Ophthamology and Otolaryngology questions
A 2-year-old child is brought to your office by her parents. You notice mild but obvious strabismus. Unless she undergoes ophthalmologic treatment, what is the likely outcome? (A) Amblyopia (B) Esotropia (C) Exotropia (D) Hypophoria (E) Crossed eyes
(A) Amblyopia is the permanent decrease in visual acuity in a child caused by abnormal visual exposure during the maturation process. During this time it is important for the retina and central nervous system to integrate. Strabismus, which can cause blurred retinal image in one or both eyes can lead to this permanent visual disorder.
Your patient is a 35-year-old male who is HIV positive. He states that he has a loss of appetite and odynophagia. You examine the mouth and find white plaques on the tongue and buccal mucosa. Gentle scraping with a tongue blade removes the white plaques revealing erythematous raw areas underneath. What is the most likely diagnosis? (A) Candidiasis (B) Squamous cell carcinoma (C) Basal cell carcinoma (D) Hairy leukoplakia (E) Diphtheria
(A) Candidiasis produces a thick white coating on the tongue that is easily scraped off, revealing a raw erythematous area underneath. Candida is common is immunocompromised patients. Oral cancers, most commonly squamous cell carcinomas are more common in abusers of tobacco and alcohol over the age of 50. Corynebacterium diphtheriae produces a red throat and gray exudate or the uvula, pharynx, and tongue. Although this patient is HIV positive and therefore at risk for hairy leukoplakia, the feathery white lesions of hairy leukoplakia cannot be scraped off.
A patient is seen in the emergency department following mild to moderate trauma to the eye. The patient states that his pain is 8/10. Examination is essentially normal except for epiphora and significant photophobia. What is the most appropriate treatment for this patient? (A) Antibiotic ointments or drops (B) Emergent consultation with an ophthalmologist (C) Complete bed rest and avoidance of ASA and other NSAIDs (D) Medications to cause miosis such as pilocarpine (E) Oral or topical NSAIDs for pain relief
(A) Corneal abrasions are treated with antibiotic drops and occasionally patching. Ophthalmology referral is generally not necessary. Complete bed rest and avoidance of anticoagulating medications are appropriate treatment of hyphema or blood in the anterior chamber. Agents which cause mydriasis, not miosis, are appropriate adjuncts to treatment for corneal abrasion.
A 17-year-old Asian male presents to the clinic complaining of increasingly painful left ear for the prior 3 days which has now become severely painful. He is a swimmer on the school swim team. The pain is now so severe that the ear is painful to touch. The left ear displays tenderness on motion of the tragus and there is significant edema along with a small amount of purulent drainage. Culture of the ear would most likely grow: (A) Pseudomonas aeruginosa (B) Staphylococcus aureus (C) Haemophilus influenzae (D) Moraxella catarrhalis (E) Streptococcus pneumoniae
(A) External otitis is usually caused by gram-negative rods like Pseudomonas or Proteus
A 5-year-old child presents to your pediatric practice with her parents complaining of a 2-day history of fever (101°F), sore throat, and tearing and mild erythema of both eyes. Since it is summer, she has been taking swimming lessons in a public pool. There is no cough, nasal congestion, pain, or photophobia. Your examination shows a small amount of exudate in the eyes bilaterally along with a large amount of clear discharge. There are conjunctival follicles present in both eyes and follicles of the pharyngeal mucosa. There is nontender adenopathy in the preauricular area. What is the most likely diagnosis for this patient? (A) Viral conjunctivitis (B) Bacterial conjunctivitis (C) Allergic conjunctivitis (D) Bacterial pharyngitis (E) Blepharitis
(A) Fever, pharyngitis, conjunctivitis, and findings of preauricular lymph nodes point to viral conjunctivitis. Common in children, it is sometimes associated with contaminated swimming pools. Bacterial conjunctivitis is characterized by erythematous conjunctiva, along with significant purulent discharge and is usually unilateral. Allergic conjunctivitis is associated with pruritus along with clear watery drainage. Bacterial pharyngitis is most commonly associated with pharyngeal erythema and exudate, along with tender anterior cervical adenopathy.
Gingival hyperplasia may be a complication of chronic administration of which of the following medications? (A) Phenytoin (Dilantin) (B) Valproic acid (Depakote) (C) Phenobarbital (D) Clonazepam (Klonopin) (E) Carbamazepine (Tegretol)
(A) Gingival hyperplasia is a known possible complication of dilantin. The prevalence of phenytoininduced gingival hyperplasia is estimated at 15% to 50% in patients taking the medication.
A child with notching of the maxillary incisors (Hutchinson's teeth or incisors) most likely has: (A) A history of congenital syphilis (B) A history of intraoral infection with Mycoplasma pneumonia (C) A history of in utero exposure to tetracycline (D) Been given a sulfa product before the age of 2 months (E) Continued using a pacifier past the age of 2 years
(A) Notching of the incisors is sometimes but not always caused by congenital syphilis. None of the other listed options cause Hutchinson's incisors.
A 70-year-old woman with a history of glaucoma and diabetic retinopathy presents to the ED stating that she fell down and bumped her head earlier in the evening. She is now experiencing a sensation of flashing lights and floaters in her right eye. She has decreased visual acuity and feels there is a curtain over her visual field. Fundoscopic examination is difficult and therefore nondiagnostic. What is the next step that you should take? (A) Emergency ophthalmology referral (B) Fasting blood glucose (C) CT scan of the head (D) Neurological examination (E) Admission to the hospital for head injury observation
(A) Patients with retinal detachment frequently complain of unilateral photopsia or a sensation of flashing light, an increased number of floaters (posterior vitreous detachment), decreased visual acuity and metamorphopsia, or wavy distortion of an object. Emergency referral to an ophthalmologist is warranted if a retinal detachment is suspected.
