with other manifestations of viral illness, which can include headache, malaise, body aches, and cough. Nasal drainage in viral rhinitis is most often clear or white and can be accompanied by nasal congestion and sneezing. The nasal septum and turbinates are typically erythematous and edematous. Patients with vasomotor rhinitis present with symptoms of nasal obstruction and clear nasal drainage. The symptoms are often associated with changes in temperature, eating, exposure to odors and chemicals, or alcohol use. Some clinicians suggest that abnormal autonomic regulation of nasal function leads to vasomotor rhinitis. The presence of fever in conjunction with copious, purulent green nasal discharge should raise suspicion for underlying infection, especially bacterial rhinosinusitis.

A 26-year-old man presents with an eye issue. He does not wear corrective lenses. The only change of lifestyle that he states is that, a few months ago, he quit his office job and began to "help out a buddy" in the construction business. On physical examination, there is a triangular fold of tissue extending from the medial conjunctiva to the cornea in both eyes. Question What is the most likely diagnosis? Answer Choices 1 Keratoconjunctivitis sicca 2 Pinguecula 3 Chalazion 4 Pterygium 5 Hordeolum

Pterygium Explanation The clinical picture is suggestive of pterygium. The common presentation is a fleshy, triangular intrusion of the conjunctiva onto the nasal side of the cornea that is often bilateral. It is usually associated with constant exposure to sand, wind, or sunlight. Keratoconjunctivitis sicca (or dry eyes) is a condition of lacrimal gland hypofunction commonly seen in elderly women. Pinguecula is a yellow elevated conjunctiva nodule in the area of the palpebral fissure on the nasal side of the eye. It is common in patients over 35 years of age. Chalazion is a chronic eye stye. Hordeolum is an acute stye.

A 69-year-old woman presents with epistaxis. She has been applying pressure to her nose for the last hour, but she came to the emergency room when the bleeding did not subside. Past medical history is significant for type II diabetes, hypertension, and an acute myocardial infarction 2 years ago, which was treated with stent placement. On physical exam, the patient is afebrile, with pulse 92 beats per minute, respirations 23 per minute, and a blood pressure of 185/105. There is blood flowing through both nares, and blood is seen down the posterior oropharynx. Examination of the nasal cavity does not reveal a specific area of bleeding. Question What is the appropriate next step for this patient? Answer Choices 1 Resume placing direct pressure 2 Cauterization of the nasal cavity 3 Anterior nasal packing 4 Posterior nasal packing 5 Surgical ligation of the nasal artery supply

Posterior nasal packing Explanation Posterior nasal packing is correct. The presence of blood in the posterior oropharynx indicates posterior epistaxis. Posterior epistaxis is responsible for approximately 5% of cases of epistaxis, and it most commonly presents in patients with history of hypertension and atherosclerosis. Posterior epistaxis does not respond to direct pressure. Posterior nasal packing is the appropriate next step in treatment. Resume placing direct pressure, cauterization of the nasal cavity, and anterior nasal packing are incorrect. These are all treatments for anterior epistaxis, and they would not be effective in posterior epistaxis. Surgical ligation of the nasal artery supply can be used in the treatment of posterior epistaxis. However, it is reserved for patients who do not respond to posterior nasal packing.

A 30-year-old woman presents to the emergency room at 7 am with severe pain and swelling of her right eye. She was awakened early the previous evening due to the discomfort and swelling of the surrounding conjunctiva. She found it difficult to sleep due to the discomfort. She planned on going to work, but the swelling had closed her eye shut, and she developed excruciating pain in the eye that radiated internally. The patient does not recollect any previous trauma or injury to the eye. She uses contact lenses, but they were not in use due to the condition of her eye. The contact lenses were stored in a small pillbox container with some fluid that she later described as tap water. She ran out of sterile cleaning and soaking solution for the contact lenses, so she has been using tap water as a substitute for approximately 5 days. She frequently sleeps with her contacts in. The patient is afebrile. Pulse is 70/min, and blood pressure is 135/80 mm Hg. Lungs are clear, and there is no evidence of lymphadenopathy. The eye has a profound conjunctivitis that is acute and follicular. Purulent drainage is present. The acute nature of the conjunctivitis requires an ophthalmologist consult. The ophthalmologist obtains ocular fluid for culture and Gram stain. CBC results are unremarkable. The Gram stain reveals the following results (see image). Prompt and aggressive therapy is initiated. What is the most likely organism causing this acute eye threatening infection? Answer Choices 1 Chlamydia trachomatis 2 Pseudomonas aeruginosa 3 Haemophilus aegyptius 4 Bacillus cereus 5 Acanthamoeba spp 6 Staphylococcus aureus 7 Candida albicans