A patient presents in your clinic with a rash 2 days after having a sore throat and a fever examination reveals Pastia's lines, a "strawberry tongue," and circumoral pallor. Labs show a positive ASO titer. The patient is on no medications to have caused the rash or prevented it. What is your diagnosis? (A) Scarlet fever (B) Erythema infectiosum (C) Infectious mononucleosis (D) Rubella (E) Rubeola
(A) Strawberry tongue: erythematous and sometimes edematous tongue with prominent papillae (Strawberry tongue), pink or red linear lesions seen in the body folds, especially the antecubital and axillary folds (Pastia's lines), and a positive antistreptolysin test, indicating previous streptococcal infection, clinch the diagnosis of Scarlet fever.
A 45-year-old female relates a history of recurring bouts of uveitis, primarily posterior. Chemistry panel shows elevated serum calcium and uric acid levels. As part of the workup, a chest x-ray is obtained and reveals bilateral hilar adenopathy. Her uveitis is most likely secondary to what diagnosis? (A) Sarcoidosis (B) Alpha-1 antitrypsin deficiency (C) Silicosis (D) Tuberculosis (E) Histoplasmosis
(A) The etiology of uveitis is generally immunologic. Posterior uveitis is generally associated with sarcoidosis, toxoplasmosis, tuberculosis and syphilis. Of these, sarcoid presents with hilar lymphadenopathy, elevated ACE, calcium and uric acid levels. Alpha-1 antitrypsin deficiency is not associated with uveitis, but rather COPD. Silicosis is a pulmonary disease caused by inhalation of silicon dioxide dust. Elevated serum calcium and uric acid is not seen. Radiographs typically show bilateral alveolar filling and a ground-glass appearance. Tuberculosis may present with hilar lymphadenopathy, but elevated ACE, calcium, and uric acid levels are not characteristic of tuberculosis. Histoplasmosis may rarely involve asymptomatic ocular involvement. CBC may show anemia and elevated lactate dehydrogenase and alkaline phosphatase.
A 19-year-old female presents with pain, redness, and swelling of the upper eyelid for the last 3 days. There are no visual changes or photophobia. Examination reveals a tender, erythematous, and outward-pointing edema of the right eyelid. The most likely diagnosis is which of the following? (A) Hordeolum (B) Chalazion (C) Subconjunctival hemorrhage (D) Entropion (E) Blepharitis
(A) The lesion described is a hordeolum. A chalazion is a granulomatous lesion and is nontender. It is associated with redness and swelling of the conjunctiva. Blepharitis presents bilaterally and is a chronic condition. Subconjunctival hemorrhage affects the conjunctiva only. Entropion is inward turning of the lower eyelid which presents in older people.
What is the most common site for epistaxis in adults? (A) Woodruff's plexus (B) Anterior ethmoid (C) Hasselbach's plexus (D) Sphenopalatine artery (E) Kiesselbach's plexus
(E) The most common site of epistaxis is in the anterior septum where a confluence of veins creates a superficial venous plexus known as the Kiesselbach plexus.
A 22-year-old mixed martial arts practitioner presents after an injury during a match which has resulted in a fluctuant, mildly tender edematous lesion of the anterior-superior outer portion of the right pinna. Which of the following is the most appropriate treatment? (A) Refer to otolaryngology for definitive treatment with I & D and pressure dressing (B) Perform I & D only if the pinna becomes erythematous and extremely tender (C) Prescribe a 10-day course of amoxicillin/ clavulanate (augmentin) and schedule a follow-up appointment in 2 weeks (D) Apply a soft bulky dressing to the pinna and recommend no further treatment, but have the patient follow-up only if he develops a temperature greater than 101 degrees
(A) The most appropriate course of action for this patient is to refer immediately for I & D by an ENT specialist for the best results. The cartilage of the pinna requires vascular supply from the perichondrium. If deprived of blood, the devascularized tissue can become permanently damaged resulting in the so-called "cauliflower ear." This is frequently caused by blunt trauma such as that experienced by wrestlers, boxers, and martial artists. Although antibiotics are frequently given in addition to I & D, they will not prevent tissue necrosis. A pressure dressing is applied after I & D.
A woman in her third trimester of pregnancy believes that she may have been exposed to cytomegalovirus at some point in her pregnancy. Exposure to cytomegalovirus increases the risk of which of the following disorders? (A) Limb deformity (B) Sensorineural hearing loss (C) Neonatal sepsis (D) Intraventricular hemorrhage (E) Cleft palate
(B) Congenital CMV infections are generally not apparent at birth. Five percent to 25% of asymptomatic infants with CMV infections develop significant hearing, visual, or dental abnormalities over the next several years. Hepatic pathology is also common in exposed infected infants, but of the options given, sensorineural hearing loss is the most likely complication of CMV infection.
A 66-year-old male with poorly controlled diabetes mellitus presents to the emergency department with a sudden onset and rapid progression of sore throat with severe pain with swallowing saliva. Upon examining the throat, you note mild erythema. Which of the following is true? (A) Treatment is supportive and based on symptom relief (B) Inpatient treatment is needed (C) Patient should be given IM ceftriaxone and prednisone and follow-up in 48 hours (D) Laryngoscopy is absolutely contraindicated (E) Needle biopsy should be performed
(B) Epiglottitis should be suspected when there is rapid onset of severe sore throat, or when the pain and odynophagia is disproportional to the physical examination findings. It is more common in patients who have diabetes. Contrary to children, indirect laryngoscopy is generally safe in adults. The patient should be hospitalized for airway maintenance, and IV treatment. Fewer than 10% of adults require intubation.