Pseudomonas Explanation Pseudomonas aeruginosa is a Gram-negative rod; it is a non-lactose fermenting, oxidase-positive motile bacteria. Growth on MacConkey agar is usually characterized by the production of a "grape-like" smell. A blue-green color, due to the production of the diffusible fluorescent pigments pyoverdin and pyocyanin, is characteristic of the colonies growing on MacConkey. Pseudomonas aeruginosa is a very common opportunistic source of human infections, especially in the hospital setting. Pathogenesis is due to its minimal nutritional requirements, relative resistance to antibiotics, and a host of other invasive and toxicogenic substances that it produces. It can cause a keratitis that is rapid in its development. The infection is usually the result of a previous injury to the eye, which causes an interruption in the epithelial surface and allows bacterial invasion of the underlying stroma. It can also be caused by contact lenses. Fever is usually absent, and leukocytosis is absent or minimal. The infection can lead to corneal ulceration, resulting in the rapid loss of ocular function; therefore, these infections need to be approached as a medical emergency. Scrapings from the floor of the ulcer exhibiting Gram-negative rods are strongly indicative of Pseudomonas aeruginosa and should necessitate treatment. Immediate initiation of combined topical and subconjunctival therapy with an aminoglycoside antibiotic such as gentamicin or tobramycin is advised. Topical steroids are sometimes used to reduce ocular inflammation. Chlamydia trachomatis is an obligate intracellular parasite with a unique biphasic life cycle. It does not Gram stain; laboratory procedures used for diagnosis include isolation in tissue culture, EIA detection of antigen, immunofluorescent staining, cytologic examination for intracytoplasmic inclusions, and by the demonstration of nucleic acid by direct hybridization or by amplification techniques. It can cause inclusion conjunctivitis and ocular trachoma (as well as urethritis, lymphogranuloma venereum, urogenital infections, infertility, salpingitis and endometritis, reactive arthritis, etc.). The inclusion conjunctivitis presents as an acute follicular conjunctivitis and is usually self-inoculated from an infected genitourinary site. The patient frequently notes a foreign body presence in the eye. These symptoms are usually unilateral, and in the first 2 weeks, there is a mucoid discharge that becomes purulent. Usually the inclusion conjunctivitis resolves without complications, but some untreated or improperly treated cases can result in a prolonged infection that can last for months, and it can produce conjunctival and corneal scarring that is similar to mild ocular trachoma. Antibiotics, such as the tetracyclines, macrolides, rifampin, and some of the fluoroquinolones, have activity against chlamydia. Haemophilus aegyptius is a Gram-negative coccobacillus; it is non-motile, fastidious bacteria requiring the presence of special factors for its growth on agar media. These factors are hemin and nicotinamide adenine dinucleotide, which are present in chocolate agar. The organism is indigenous to humans. It is an important cause of a purulent conjunctivitis called pink eye, and it can occur in outbreaks because of its contagious nature. The diffuse pink color of the sclera and the presence of a serous or purulent discharge are virtually diagnostic of Haemophilus aegyptius infection. Leukocytosis is absent. The infection is not acute in presentation. The treatment of Haemophilus aegyptius is with topical antibiotics. Because of the infectious nature of the infection, instructions should be provided to the patient to help prevent the spread of the infection to others. Bacillus cereus is a Gram-positive (or Gram-variable) rod that is aerobic and spore forming; it is ubiquitous in nature. Bacillus cereus is an important cause of food poisoning. It has also been recognized as an ocular pathogen. The ocular infection is acute in presentation and requires aggressive intervention to save the eye. It is many times associated with metal-on-metal projectile injuries, soil and dust contamination as seen in rural farm areas, and drug abuse. The presence of progressive corneal deterioration and ring abscess formation is a complication of panophthalmitis caused by Bacillus cereus. Except for infections with Pseudomonas aeruginosa, this finding is almost pathognomonic of Bacillus cereus. Because of the seriousness of the infection, early diagnosis is important. Patients presenting with ocular infections after trauma or in the setting of drug abuse should arouse suspicion. As with Pseudomonas aeruginosa, it is important for the prompt initiation of therapy before permanent structural changes occur, leading to loss of vision. Clindamycin and gentamicin in combination, administered intravitreally, is the course of therapy favored by ophthalmologists. The prognosis is poor and usually results in the loss of the eye unless an aggressive approach is undertaken; even then, there is assuredly some loss of vision. Topical steroids are sometimes used to reduce ocular inflammation. Acanthamoeba is a free-living amebae that can cause granulomatous amebic encephalitis and keratitis. Detection is usually made by observing the free-living motile organisms in a wet prep preparation. Acanthamoeba keratitis is a corneal infection that occurs in healthy people and is usually associated with contact lens wearers. To prevent Acanthamoeba keratitis, it is recommended that contact lenses be cleaned and stored with Benzalkonium chloride-preserved saline and solutions containing thimerosal with edetate. Swimming in fresh water (where the organism is naturally found) with contact lenses can predispose the wearer to Acanthamoeba keratitis. The keratitis is slow in developing and is frequently mistaken for herpes, bacterial, or fungal keratitis. Frequently, the average delay to definitive treatment can range from days to months. Symptoms include blurred vision, conjunctivitis, tearing, severe pain to the eye, and photophobia. The keratitis achieves an advanced stage in several days to several months, and it can exhibit patchy stromal infiltrates and dendriform epithelial involvement without frank corneal ulceration in its early stages. A ring corneal infiltrate is characteristic of this keratitis in its late stages. Early diagnosis, aggressive surgical debridement, and medical management can prevent eye damage. High concentrations of topical antimicrobial drugs (1% miconazole, 0.1% propamidine isethionate, and Neosporin) for a minimum of 3 - 4 weeks is part of the antibiotic therapeutic regimen employed in the treatment of Acanthamoeba keratitis. Staphylococcus aureus is a Gram-positive staining cocci that is catalase positive and coagulase positive. It is probably the 2nd most common bacterial isolate of human infections behind Escherichia coli and the most common cause of bacterial endophthalmitis. Staphylococcus aureus has a host of invasive and toxigenic characteristics that enhance the pathogenesis of the organism in the human host. The organism has been described as an etiologic agent of many infections including, but not limited to, conjunctivitis, endocarditis, septicemia, abscesses, and urinary tract infections. The conjunctivitis caused by Staphylococcus aureus is usually characterized as non-severe where there is little to no lid edema, scant purulent discharge, and normal cornea; however, in some cases the presentation can be severe. Topical agents are usually used to treat this infection such as cephalosporins or semisynthetic penicillins. In suspected cases of resistance, topical vancomycin should be considered. Candida albicans is a yeast. Yeast appear on Gram stain as large Gram-positive organisms that are approximately 3 - 5 times larger than Gram-positive cocci. They are aerobic and generally grow well on most non-selective agar media. Endophthalmitis due to yeast is generally a common and serious complication of intravenous drug use. Candida albicans is the most common fungal cause. It is usually of hematogenous origin, where the patient has infective endocarditis or some other infective process occurring. The symptoms are blurred vision, decreased vision, white cotton appearing exudative lesions in the choroid and retina with vitreous haziness, and eye pain. A definitive diagnosis is made by obtaining vitreous fluid for Gram stain and culture. The treatment consists of parenteral amphotericin B together with flucytosine. Intraocular amphotericin B administration as therapy is controversial. The incidence of permanent intraocular damage is high.

Using the Weber and Rinne tests, a left-sided conduction hearing loss will manifest as what? Answer Choices 1 Sound lateralization to the right on the Weber test, and left-ear sound longer through bone in the Rinne test 2 Sound lateralization to the right in the Weber test, and left-ear sound longer through air in the Rinne test 3 Sound lateralization to the left in the Weber test, and left-ear sound longer through bone in the Rinne test 4 Sound lateralization to the left in the Weber test, and left-ear sound longer through air in the Rinne test 5 No sound lateralization in the Weber test, but sound longer through bone in the Rinne test

Sound lateralization to the left in the Weber test, and left-ear sound longer through bone in the Rinne test Explanation In the Weber test, sound lateralizes to the impaired ear in conduction hearing loss, and to the good ear in unilateral sensorineural hearing loss. In the Rinne test, sound is heard longer through bone in conduction hearing loss, and it is heard longer through air in sensorineural hearing loss. Therefore, in left-sided conductive hearing loss, sound will lateralize to the left in the Weber test, and left-ear sound will be heard longer through bone in the Rinne test.

A 23-year-old man presents 2 hours after being involved in a road traffic accident in which he sustained right-sided periorbital injuries. He is seeing double; he denies headache, vomiting, and loss of consciousness. On examination, he is alert and oriented in time, space, situation, and person. His right eye is deviated downwards and temporally. Question What finding would you also expect to find in this patient? Answer Choices 1 Loss of the corneal reflex 2 Ptosis 3 Pupillary constriction 4 Corneal anesthesia 5 Eye adduction

Ptosis The correct response is ptosis. The clinical picture is suggestive of injury to the oculomotor nerve, which is the 3rd cranial nerve. It innervates the following striated muscles: Superior rectus Inferior rectus Medial rectus Inferior oblique Their denervation results in infraduction and abduction of the eye. The oculomotor nerve also innervates the levator palpebrae superioris and the pupillo-constrictor. Their denervation results in ptosis and mydriasis respectively. Causes of 3rd cranial nerve palsy include: Intracranial and intraorbital lesions (e.g., neoplasms) Head and orbital trauma Ocular myopathies Cerebral aneurysms Transtentorial herniation Patients usually present with diplopia, which is also known double vision. They may also mention the inability to see with 1 eye if the ptosis is severe enough to cover the pupil. They may also mention blurred vision and a glare in bright lights due to the mydriasis. Corneal anesthesia with loss of corneal reflex is a result of interruption of the trigeminal nerve supply to the cornea and conjunctiva.

A 52-year-old man presents with a concern of hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only 1 side (his left). Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms. The patient's past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use. On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed; it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells. Question What choice represents the best intervention for this patient's current condition? Answer Choices 1 Referral for chemotherapy 2 Referral for electroencephalography 3 Referral for surgery 4 Referral for unilateral hearing aid 5 Referral for ventricular shunt

Referral for surgery Explanation This patient is presenting with a vestibular schwannoma (or acoustic neuroma), which is affecting his vestibulocochlear nerve (cranial nerve VIII). This is one of the more common benign head and neck neoplasms. A common presentation is unilateral hearing loss and tinnitus. Treatment is typically surgical removal; another possibility is radiation therapy. Of the choices listed, referral for surgery is the best option; if he turns out to be a poor surgical candidate, radiotherapy should be discussed. This patient should not be referred for chemotherapy. Schwannomas are not typically responsive to chemotherapy, so doing so could delay appropriate treatment. If the patient was describing seizures, the provider should refer for electroencephalography (EEG), especially as some brain tumors are associated with seizures. However, this patient denied other neurological symptoms and has been clearly shown to have an intracranial mass. Referral for EEG would also delay definitive treatment. A referral for unilateral hearing aid would not fix this man's hearing loss; the treatment of his brain tumor would be delayed. A referral for ventricular shunt should be done for patients with hydrocephalus. Shunts have no role in schwannoma treatment.

A 1.5-year-old boy presents with a squint in the left eye. His mother informed you that the child's eyes were quite normal until about 2 months ago, when she noticed asymmetric movements of her son's eyes. She also felt that the child could not see properly with his left eye. There is no history of trauma to the eye. Child was born at full term and his growth and development were within normal limits. Eye examination showed both eyeballs were equal in size. There was loss of vision in the left eye and a convergent squint in the same eye. Fundus examination showed absence of red reflex in the left eye, and instead a white pupillary reflex (leukocoria) was seen. X-ray of the skull showed calcification within the globe. Question What is the most likely diagnosis? Answer Choices 1 Retinal detachment 2 Congenital cataract 3 Retinoblastoma 4 Congenital glaucoma 5 Persistent hyperplastic primary vitreous

Retinoblastoma Explanation The most likely diagnosis is retinoblastoma, as it is the most common primary ocular tumor in children below 5 years of age. 90% of cases are diagnosed below 3 - 4 years of age. The index case is a 1.5-year-old boy who has presented with a recent appearance of squint and absence of normal red reflex in the left eye, replaced instead by a white pupillary reflex (leukocoria). This is due to reflection of light from the white-colored tumor and loss of vision in that eye. The diagnosis is further supported by calcification seen in the globe in the X-ray of the skull. Fundoscopy may show the tumor as a white mass, which may be small and flat or may be large and protuberant. Orbital inflammation, hyphema, and irregular pupil are seen in advanced stages of the disease. Retinoblastoma gene is a recessive gene located on the chromosome13 at the 13q 14 regions, and the tumor may arise from any of the nucleated layers of the retina. Besides direct observation, ultrasonography or CT scan may help to confirm the diagnosis and demonstrate calcification within the mass. As biopsy can lead to the spread of the tumor, histopathological confirmation of the tumor can be made only after removal of the affected eye Retinal detachment in infants and children more commonly occurs due to trauma, secondary to other abnormalities like myopia, or after cataract surgery. It can also occur in diabetes, sickle cell disease, and retinopathy of prematurity. Presenting signs can be loss of vision, secondary strabismus (squint), nystagmus, and leukocoria (white pupillary reflex). Calcification seen on an X-ray of the skull in retinoblastoma is absent in retinal detachment. Also ultrasonography and neuroimaging may be required to establish the cause of detachment. Congenital glaucoma (elevated intraocular pressure) usually manifests during the first 3 years of life. The classical triad of symptoms of congenital glaucoma are epiphora (excessive lachrymation), photophobia (sensitivity to light), and blepharospasm (squeezing of the eyelids). These symptoms are due to corneal irritation. As the cornea and sclera are more elastic during early childhood, the elevated intraocular pressure therefore leads to expansion of the eyeball, including the cornea, and development of buphthalmos (ox eye), which means a large eye. This leads to corneal edema and conjunctival congestion. The cornea may become cloudy. There is no white pupillary reflex or calcification in the globe seen on an X-ray of the skull. A cataract is an opacity in the lens and may cause significant impairment of vision. It may be an isolated defect or may be a part of a generalized disorder. Common causes are intra uterine infections like rubella, cytomegalovirus infection, toxoplasmosis, metabolic disorders like galactosemia, and chromosomal disorders like trisomy 13, 18, and 21. Trauma to the eyeball is a major cause of cataract in children. The red reflex may be absent or may be irregular or there may be a white pupillary reflex. The retina and the blood vessels may not be visualized due to the lenticular opacities. Nystagmus may be present. Poor visual fixation, squint, and poor social smile may be seen later on. Calcification in the globe is not present in cataract. Persistent hyperplastic primary vitreous (PHPV) is caused by persistence of portions of the fetal hyloid vascular system and the associated fibromuscular tissue. The condition is usually unilateral, and the affected eye is smaller than normal. The anterior chamber is shallow, and the lens is also smaller than normal. Other presenting signs are white pupillary reflex (leukocoria) strabismus and nystagmus. The course is progressive and outcome is poor. The major complication is spontaneous intraocular hemorrhage, swelling of lens caused by rupture of posterior capsule, and glaucoma. Sometimes the distinction between PHPV and retinoblastoma can be difficult. Ultrasonography and CT scan can be useful diagnostic aids that may show calcification within the mass in the case of retinoblastoma.