For which of the following conditions is a lateral cervical x-ray with a soft tissue technique a useful part of the workup? (A) Allergic rhinitis (B) Epiglottitis (C) Asthma (D) Quinsy (E) Croup
(B) Epiglottitis will show a "thumb sign" on the lateral C-spine x-ray. The thumbprint sign or "thumb sign" describes a swollen, enlarged epiglottis; usually with dilated hypopharynx and normal subglottic structures.
While examining a 6-year-old female, you note an alarming finding suggestive of cystic fibrosis. Which of the following nasal conditions is suggestive of this disease? (A) Chronic rhinitis (B) Nasal polyps (C) Choanal atresia (D) Perennial allergic rhinitis (E) Acute sinusitis
(B) Finding nasal polyposis in a child is a "red flag" condition and should make the clinician suspicious of possible cystic fibrosis. Usually this disease is diagnosed in early childhood generally with lung involvement and often failure to thrive. The children may also experience chronic sinusitis and recurring ear infections. Polyps generally appear between the ages of 5 and 14. Alert clinicians should order a sweat chloride test.
A 65-year-old gentleman presents with an acute onset of right facial nerve paralysis. Physical examination shows vesicular lesions on the ipsilateral pinna. What is the most likely diagnosis? (A) Bell's palsy (B) Ramsay-Hunt syndrome (C) Moebius syndrome (D) Millard-Gubler syndrome (E) Melkersson-Rosenthal syndrome
(B) Herpes zoster oticus (Ramsay-Hunt syndrome) consists of acute facial palsy combined with otalgia and varicella- or vesicular-type lesions. There is intense ear pain, pathognomonic lesions on the pinna, and facial paralysis. The cause is the herpes varicella virus.
When seeing a 64-year-old gentleman for a routine follow-up of hypertension and hyperlipidemia, examination of the retina shows white lesions with irregular borders. They are moderate in size. What are these lesions are called? (A) Hard exudates (B) Cotton-wool patches (C) Drusen (D) Intraluminal plaques (E) Retinal infiltrates
(B) Hypertension sometimes produces fluffy grayish or white lesions of the retina called cotton-wool spots. Hard exudates are usually small and round and are sharply outlined bright yellow retinal lesions. Drusen are little round yellow spots, maybe hard or softly outlined and are associated with age-related macular degeneration. Preretinal hemorrhages appear as a horizontal line of demarcation and obscure the underlying retinal vessels.
While working in a university health clinic, you are evaluating a 19-year-old female student with complainant of sore throat, fatigue for 14 days. She has a low-grade fever of 100°F. Examination shows exudative pharyngitis along with tender anterior and posterior lymphadenopathy. A rapid strep antigen test is negative. What is the next step in treating this patient? (A) Review history for recurring tonsillitis (B) Perform a monospot test (heterophile antibody) (C) Advise the patient that it is viral and treat presumptively (D) Treat with penicillin (E) Await confirmation of culture before definitive treatment
(B) Mononucleosis is a frequent cause of exudative pharyngitis in the absence of strep pharyngitis. It is often associated with anterior and posterior cervical adenopathy along with generalized lymphadenopathy and an enlarged spleen. Obtaining a monospot can provide the definitive diagnosis. While reviewing the history is certainly an aspect of every patient encounter, reviewing the history for similar episodes is unlikely to lead to a diagnosis for this patient. Although the patient does likely have a viral infection, it is appropriate to evaluate for mononucleosis. A rapid strep test was negative and the course of this patient's illness has run longer than strep pharyngitis usually runs. A monospot test is rapid and easy to obtain. There is no benefit to withholding the test at this time.
You are evaluating a patient for recurring bouts of vertigo. The attacks generally last less than half an hour and are associated with decreased lowfrequency hearing in the left ear along with nonpulsatile tinnitus in the ipsilateral ear. You obtain an audiogram which shows a low-frequency hearing loss in the left ear only. Which of the following is the most likely diagnosis based on the patient history? (A) Benign paroxysmal positional vertigo (B) Ménière syndrome (C) Vestibular neuronitis (D) Labyrinthitis (E) Acoustic neuroma
(B) Ménière syndrome is characterized by bouts of vertigo along with unilateral low-frequency sensorineural hearing loss with tinnitus in the affected ear. Eustachian tube dysfunction usually results in a conductive hearing loss. Benign paroxysmal vertigo (BPPV) is not associated with unilateral hearing loss. The vertigo of BPPV is associated with positional change. Vestibular neuronitis and labyrinthitis present with acute severe vertigo and often nausea and vomiting and neither is associated with unilateral hearing loss. An acoustic neuroma is usually associated with a hearing loss across all frequencies which is generally insidious in onset.
A 50-year-old woman presents with a progressive sense of decreased hearing in her right ear over the course of the last 20 years. Her father had hearing problems at a young age as well, but never underwent any type of workup. She denies any history of ear problems or infection as a child, ear trauma, or excessive noise exposure. The entire physical examination of the ear is normal and the tympanogram testing is within normal limits. The Weber test lateralizes to the ear with the decreased hearing (the right). Air conduction is greater than bone conduction in the left ear, but the right ear shows bone conduction better than air conduction. What is the most likely diagnosis? (A) Serous otitis media (B) Otosclerosis (C) Presbycusis (D) Myringosclerosis (E) Idiopathic hearing loss
(B) Otosclerosis is a progressive, familiar condition in which the bones of the middle ear (the ossicles) soften and then harden (or sclerose) at the joints. This results in increased impedance to the passage of sound through the ossicles causing conductive hearing loss. Diagnosis may be made based on the family history of hearing loss which proves via tuning forks or audiometry to be conductive. The physical examination would show normal tympanic membranes. Presbycusis and "idiopathic hearing loss" or sudden onset sensorineural hearing loss cause sensorineural loss and myringosclerosis does not generally produce any hearing loss. Serous otitis media would be apparent on pneumatoscopy.