A 42-year-old man presents with a 4-day history of worsening headache, stuffy nose, and excessive yellow colored nasal discharge. He admits to facial pain, as well as a dry cough. He denies shortness of breath, abdominal pain, nausea, or vomiting. He is a non-smoker, has no significant past medical history, and is only taking acetaminophen. On exam, he has a slight fever of 99.2° F taken orally, pulse 86/min, BP 120/76 mmHg left arm sitting, and SPO2 94% on room air. Lungs are clear and abdomen normal. Nasal mucosa appears boggy, and there is tenderness with palpation over the facial bones (maxillary area). Pharynx is without exudates. Question Which of the following organisms is the most common cause of this patient's signs and symptoms? Answer Choices 1 S. pneumoniae 2 H. influenzae 3 Moraxella catarrhalis 4 Adenovirus 5 Rhinovirus

Rhinovirus Explanation The condition being described in this clinical scenario is highly indicative of acute viral rhinosinusitis (acute sinusitis). Acute sinusitis clinically includes such symptoms and signs as green/yellow purulent discharge, facial pain or pressure over the affected sinus, nasal obstruction, congestion, and may also include cough, malaise, fever, or even headache. Acute sinusitis has an acute onset of symptoms, ranging from 1-4 weeks in length of duration by the time the patient presents clinically. More commonly, the origin of sinusitis is viral, and more commonly viral rhinosinusitis originates from infection of the viral organisms that cause the common cold, making the correct answer rhinovirus. Adenovirus is not the appropriate choice in this scenario. Symptoms and signs that are viral in origin will resolve as time passes and not intensify or worsen. If a case of acute Rhinosinusitis is suspected to be bacterial in origin, the most common organisms that lead to this include S. pneumoniae, H. influenzae, and Moraxella catarrhalis; viral etiologies of acute rhinosinusitis are much more commonly seen in otherwise healthy adult patients.

A 28-year-old woman presents with an itchy throat, prolonged sneezing episodes, watery red eyes, and inflamed nasal membranes. Her temperature is normal and a throat culture is negative. She is most likely has allergic rhinitis. Which of the following factors is a major disadvantage of the drug diphenhydramine? Answer Choices 1 Weight gain 2 Sedation 3 Constipation 4 Jaundice 5 Addiction

Sedation The H2 receptor is involved in stimulating gastric acid secretion from parietal cells in the gastric mucosal glands. It also has a cardiac stimulatory effect. H2 receptor activity is expressed by activation of adenylate cyclase and concomitant increased cAMP levels. The H3 receptor seems to be active mainly in the CNS, where it may be involved in modulating histamine neurotransmission at some presynaptic membranes. Histamine itself has no therapeutic applications, but compounds that block its actions at the H1 receptor (H1 receptor antagonists; antihistamines) are very important clinically. There are many kinds of H1 blockers from several different chemical classes. Some are listed in Figure I6.10 below. H1 blockers do not have any effect on the formation or release of histamine from storage sites. They compete with histamine for receptor sites on target cells. H1 receptor blockers do not serve as histamine agonists due to the differences between their structures. Some H1 blockers may also show some affinity for the serotonin, adrenergic, and cholinergic muscarinic receptors. H1 blockers competitively inhibit the effects of histamine. All show varying degrees of sedative and anti-motion sickness effects in the CNS. Since some may act at other receptors (noted above), they may block muscarinic, α-adrenergic, and serotonin receptor mediated effects.

A 25-year-old woman presents with watery eyes and a runny nose. The symptoms get worse after she has been outside, especially if she plays in the grass with her 2-year-old. Allergy testing reveals that she is highly allergic to several grass pollens. Allergy shots using grass pollens as the antigens might be helpful; what event must occur in order for the body to synthesize the complete antibody protein specific for her allergy? Answer Choices 1 Different rRNA molecules must be spliced together 2 Site-specific recombination of DNA must occur 3 All antibody molecules not specific for these antigens must be degraded 4 Various protein precursors must be joined into 1 polypeptide chain 5 Specific DNA sequences must be amplified

Site-specific recombination of DNA must occur Explanation The correct response is site-specific recombination of DNA must occur. Allergy shots are given to individuals who have an allergic reaction to common allergens (e.g., mold or pollen from grasses, ragweed, and trees). A small amount of the allergen is injected into the patient and the body starts making antibodies to the allergen; this allows the body to fight the allergen, and relieve the symptoms of the allergic reaction. The mature antibody molecule is composed of 4 polypeptide chains, 2 heavy chains, and 2 light chains. Generation of the mature antibody molecule, specific to a given antigen, requires rearrangement of immunoglobulin genes in the B cells. There is a 'pool' of gene segments that eventually must be brought together to synthesize the mature antibody molecule. During B cell development, a complete coding sequence for the 2 Ig chains is assembled from the pool of gene fragments by a process called site-specific genetic recombination. Site-specific recombination alters the relative position of gene sequences in the chromosome and requires specific enzymes. Site-specific recombination events primarily occur as a mechanism to change the program of genes expressed at specific stages of development. The most significant site-specific recombination event is the somatic cell gene rearrangement which takes place in the immunoglobulin genes during B-cell differentiation in response to antigen presentation. Extremely diverse potential for antibody production occurs as a result of these gene rearrangements in the immunoglobulin genes. A typical antibody molecule is composed of both heavy and light chains. The genes for both heavy and light peptide chains undergo somatic cell rearrangement, which yields approximately 3,000 different light chain combinations and approximately 5,000 heavy chain combinations. The gene sequences needed to form the mature antibody chains are brought together. A complete Ig chain can only be synthesized after this genetic recombination occurs.