A 28-year-old man presents with bilateral conjunctivitis, dysuria, pain in his lower back and right Achilles tendonitis. What is the most likely diagnosis? (A) Ankylosing spondylitis (B) Reiter syndrome (C) BehÇet disease (D) Polyarteritis nodosa (E) Gonococcal disease
(B) Reiter syndrome is a disorder that consists of a triad of the following symptoms: arthritis, conjunctivitis, and urinary tract symptoms. It is sometimes referred to as a reactive arthritis, responding to an infection elsewhere in the body particularly in the GI or genitourinary tract. The diagnosis is based on history and physical examination findings.
Oral carcinomas in general, __________________ ______________. (A) Are treated primarily with radiation if they are small (B) Are related to tobacco use and excessive alcohol consumption (C) Are more likely to result from leukoplakia than erythroplakia (D) Are rapidly growing tumors with early metastatic potential (E) Range from well to poorly differentiated adenocarcinomas
(B) Squamous cell carcinoma accounts for 90% of oral cancer. Alcohol and tobacco use are the major risk factors. Leukoplakia represents early invasive squamous cell carcinoma or dysplasia in 2% to 6% of cases. Erythroplakia is more aggressive and undergoes malignant transformation more frequently. Local resection is the treatment of choice for smaller lesions, and radiation is not generally used as first-line treatment for small lesions.
A 75-year-old man presents with sudden unilateral vision loss. His history includes some prior episodes of visual loss that completely resolved spontaneously. In the past, to evaluate these episodes, he underwent a carotid ultrasound which confirmed a suspected diagnosis of bilateral carotid stenosis. Considering the patient's current painless sudden visual loss, which of the following findings would you expect to find with fundoscopic examination? (A) Retinal lines that have the appearance of a "ripple on a pond" or a "billowing sail" (B) A pale or milky retina with a cherry-red fovea (C) Enlarged physiologic cup, occupying more than half of the disc's diameter (D) A swollen disc with blurred margins; no visible physiologic cup (E) Yellowish-orange to creamy-pink disc with sharp margins and a centrally located physiologic cup
(B) The central retinal artery occlusion occurs when small emboli become lodged in retinal arterioles. Recurrent small emboli frequently cause amaurosis fugax or transient visual loss. Fundoscopic examination will show a pale retina with a cherry-red spot at the fovea. (
A 35-year-old female presents complaining that she experiences several minutes of vertigo-associated turning over in bed for the last 3 days. She denies hearing loss, otalgia, and tinnitus. The Dix-Hallpike maneuver shows rotary nystagmus diminishing with repeated testing. What is the most likely diagnosis? (A) Central nervous system (CNS) lesion. (B) Benign positional vertigo (C) Labyrinthitis (D) Ménière syndrome (E) Vestibular neuronitis
(B) The description is consistent with positional vertigo which is assumed to be caused by tiny canaliths in the inner ear. It is a benign, self-limited condition, and can be treated with an 80% success with canalith repositioning procedure. The Dix- Hallpike maneuver is a positional testing that is used to confirm the diagnosis. The vertigo must be positional in nature. Ménière syndrome is associated with unilateral tinnitus and hearing loss in addition to vertigo, which is not positional. Vertigo associated with labyrinthitis and vestibular neuronitis is not positional. Central lesions do not typically have an association of the vertigo and nystagmus. Vestibular nystagmus should differentiate positional vertigo from a central lesion.
What pathogen is most likely associated with acute onset pain, redness, and outward-pointing edema of the eyelids? (A) Aspergillus species (B) Staphylococcus aureus (C) Haemophilus influenzae (D) Candida albicans (E) Streptococcus aureus
(B) The lesion, a hordeolum is most likely caused by a staphylococcal infection, typically Staphylococcus aureus.
Your patient is a 70-year-old female. She states that her children and grandchildren have asked her to seek medical attention as she seems to be losing her hearing. She is in generally good health and her only medications are a multiple vitamin along with calcium and vitamin D. You examine her ears and find the external auditory canals to be free of cerumen and the tympanic membranes to be normal in appearance. What other complaint is the patient most likely to experience? (A) Otalgia (B) Tinnitus (C) Vertigo (D) Pressure sensation in the ears (E) Tympanic membrane perforation
(B) The patient most likely has age-related sensorineural hearing loss or presbycusis. This is often associated with tinnitus. There is usually no pain or pressure sensation associated with presbycusis. Isolated age-related hearing loss is not associated with vertigo. The examination findings indicated that the tympanic membranes were normal.
Your patient, who is a 39-year-old truck driver presents stating that he has had a growth for at least 8 years on his eyes. Your examination shows a fleshy triangular area of conjunctivae encroaching onto the nasal aspect of the cornea bilaterally. It has begun affecting his vision. What is the best intervention at this time? (A) Artificial tears (B) Excision (C) Iridotomy (D) Topical NSAIDs (E) Reassurance, this is a benign condition
(B) The patient stated that the lesion was affecting his vision. Therefore, and especially as the patient is a truck driver, he requires excision of this lesion. Artificial tears along with topical NSAIDs or corticosteroids may help symptoms of an irritated pterygium, but do not provide definitive treatment. An iridotomy is the recommended treatment for acute angle closure glaucoma
You determine that a patient with bilateral hearing loss should undergo an audiogram for a more complete evaluation of her hearing loss. As part of the examination, you perform Weber and Rinne tests and find that Weber is equal in both ears and air conduction is greater than bone conduction is greater in both ears. Therefore, you suspect that her hearing loss, if any, is most likely: (A) Conductive (B) Sensorineural (C) There is no hearing loss; Weber and Rinne tests are both normal (D) Mixed hearing loss (sensorineural and conductive) (E) Idiopathic
(B) This woman's hearing loss is most likely age-related sensorineural hearing loss, or presbycusis. In a conductive hearing loss, the Weber is transmitted to the ear with decreased hearing and the bone conduction is greater than the air conduction (even with bilateral conductive losses). The patient's history states that there is a hearing loss.
The next patient is a 72-year-old gentleman with poorly controlled type 2 diabetes on oral medications. He has been treated for the past 3 weeks with ear drops for external otitis, but the infection continues to worsen. Your examination today reveals profuse foul-smelling purulent drainage along with granulation tissue in the auditory canal. What is the next step in managing this patient? (A) Debride the canal and start on an oral antipseudomonal antibiotic such as ofloxacin. (B) Perform a gram stain and culture of the discharge. (C) Request an emergent CT of the head. (D) Prescribe oral, antibiotics, topical otic antibiotics and provide pain management. (E) Improve management of the patient's diabetes and your conservative therapy will become more efficacious.
(C) A CT scan is imperative at this time to confirm the diagnosis of malignant external otitis. Granulation tissue in the canal is suggestive of this condition as are cranial nerve palsies. In addition, the diagnosis is suggested by the patient's history of poorly controlled diabetes. Persistent external otitis can evolve into osteomyelitis of the skull base.
A 40-year-old female presents with a foreign-body sensation in the right eye. Over the last 3 weeks, she has had gradually increasing painless swelling around the right lower eyelid. Your examination shows a nontender discrete nodule on the right lower eyelid. There is no evidence of injection or discharge and her visual acuity is normal. The most likely diagnosis is: (A) Blepharitis (B) Pterygium (C) Chalazion (D) Dacryocystitis (E) Hordeolum
(C) A chalazion is a granulomatous sterile inflammation of a Meibomian gland. Chalazions develop gradually producing hard, painless discreet swelling of the upper or lower eyelid. Pterygia do not affect the eyelids, they are conjunctival lesions. Dacryocystitis is a localized infectious process of the lacrimal sac. They are warm and tender. Hordeolum is acutely developing inflammatory lesion. Blepharitis usually occurs bilaterally and involves the entire upper or lower eyelid. Pterygiums are conjunctival lesions not involving the eyelids. Dacryocystitis produces a warm, tender localized infection of the lacrimal sac. Hordeola are acutely developing inflammatory lesions
A 43-year-old male presents with "lifelong" history of chronic ear infections and episodic purulent drainage from his right ear canal. The patient currently is without symptoms. Examination of the ear shows a clear external canal, but the tympanic membrane is retracted and there is a pocket of white material and an opacity of the pars flaccida. The Weber test lateralizes to the right and Rinne shows AC > BC on the left and BC > AC on the right. What is this finding called? (A) Tympanosclerosis (B) Otosclerosis (C) Cholesteatoma (D) Keratosis obturans (E) Malignant otitis externa
(C) A cholesteatoma is a squamous epithelial-lined sac that gradually increases in size and can eventually erode through bones, for example, the ossicular chain or nerves (i.e., facial nerve). It may become infected and drain intermittently. It is sometimes a complication of chronic otitis media or may result from perforation of the tympanic membrane involving the margin or pars flaccida. Myringosclerosis (scarring of the tympanic membrane) presents as white one-dimensional translucent patches on the TM. Tympanosclerosis and otosclerosis involve pathology of the middle ear. Keratosis obturans is accumulation of scaly sloughed-off keratin in the external auditory canal.
After being involved in an altercation the night before a 24-year-old male presents to the ER with persistent double vision. His left periorbital area displays significant ecchymosis and edema. Based on the history, what other findings do you expect on physical examination and what diagnostic test will confirm the diagnosis? (A) Hyphema; Schiotz tonometer (B) Hyphema; plain radiograph (C) Restricted ocular movement; CT scan (D) Restricted ocular movement; plain radiography (E) Ruptured globe; retinal angiography
(C) A history of facial/orbital trauma that results in diplopia is suggestive of an orbital blowout fracture with entrapment. One would expect restricted extraocular movements. Plain films could help identify injury to the bones, the CT is the best assessment of orbital trauma
While working in the ER you are triaging a patient who experienced facial trauma. You note blood in the anterior chamber of the patient's left eye. What is a possible complication for this patient? (A) Retinal detachment (B) Cataract formation (C) Glaucoma (D) Chronic conjunctivitis (E) Complications are extremely rare and most patients return to normal vision
(C) Acute angle closure glaucoma may be brought on by hemorrhage causing excessive red blood cells in the anterior chamber damaging the trabecular meshwork. Globe rupture and intraocular foreign body may occur during injury, not retinal detachment. Cataracts are not a complication of hyphema. Hyphema does not involve the conjunctiva so chronic conjunctivitis is not a concern. The patient requires complete rest and daily ophthalmologic assessment until there is total resolution. (
A 23-year-old male patient states that he was injured during an altercation about 5 to 6 days ago. He was hit in the face during the disagreement. He states that the nasal swelling that he had experienced has decreased, but he has had increasingly more difficulty breathing through his nose. Upon examination, you note soft fluctuant swelling of the septum bilaterally. There is no tenderness to palpation. What is the most appropriate intervention? (A) Intranasal steroids for 2 to 3 weeks to reduce nasal inflammation (B) Broad-spectrum antibiotic to prevent abscess formation (C) Emergent referral to otolaryngology (ENT) provider (D) CT scan to rule out complex nasal fracture (E) Needle aspiration of the fluctuant area with cultures
(C) Emergency referral for surgical drainage of the nasal septal hematoma is required. Drains and packing must be placed to prevent reaccumulation of the hematoma. Additionally, the integrity of the nasal septal cartilage must be evaluated. Failure to drain the subperichondrial hematoma would cause necrosis of the nasal cartilage and result in saddle nose deformity.