What is the most frequent malignant neoplasm involving the larynx? Answer Choices 1 Adenocarcinoma 2 Squamous cell carcinoma 3 Squamous papilloma 4 Metastatic tumor from another site 5 Fibrosarcoma

Squamous cell carcinoma Explanation The correct response is squamous cell carcinoma. Because the tissue of the larynx includes both mesenchymal and epithelial elements, many types of carcinomas and sarcomas may arise in this location. While adenocarcinomas, fibrosarcomas, and even metastatic tumors may be seen, by far the most common malignant neoplasm is squamous cell carcinoma. Squamous cell carcinomas comprise greater than 90% of all neoplasms in this location. The tumors arise from the squamous epithelium, which lines the larynx, and are most likely preceded by squamous atypia and dysplasia. Lesions may arise anywhere within the larynx. Lesions of the true vocal cord are the most common in the U.S. and are more likely to be detected early because they cause hoarseness. Squamous cell carcinomas are more common in men, with cigarette smoking a major contributer to their development. Squamous papillomas are exophytic benign neoplasms that may arise in any age group.

An 18-year-old man presents with blurred vision and some eye pain that began 2 days ago and has become progressively worse. Upon examination, the eye is slightly edematous with a white to yellow exudate present under the eyelid and at the corner. The rest of his clinical and physical history is unremarkable. A conjunctival scraping is obtained and gram stained. Based on the gram stain result, the conjunctival scraping was sent to the laboratory for culture and sensitivity. The patient is given instructions for topical antibiotic ointment treatment (polymixin B/trimethoprim) to be administered every 2-4 hours for 7-10 days. Pathology later shows that the conjunctival scraping culture grew out a beta hemolytic organism that was catalase positive, coagulase positive, and gram stained as gram-positive cocci. What is the most likely causative organism of the patient's conjunctivitis? Answer Choices 1 Chlamydia trachomatis 2 Pseudomonas aeruginosa 3 Haemophilus aegyptius 4 Bacillus cereus 5 Acanthamoeba spp 6 Staphylococcus aureus 7 Candida albicans

Staphylococcus aureus Explanation Staphylococcus aureus is a gram-positive staining cocci that is catalase positive, coagulase positive, and frequently beta hemolytic on blood agar. It is probably the 2nd most common bacterial isolate of human infections behind Escherichia coli and the most common cause of bacterial endophthalmitis. The organism has been described as an etiologic agent of many infections, including but not limited to, conjunctivitis, endocarditis, septicemia, abscesses, and urinary tract infections. The conjunctivitis caused by Staphylococcus aureusis usually characterized as non-severe where there is little to no lid edema, scant purulent discharge, and normal cornea; however, in some cases the presentation can be severe. Chlamydia trachomatis is an obligate intracellular parasite with a unique biphasic life cycle. It does not gram stain, and laboratory procedures used for diagnosis include isolation in tissue culture, EIA detection of antigen, immunofluorescent staining, cytologic examination for intracytoplasmic inclusions, and by the demonstration of nucleic acid by direct hybridization or by amplification techniques. It can cause inclusion conjunctivitis and ocular trachoma. The inclusion conjunctivitis presents as an acute follicular conjunctivitis and is usually self-inoculated from an infected genitourinary site. The patient frequently complains of a foreign body presence in the eye. These symptoms are usually unilateral, and in the first 2 weeks, there is a mucoid discharge that becomes purulent. Pseudomonas aeruginosa is a gram-negative rod, non-lactose fermenting, oxidase-positive motile bacteria. Pathogenesis is due to its minimal nutritional requirements, relative resistance to antibiotics, and a host of other invasive and toxinogenic substances that it produces. It can cause a keratitis that is rapid in its development. The infection is usually the result of a previous injury to the eye, which causes an interruption in the epithelial surface and allows bacterial invasion of the underlying stroma. Scrapings from the floor of the ulcer exhibiting gram-negative rods are strongly indicative of Pseudomonas aeruginosa and should necessitate treatment. Haemophilus aegyptius is a gram-negative coccobacillus, non-motile, fastidious bacteria requiring the presence of special factors for its growth on agar media. These factors are hemin and nicotinamide adenine dinucleotide, which are present in chocolate agar but not on other isolation media. The organism is indigenous to humans. It is an important cause of a purulent conjunctivitis called "Pink Eye" and can occur in outbreaks because of its contagious nature. The diffuse pink color of the sclera and the presence of a serous or purulent discharge are virtually diagnostic of Haemophilus aegyptius infection. Leukocytosis is absent. The infection is not acute in presentation. Bacillus cereus is a gram-positive (or gram-variable) rod that is aerobic, spore-forming, and is ubiquitous in nature. Bacillus cereus is an important cause of food poisoning. It has also been recognized as an ocular pathogen. The ocular infection is acute in presentation and requires aggressive intervention to save the eye. The presence of progressive corneal deterioration and ring abscess formation is a complication of panophthalmitis caused by Bacillus cereus. Except for infections with Pseudomonas aeruginosa, this finding is almost pathognomonic of Bacillus cereus. Because of the seriousness of the infection, early diagnosis is important. Patients presenting with ocular infections after trauma or in the setting of drug abuse should arouse suspicion. Acanthamoeba is a free-living amebae that can cause granulomatous amebic encephalitis and keratitis. It can not be cultured by routine culture methods. Detection is usually made by observing the free living motile organisms in a wet prep preparation. Acanthamoeba keratitis is a slow-developing corneal infection that occurs in healthy people and is usually associated with contact lens wearers. Symptoms include blurred vision, conjunctivitis, tearing, severe pain to the eye, and photophobia. The keratitis achieves an advanced stage in several days to several months and can exhibit patchy stromal infiltrates and dendriform epithelial involvement without frank corneal ulceration in its early stages. Candida albicans is a yeast. Yeasts appear on gram stain as large gram-positive organisms, approximately 3-5 times larger than gram-positive cocci, and are nonhemolytic on blood agar. They are aerobic and generally grow well on most non-selective agar media. Endophthalmitis due to yeast is generally a common and serious complication of intravenous drug use. Candida albicans is the most common fungal cause. It is usually of hematogenous origin where the patient has infective endocarditis or some other infective process occurring. The symptoms are blurred vision, decreased vision, white cotton appearing exudative lesions in the choroid and retina with vitreous haziness, and eye pain. A definitive diagnosis is made by obtaining vitreous fluid for gram stain and culture.

A 15-year-old boy presents to your office for evaluation of a lesion on the side of his upper lip. The lesion appears on the outer edge of the upper lip. It appears as a small, well-circumscribed elevation with crusting. You tell the patient that the diagnosis is herpes simplex. What type of lesion is this? Answer Choices 1 Vesicle 2 Bulla 3 Nodule 4 Pustule 5 Tumor

Vesicle Explanation A vesicle is a circumscribed elevation of the skin less than 1 cm in diameter. It contains fluid. Bullae are larger than vesiclesand are produced by factors that include chemicals, friction, and heat. A nodule is a solid lesion larger than 1 cm in diameter. It consists of inflammatory cellular infiltrates or neoplasms. Pustules are circumscribed accumulation of pus in the skin. The lesion may or may not be raised. Tumors vary in size and are new skin growths composed of skin and subcutaneous tissue. They may be malignant or benign.

Which of the following examinations is a major component of routine monitoring of chronic, open angle glaucoma? A Pupillary response B Corneal reflex testing C Visual field testing D Accommodation E Visual acuity

Visual Field Testing Tonometry, gonioscopy, monitoring of the disc-to-cup ratio, and visual field examination are the routine exams done when monitoring primary open angle glaucoma.

A 25-year-old man presents to you with an acute otitis media with serous otitis in the right ear. You perform the Weber and Rinne tests. Question Which of the following results would you most likely expect to find? Answer Choices 1 Weber - sound is heard louder in right ear, Rinne - bone conduction exceeds air conduction in right ear 2 Weber - sound is heard louder in left ear, Rinne - bone conduction exceeds air conduction in right ear 3 Weber - sound is heard louder in right ear, Rinne - air conduction exceeds bone conduction in right ear 4 Weber - sound is heard louder in left ear, Rinne - air conduction exceeds air conduction in right ear 5 Weber - sound is equal in both ears, Rinne - bone conduction greater than air conduction in right ear

Weber - sound is heard louder in right ear, Rinne - bone conduction exceeds air conduction in right ear Explanation Otitis media and serous otitis are examples of causes of conductive hearing loss. When a conductive hearing loss exists, the Weber test will result in the appearance of a louder sound in the affected ear and the Rinne test will result in bone conduction exceeding air conduction in the affected ear. The other answers are incorrect because in a sensorineural hearing loss, the Weber test results in a louder sound in the unaffected ear and the Rinne test will result in air conduction exceeding bone conduction in the affected ear.

A 52-year-old man presents with concerns over hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only 1 side (his left). Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms. The patient's past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use. On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed, and it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells. Question After completing treatment for his current condition, what is the best approach for health maintenance of this patient? Answer Choices 1 Full body bone scans every 2 years 2 Prophylactic antibiotics 3 Serum blood tests of inflammatory markers every 6 months 4 Testing only if the patient reports return of symptoms 5 Yearly head imaging

Yearly head imaging Explanation This patient is presenting with a vestibular schwannoma (or acoustic neuroma), affecting his vestibulocochlear nerve (cranial nerve VIII). This is one of the more common benign head and neck neoplasms. A common presentation is unilateral hearing loss and tinnitus. Treatment is typically surgical removal, or possibly radiation therapy. After completing therapy, yearly head imaging is recommended to monitor for recurrence. Full body bone scans every 2 years are not recommended for vestibular schwannomas; they are not likely to metastasize to bone. Prophylactic antibiotics have no role in the original formation or the recurrence of schwannomas. Some other benign neoplasms in the ear, such as cholesteatomas, are associated with chronic ear infections, but antibiotics are still not helpful after treatment of those growths either. Serum blood tests of inflammatory markers every 6 months are not helpful for schwannoma monitoring. Schwannomas are not considered an inflammatory disease and typical serum markers (erythrocyte sedimentation rate and C-reactive protein) may be entirely normal in affected individuals. Testing only if the patient reports return of symptoms is also not appropriate, because of the usual slow-growing nature of schwannomas. Because of very slow hearing loss or balance problems (if the vestibular portion of the nerve is affected), patients with schwannomas may adapt and easily miss these symptoms for years.

A 33-year-old man presents with acute left eye pain. He was working in his garage on a woodworking project, and as he hammered in a nail, he felt that something hit him in the left eye. On examination, you note that the left pupil has a teardrop appearance. Question What diagnostic test/procedure will most likely confirm your diagnosis? Answer Choices 1 Flourescein stain 2 An X-ray of the orbits 3 Test extra ocular movements (EOMs) 4 Check visual acuity 5 Test intraocular pressure

an x-ray of the orbit Explanation The clinical picture is suggestive of an intraocular foreign body or penetrating injury to the eye. This is commonly seen in individuals with a history of pounding on metal or using grinding equipment. The patient may give a history of "something hitting my eye" or "something was pulled out of my eye. His pupil is teardrop shaped, indicating penetration of the globe. An X-ray or CT scan of the orbit should be ordered to rule out radiopaque foreign bodies. Referral to an ophthalmologist is recommended. Fluorescein staining is indicated for a corneal abrasion. To avoid extrusion of intraocular contents, EOMs should not be performed. Visual acuity should be tested but alterations in visual acuity will not confirm your diagnosis. Testing intraocular pressure is indicated if you suspect glaucoma.

A 22-year-old woman presents with nosebleed. Her nosebleed occurred spontaneously with no known injury. Her past medical history is significant for seasonal allergies and migraine. Examination reveals bleeding from the nasal septum. Question What is the appropriate initial treatment for this patient? Answer Choices 1 Have patient lean back to drain blood from nose 2 Apply direct pressure with patient leaning forward 3 Posterior nasal packing 4 Cauterization of the nasal cavity 5 Surgical ligation of the nasal artery supply

apply direct pressure with patient leaning forward Explanation Apply direct pressure with patient leaning forward is correct. The patient has epistaxis. The majority of cases of epistaxis originate from Kiesselbach's plexus in the anterior nose. Patient should first have direct pressure applied to the nose while the patient is leaning forward. Pressure should be continued for a minimum of 5 minutes. Have patient lean back to drain blood from nose is incorrect. Leaning back will cause the blood to collect in the posterior pharynx. Blood in the posterior pharynx may cause nausea or airway obstruction. Posterior nasal packing is incorrect. This patient has anterior epistaxis, so posterior packing should not be done. Cauterization of the nasal cavity is incorrect. Cauterization may be required for severe bleeding, but it is not a first line treatment. Surgical ligation of the nasal artery supply is incorrect. Surgery may be required for severe bleeding, but it is not a first line treatment.