A 39-year-old male states that he was holding his baby daughter and she put her fingers in his right eye. He now presents to the ED with acute eye pain and photophobia. His right eye appears grossly normal except for increased tearing. Which of the following is the diagnostic study of choice in this patient? (A) Schiotz or applanation tonometry (B) Fundoscopic examination and refraction (C) Fluorescein staining (D) Schirmer test (E) Visual acuity testing
(C) Fluorescein staining is the diagnostic evaluation of choice to diagnose corneal abrasions which, based on the history, is the patient's most likely diagnosis. While ophthalmic evaluation and refraction should be performed in all patients with eye complaints they do not definitively diagnose a suspected corneal abrasion. Tonometry is used to measure intraocular pressure in patients and is an evaluation for glaucoma. Schirmer test is used when a person experiences very dry eyes or excessive watering of the eyes and measures the function of the lacrimal glands.
An 18-month-old little girl, described by her mother as an active explorer, presents with foul smelling unilateral nasal drainage and decreased activity. What is the most likely cause of the patient's symptoms? (A) Ethmoid sinusitis (B) Nasal polyp (C) Impacted foreign body (D) Maxillary sinusitis (E) Acute viral rhinitis
(C) Foreign bodies in the nose create foul smelling purulent and sometimes bloody unilateral nasal drainage. Unilateral purulent nasal drainage should be considered a foreign body until proven otherwise and clinicians must always rule out nasal foreign bodies with a complaint of unilateral purulent nasal drainage, particularly in a child or a patient with decreased cognitive abilities.
A 4-year-old girl presents with fever, rash, bilateral occipital, and posterior cervical adenopathy along with conjunctivitis. What is the pathognomonic physical examination finding for measles (rubeola)? (A) Gray pharyngeal membrane (B) Exudative pharyngitis (C) Koplik spots (D) Steeple sign (E) Thumbprint sign
(C) Koplik spots are pathognomonic of measles and consist of bluish-white dots ∼1 mm in diameter surrounded by erythema. The lesions appear first on the buccal mucosa opposite the lower molars but rapidly increase in number to involve the entire buccal mucosa. They fade with the onset of rash. They may even be used to isolate children to prevent epidemics as they appear prior to maximum infectivity. Gray pharyngeal pseudomembrane is pathognomonic of diphtheria. Exudative pharyngitis is seen with mononucleosis and streptococcal pharyngitis. Steeple sign is seen in croup, and a thumbprint sign is seen with epiglottitis.
A previously healthy 14-month-old little boy is brought into your pediatric clinic with his mother who states that he has nasal blockage and "stinky green" nasal drainage from the left nostril only for 2 days. Apart from the unilateral purulent nasal drainage, the remainder of the examination is normal. What is the most likely diagnosis? (A) Nasal polyps (B) Frontal sinusitis (C) Nasal foreign-body impaction (D) Deviated nasal septum (E) Choanal atresia
(C) Nasal drainage which is purulent and unilateral in a child or someone with cognitive compromise should be considered to be a foreign-body impaction until proven otherwise. Nasal polyps do not typically cause purulent drainage. However, if a child presents with nasal polyposis, consideration should be given a workup for cystic fibrosis, possibly including a sweat chloride test.
Which of the following patients should undergo audiologic evaluation? (A) A 35-year-old female with a history of tympanostomy tubes as a child (B) A 6-year-old little girl with otitis media (C) A 69-year-old healthy female (D) A 40-year-old male whose father developed hearing loss in his mid-60s (E) A 58-year-old male with chronic cerumen impaction
(C) Routine audiology screening is recommended in all adults who have reached the age of 65. None of the other patients requires an audiogram based on their presentations.
A 60-year-old female with a history of well-controlled diabetes presents with acute episode of left facial paralysis. She is still able to wrinkle and elevate her forehead bilaterally. She has been in good health recently and has not experienced otalgia. The ears are normal both grossly and to otoscopic examination. Tuning forks yield negative Weber and Rinne. Eye examination is also completely normal to include visual acuity, extraocular movements, and pupillary responses. Based on physical examination findings, what is the most likely diagnosis? (A) Bell's palsy (B) Ramsay-Hunt syndrome (C) Cerebrovascular accident (D) Peripheral facial nerve palsy (E) Diabetic neuropathy
(C) Sparing of the forehead in facial paralysis as in this patient is indicative of a lesion superior to the nucleus of the VII cranial nerve such as a brain tumor or a stroke. Ramsay-Hunt is accompanied by painful vesicular lesions.
A 49-year-old female complains of 2-week history of severe left ear pain. She states that chewing exacerbates her ear pain. Her hearing is unchanged. Examination shows tenderness to palpation anteriorly of an otherwise normal appearing external canal meatus. The examination of the tympanic membrane is normal. The patient's diagnosis is most likely: (A) Otitis externa (B) Otitis media (C) Temporomandibular joint disorder (D) Furuncle of the canal (E) Chondritis
(C) TMD is a common cause of pain referred to the ear. It may be an inflammatory response to dental procedures or caused by bruxism. The tipoffs to this diagnosis are the pain increased by eating and normal ear examination apart from tenderness over the TMJ within the ear canal. In a retrospective study of 4,528 patients with TMD, the most common presenting signs and symptoms were: pain (96.1%), ear discomfort or dysfunction (82.4%), headache (79.3%), TMJ discomfort or dysfunction (75.0%).