A 58-year-old Caucasian man presents with a bleeding mole on his face. The mole is located on his left cheek has been present for the past several years but has started to spontaneously bleed over the last 3 months. The patient denies any other moles with the same characteristics and just wants it taken care of so it is not as bothersome. The patient denies weight loss, night sweats, or fevers; he has no recent changes in his appetite or sleeping issues. He is a farmer and owns over 100 acres that he plants and harvests yearly and has done so for the past 40 years. On physical examination, you find a 3 cm pink papule that is pearly in appearance and possesses a telangiectatic characteristic to it. Central ulceration is present. Question Given the history and physical exam findings, what is the most likely diagnosis for this patient? Answer Choices 1 Malignant melanoma 2 Squamous cell carcinoma 3 Basal cell carcinoma 4 Benign nevi 5 Actinic keratosis

basal cell carcinoma Explanation The patient in this clinical case scenario most likely has basal cell carcinoma (BCC). BCC is a common skin cancer that arises from the basal layer of the epidermis. BCC is particularly common in Caucasians and has a 30% higher incidence in men than in women. BCC incidence also increases with age, with persons aged 55-75 having a 100-fold higher incidence than those under 20. BCC clinically presents in four or so different clinical types, the nodular form being the most common (making up 60% of the BCC cases). Nodular BCC is described as a pin or flesh-colored papule that is pearly or translucent and evidence of a telangiectatic vessel within the papule. Ulceration is common, sometimes referred to as a "rodent ulcer." The other types of BCC include superficial, morpheaform, other subtypes, and even several BCC syndromes. Squamous cell carcinoma of the skin typically appears as small, red, conical, hard nodules that occasionally will ulcerate. The presence of a pearly appearance helps distinguish BCC from squamous cell, although the two malignancies present in the same patterns. Malignant melanoma of the skin is described as being a flat or raised pigmented lesion. The mnemonic of the "ABCD" rule is what is used to help screen suspicious lesions: Asymmetry, Border irregularity, Color variegation, and Diameter > 6 cm. Benign nevi are common, but any skin lesion that has an ulcer and tendency to bleed should be urgently evaluated to rule out the worst-case scenario. Actinic keratosis is also an incorrect choice. These are generally small (0.2 cm-0.6 cm) macules or papules that could be flesh color, pink, or even slightly hyper pigmented; however, they will feel like sandpaper and are generally tender when palpated. The clinical scenario does not match this description.

A 35-year-old woman presents with a 24-hour history of purulent drainage and erythema of her right eye. After a brief physical examination, cultures of the drainage are taken and she is started on a medication prophylactically that would cover the most common bacterial causes of conjunctivitis (including sexually transmitted diseases). Question On what medication, in either an oral or topical form, would she most likely be started? Answer Choices 1 Erythromycin 2 Tetracycline 3 Bacitracin 4 Olopatadine 5 Acyclovir

erythromycin Explanation Erythromycin ophthalmic ointment, applied 2 - 4 x daily, is a treatment option for non-sexually transmitted bacterial conjunctivitis. If trying to cover all bacterial etiologies of conjunctivitis, then erythromycin can be given in the oral form in order to include good coverage for both gonococcal conjunctivitis and chlamydial conjunctivitis. If the erythromycin ophthalmic ointment were to be prescribed in a patient with a sexually transmitted bacterial conjunctivitis, there may still be a partial or complete resolution of symptoms. Erythromycin, in either the topical or oral form, has a good chance of treating any bacterial cause of conjunctivitis until the culture results confirm the etiologic agent. Tetracycline 250 mg po 4 x daily for 3 weeks is a good treatment choice for chlamydial conjunctivitis should the cultures reveal this as the cause; however, it would not be a good prophylactic choice while waiting for lab results. Bacitracin ophthalmic ointment applied 2 - 4 x daily for 5 days is a good treatment option for patients with bacterial conjunctivitis that is not from a sexually transmitted disease. In these cases, the most common etiologic agent is Staphylococcus aureus. Olopatadine is an antihistamine ophthalmic solution that is used in the treatment of ocular itching associated with allergic conjunctivitis. It would not be of any help in a patient with bacterial conjunctivitis, regardless of the etiology. Acyclovir is an antiviral that is prescribed 400 mg po 5 x a day for 7 days in cases of herpetic viral conjunctivitis. It would not be of any help in a patient with bacterial conjunctivitis, regardless of the etiology.

A 35-year-old man presents with what he describes as a "weird-looking tongue". He denies any soreness, tenderness, or recent injury to the tongue. He is not on any medications. On exam, the tongue has erythematous areas that are smooth and appear to be without papillae. There are also areas that have not been denuded and are still rough to the touch. No lesions, white patches/areas, or ulcerations are appreciated, and the tongue protrudes symmetrically. What is the most likely diagnosis? Answer Choices 1 Hairy leukoplakia 2 Atrophic glossitis 3 Hairy tongue 4 Geographic tongue 5 Candidiasis

geographic tongue Explanation A geographic tongue is a benign condition with unknown cause; it is characterized by a map-like pattern of smooth, red areas that do not have papillae as well as rough areas that still have papillae. Atrophic glossitis (or smooth tongue) presents as having a smooth surface due to papillae loss. The loss may indicate deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron. Candidiasis is an infection that may cause the tongue to have a white coating, which can be scraped, and a sample can be analyzed for the presence of Candida. Hairy leukoplakia may be seen in people infected with HIV and AIDS. It is characterized by raised areas that are whitish-tan in color that have a feathery appearance. It is different from candidiasis of the tongue in that hairy leukoplakia cannot be scraped off. A 'hairy tongue' is not actually due to hair growth on the tongue; it consists of elongated papillae that have the appearance of grayish-black hair to the naked eye. This condition may be caused by antibiotic use, or there may not be any reason.

A woman presents with an otherwise healthy 12-month-old boy because she notice that he has crossed eyes that are different colors. His mother has been smoking for about 10 years, and she smokes during the pregnancy. She remembers that her brother died when he was 3 because he had a tumor in both his eyes. Physical exam reveals heterochromia iridis and leukocoria. Question What is the main risk factor for the condition of this child? Answer Choices 1 Heredity 2 Leukocoria 3 Smoking 4 Heterochromia iridis 5 Strabismus

heredity Explanation The correct response is heredity. The child most likely has inherited retinoblastoma. Retinoblastoma is a rapidly developing cancer that generally affects children under the age of 6. It is most commonly diagnosed in children aged 1 - 2 years. Genetic counseling is especially important when more than 1 family member has had the disease or if the retinoblastoma occurs in both eyes. Leukocoria is seen as a whitish color behind the pupil, which is usually black. It is a sensitive test best done by looking at the "red reflex." Normally, red reflection often occurs in people's eyes when taking flash photographs. Dimming the room lights and using a flashlight to shine light directly into the child's eyes can also elicit the red reflex. With leukocoria, also known as "cat's eye," red reflex is absent. This abnormality is present in approximately 60% of all children with retinoblastoma. Keeping in mind that retinoblastoma is the third most common cancer overall affecting children, red reflex is a useful screening tool. It is a sign and not a risk factor for the disease. Although smoking can affect pregnancy and a child, in this particular case, heredity is probably the main risk factor. Heterochromia iridis is a relatively late symptom caused by the tumor invasion and/or neovascularization. It is a symptom, not a risk factor. Crossed eyes, or strabismus, which occurs as a result of visual loss, is a common sign of retinoblastoma. That is the reason funduscopic examination through a well-dilated pupil must be performed in all cases of childhood strabismus. Strabismus is usually secondary to macular involvement. It is also a sign and not a risk factor for the disease.

A 16-year-old girl has just been diagnosed with severe allergic rhinitis caused by ragweed and dust mite. She is a candidate for allergy immunotherapy, which will involve weekly subcutaneous delivery of the offending allergens in increasing concentrations. Question What is the ultimate goal of this type of immunotherapy for this patient? Answer Choices 1 Immunity 2 Hypersensitization 3 Immune suppression 4 Hyposensitization 5 Eradication of infection

hyposensitization Explanation Allergy injections are a type of immunotherapy that is also known as hyposensitization. Exposure to a gradually increasing amount of allergen results in various cellular effects that lead to a decrease in the production of mast cells by the immune system. It does not result in complete immunity and does not suppress the immune system but rather decreases the reactivity of the immune system. This treatment does not serve to treat infections, as the condition that it treats is not infectious in nature.

A 42-year-old man presents with a 10-day history of worsening headache, stuffy nose, greenish nasal discharge, and a low grade fever. He has body aches and facial pain, as well as a dry cough. He denies shortness of breath, abdominal pain, nausea, or vomiting. He is a non-smoker, has no significant past medical history, and is only taking acetaminophen. On exam, he has a temperature of 100.9° F taken orally. Pulse is 86/min, BP is 120/76 mm Hg left arm sitting, and SPO2 is 94% on room air. Lungs are clear and abdomen normal. Nasal mucosa appears boggy, and there is tenderness with palpation over the facial bones (maxillary area). Pharynx is without exudates. Question What component of the history prompts you to consider giving antibiotics for treatment of this condition? Answer Choices 1 Facial pain, body aches, and a SPO2 of 94% 2 Length of time the symptoms have been present 3 Boggy nasal mucosal with facial tenderness 4 Low grade fever 5 Headache and body aches

length of time symptoms persist Explanation The condition being described in this clinical scenario is highly indicative of acute bacterial rhinosinusitis (acute sinusitis). Acute sinusitis clinically is described as including such symptoms as green/yellow purulent appearing discharge, nasal obstruction, congestion, facial pain, or pressure over the affected sinus, and may also include cough, malaise, fever, or even headache. Acute sinusitis has an acute onset of symptoms, ranging from 1-4 weeks in length of duration by the time the patient presents clinically. More commonly, the origin of sinusitis is viral; however, symptoms relating to this will resolve as time passes and not intensify or worsen.

A 55-year-old man presents with intermittent vertigo, tinnitus, and progressive hearing loss over the last 4 years. What will an MRI of the head most likely show? Answer Choices 1 No abnormalities 2 Acoustic neuroma 3 Aneurysm 4 Stroke 5 Hemorrhage

no abnormalities Explanation The clinical presentation is most consistent with Ménière disease, which is thought to be caused by excess endolymph in the labyrinth. This condition causes no MRI abnormalities.

A 2-week-old female infant is seen for her newborn well baby exam after a normal birth and delivery. She has been nursing well, has regained her birthweight and her development appears normal for her age so far. Physical examination is normal with the exception that ophthalmoscopic evaluation reveals a faint white reflex in her right eye. What is the most likely diagnosis? Answer Choices 1 Retrolental fibroplasia 2 Phakomata 3 Retinitis Pigmentosa 4 Retinoschisis 5 Retinoblastoma

retinoblastoma Explanation Retinoblastoma is the most common primary malignant intraocular tumor of childhood. It usually appears quite early in the first 5 years. Leukocoria, a white or Cat's eye reflex in the pupil is the most frequent finding. There may also be strabismus due to vision impairment. Ocular inflammation, intraocular hemorrhage, glaucoma or heterochromia iridis may be seen. On fundoscopic exam, the tumor may appear as a small to large white mass depending on its stage. Primary treatment includes enucleation, though smaller tumors diagnosed at an earlier stage may be amenable to newer alternative treatments such as cryotherapy and photocoagulation. Though leukocoria may be seen in retrolental fibroplasia or advanced stage of retinopathy of prematurity it is predominantly a disorder in preterm, low birthweight infants who received supplemental oxygen in the newborn period. These infants are susceptible due to the immaturity and subsequent damage of developing retinal vasculature. If the retina goes through various stages to ischemia and neovascularization, leukocoria may be seen representing retinal detachment and a subsequent membrane formation. Phakomata are retinal findings hallmarking hamartomatous disorders such as tuberous sclerosis. The distinctive ocular lesion is a yellowish multinodular cystic lesion arising from the retina or disc. Similar lesions can occur in neurofibromatosis. Retinitis pigmentosa is a progressive degeneration of the retina. It is characterized by pigmentary changes, arteriolar attenuation, some degree of optic atrophy and progressively deteriorating visual impairment. Granularity or mottling of the retinal pigment pattern or distinctive focal pigment aggregates can be seen fundoscopically. Retinoschisis is a congenital disorder involving splitting of the retina into an inner and outer layer. Usually good vision is maintained. An elevation of the inner layer of the retina can be seen.

A 62-year-old man presents with a 1-month history of mouth pain and non-healing white patches on his mouth. He denies infection and recent trauma to the area. Past medical history is significant for diabetes mellitus, hypertension, osteoarthritis, and gonorrhea, which was treated 6 months ago. Social history is positive for a 20-pack year smoking history and cocaine abuse; he quit both approximately 10 years ago. On examination, leukoplakia is present, as seen in the image. The patient is referred for biopsy. Question What is the strongest risk factor for the most likely diagnosis? Answer Choices 1 Age 2 Male gender 3 Recent history of gonorrhea 4 Tobacco use 5 Cocaine use

tobacco use Explanation Tobacco use and alcohol use are the strongest risk factors for oropharyngeal cancer. The patient has non-healing areas of leukoplakia, which is suggestive of malignancy. Squamous cell carcinoma is the most common type of oropharyngeal cancer, and approximately 75% of patients will have a history of tobacco and/or alcohol abuse. Oropharyngeal cancer is more common with increased age and male gender, but tobacco use is a stronger risk factor. Recent history of gonorrhea is incorrect. While human papillomavirus (HPV) is strongly associated with oropharyngeal cancer, gonorrhea is not a risk factor. Cocaine use is not associated with the development of oropharyngeal cancer.