You are examining a 64-year-old male patient with a 45 pack-year history of tobacco (both cigarette and smokeless tobacco) use. The patient complains of a 2-month history of a 2- × 0.5-cm white lesion on the right lateral ventral area of the tongue. Upon lifting the tongue with gauze, you note that the lesion is adherent to the tongue and cannot be rubbed off. What is the most likely diagnosis? (A) Squamous cell carcinoma (B) Hairy tongue (C) Leukoplakia (D) Oral candidiasis (E) Geographic tongue
(C) The lesion described, an adherent white lesion represents leukoplakia. It should be considered as a premalignant lesion as 1% to 20% of the lesions progress to carcinoma in 10 years.
A 16-year-old presents with her mother and complains of pain, irritation, and decreased hearing in the right ear since waking this morning. Upon examining the patient with an otoscope, a moth is noted in the right external auditory canal. You are not able to completely visualize the tympanic membrane. What is the most appropriate treatment? (A) Insert a wick and topical antibiotics (B) Debrox insertion and remove with suction (C) Insert 2% lidocaine solution and use suction or forceps for removal (D) Irrigate with tepid saline
(C) Two percent lidocaine will paralyze the insect, which may then be removed with suction or forceps. Topical antibiotics are only indicated in otitis externa of bacterial etiology. Wicks are indicated with significant edema to the canal, but not in the case of a foreign body. Debrox is not used with foreign bodies, but is helpful dissolving impacted cerumen. Saline irrigation should not be performed with any organic foreign bodies like beans or insects as the water may cause them to expand.
A 17-year-old female presents with sneezing, clear rhinorrhea, itchy watery nose, and eyes. You examine the young woman and find clear nasal drainage and pale, boggy, edematous turbinates. What is the most likely diagnosis? (A) Viral upper respiratory infection (B) Nasal foreign body (C) Asthma (D) Allergic rhinitis (E) Rhinitis medicamentosa
(D) Allergic rhinitis is associated with pale edematous, boggy nasal mucosa, along with clear rhinorrhea. Viral rhinitis is associated with erythematous turbinates, asthma produces expiratory wheezing and coughing, and a nasal foreign body causes foul smelling unilateral nasal drainage. (
. You are examining a 64-year-old male patient with a 45 pack-year history of tobacco (both cigarette and smokeless tobacco) use. The patient complains of a 2-month history of a 2- × 0.5-cm white lesion on the right lateral ventral area of the tongue. Upon lifting the tongue with gauze, you note that the lesion is adherent to the tongue and cannot be rubbed off. After a careful history and physical examination, what is the most appropriate intervention? (A) Place the patient on an antifungal medication (B) Obtain a facial and neck CT with enhancement (C) Advise the patient to decrease trauma to the tongue and prescribe a mouthwash containing oral corticosteroids and an antibiotic (D) Incisional or excisional biopsy (E) Reassure the patient that it will resolve without treatment
(D) Based on this lesion's description as an adherent white lesion, one cannot rule out leukoplakia without pathologic evaluation. It should be considered as a premalignant lesion as 1% to 20% of the lesions progress to carcinoma in 10 years. An incisional or excisional biopsy must be performed as there is a possibility for progression to oral carcinoma.
.A 42-year-old male presents complaining of chronic nasal blockage. History reveals that he has been using 12-hour nasal spray every 6 hours for several months. He initially used the spray as directed, but with continued usage, he finds that he has to use it more frequently, as he cannot breathe without it. He has no clear or purulent drainage and denies epistaxis. What is your diagnosis? (A) Deviated septum (B) Allergic rhinitis (C) Nasal polyps (D) Rhinitis medicamentosa (E) Chronic sinusitis
(D) Chronic use of nasal decongestant sprays for more than 5 to 7 days will usually result in rebound nasal congestion if they are not continued. This is called rhinitis medicamentosa. Treatment is based on stopping the use of the nasal inhaler.
A patient develops acute eye pain and photophobia after mild trauma to the eye. Examination of the eye is grossly normal except for photophobia and tearing. This patient is most likely suffering from which of the following conditions? (A) Subconjunctival hemorrhage (B) Hyphema or blood in the anterior chamber (C) Conjunctival abrasion (D) Corneal abrasion (E) Ophthalmoplegia
(D) Corneal abrasion can result from relatively insignificant trauma and causes ACUTE pain and photophobia. Subconjunctival hemorrhages are not painful and do not cause photophobia. Hyphema will also produce pain and photophobia, but blood will be visible in the pupil and/or iris, it causes decreased and blurry vision and usually results from more significant trauma or systemic disease. The conjunctiva is far less innervated than the cornea and lacerations are less painful than corneal abrasions
Which of the following is the most common cause of permanent blindness in people greater than 65 years of age in the United States? (A) Glaucoma (B) Cataracts (C) Diabetic retinopathy (D) Age-related macular degeneration (E) Retinal detachment
(D) In developed countries, age-related macular degeneration (ARMD) is the leading cause of blindness in patients over the age of 65. ARMD causes loss of fine/central vision and the lateral/peripheral vision is retained. There is no cure for ARMD. Early diagnosis and treatment of glaucoma is effective in protecting vision. Cataracts are the leading cause of blindness in the world, but not in the United States. Cataract surgery improves vision in 95% of people with cataracts in the developed world. Diabetic retinopathy is very common and is the leading cause of blindness in adults aged 20 to 65. The vast majority (90%) retinal detachments are effectively repaired with surgery
A 35-year-old woman presents with a history of a self-limited upper respiratory illness 3 weeks prior to this visit. She now complains of persistent weakness, difficulty chewing and malaise which worsen at the end of the day. She complains that she has difficulty keeping her right eye open toward the latter part of the day. Taking a nap usually helps to alleviate the patient's symptoms. Upon examination, you notice that the right eyelid covers the top part of her pupil. Pupillary reactions are normal. A complete neurological evaluation is otherwise negative.Which evaluation is most likely to confirm your suspected diagnosis? (A) CT scan of the brain (B) Lumbar puncture (C) Fundoscopic examination (D) Tensilon test (E) Psychiatric evaluation
(D) Myasthenia gravis (MG) is a relatively common disorder, occurring in about 2-7 in 10,000 people. It affects patients in all age groups and both sexes, but is more common in women in their 20s and 30s and in men in their 50s and 60s. The male to female ratio is about 3:2. Patients present with ptosis, diplopia, difficulty swallowing and chewing, weakness and fatigability of muscles. The weakness increases during repeated use (fatigue) or late in the day and may improve following rest or sleep. The diagnostic modality of choice is Tensilon or edrophonium testing. (
A 54-year-old morbidly obese gentleman presents complaining of persistent fatigue all day long despite a full night sleep obtained with short-acting sleeping pills which worsen his symptoms. His medical history is significant for poorly controlled hypertension. Every morning he awakens with a sore throat and a headache. Which of the following is the most likely condition this patient is suffering from? (A) Endogenous depression (B) Diabetes mellitus (C) Hypothyroid (D) Obstructive sleep apnea (E) Cushing's syndrome
(D) Obstructive sleep apnea (OSA) is caused by loss of pharyngeal muscle tone which causes it to collapse during inspiration. This causes narrowing of the airway. OSA is particularly common in overweight middle-aged males. It is frequently associated with poorly controlled hypertension. There is usually daytime hypersomnolence. Alcohol and hypnotic/sedatives may increase the symptoms
A 36-year-old female presents to the occupational health clinic with a history of a fleck of metal in the right eye obtained while working in a fabrication plant. You note a large area of subconjunctival hemorrhage and a central abrasion of the sclera. How would you rule out perforation of the globe? (A) Apply gentle pressure to the globe to see if there is an extrusion (B) Perform a magnetic resonance imaging test (C) Perform a Schiotz tonometry test (D) Perform a test using fluorescein dye (E) Do nothing until cleared by an ophthalmologist
(D) Perform a special fluorescein dye examination of the eye. This test is called a Seidel test. It consists of applying a fluorescein dye strip gently to the area of injury and then viewing it under a slit lamp with a cobalt blue light. If a perforation or leak is present, the fluorescein dye will be diluted by aqueous fluid from the injured site. If a globe rupture is suspected, an eye shield should be immediately placed over the affected eye and further examination deferred to avoid putting pressure on the eyes. An MRI is not indicated if there is a metallic object in the eye.
Which of the following is the most common cause of chronic cough in adults? (A) Common cold (B) Sinusitis (C) Asthma (D) Postnasal drip syndrome (E) Gastroesophageal reflux disease
(D) Postnasal drainage is the most common cause of a chronic cough in an adult. Asthma is the second most common cause and gastroesophageal reflux is the third cause.
Your patient who is 30 weeks pregnant complains of recent onset of severe nasal congestion. She denies rhinorrhea, facial pain, and fever. She has not had previous nasal symptoms until about a month ago. It has been becoming progressively worse. Her ENT examination is essentially normal. What is your diagnosis? (A) Allergic rhinitis (B) Perennial rhinitis (C) Vasomotor rhinitis (D) Rhinitis of pregnancy (E) Chronic rhinitis
(D) Rhinitis of pregnancy is common and can peak in the third trimester of pregnancy. Rising levels of estrogen cause an increase in hyaluronic acid in the nasal tissue thus increasing nasal edema and congestion. The obstetrician may recommend treatment with decongestants or nasal steroids, however, treatment is generally optional as the condition resolves postpartum.
A 7-year-old boy presents with his mother for evaluation of severe left ear pain for 2 days. There is no fever and there are no upper respiratory infection type symptoms. You are not able to visualize the tympanic membrane well, but upon examination there is tenderness with movement of the tragus and several palpable preauricular nodes. What is the most likely diagnosis? (A) Ramsay-Hunt syndrome (B) Acute otitis media (C) Perforated tympanic membrane (D) Acute otitis externa (E) Eustachian tube dysfunction
(D) Tenderness of the tragus and preauricular adenopathy, are present with otitis externa (OE), but not acute otitis media. Eustachian tube dysfunction causes middle ear pressure. Ramsay-Hunt syndrome is a herpes zoster infection of the ear canal and the lesions would be visible. Ramsay-Hunt syndrome is characterized by visible vesicular lesions of the ear canal, auricle, and/or mucous membrane of the oropharynx. It is extremely rare in children, particularly with the advent of varicella immunization. Otitis media does not usually present with canal edema or drainage blocking visualization of the tympanic membrane and does not typically cause tenderness of the tragus. Often only mildly tender, a perforated TM would cause pain in the middle ear and there would generally be no pain with manipulation of the tragus. The tympanic membrane is often minimally tender once the perforation occurs. Typically there is a history of pain relieved by the perforation. Generally there is no pain with manipulation of the tragus. Eustachian tube dysfunction causes middle ear pressure, generally without pain.
You are evaluating a patient with eye pain and after taking a history, measuring visual acuity, extraocular movement and grossly examining the eye, you apply fluorescein stain and examine with a Wood's lamp. You see what looks like a "tree branch" pattern. What is the most likely diagnosis? (A) Glaucoma (B) Hypopyon (C) Hyphema (D) Herpetic keratitis (E) Iritis
(D) The "tree branch" is the classical presentation of herpetic infection of the cornea. This patient should be evaluated by an ophthalmologist as soon as possible. Glaucoma may give a shallow anterior angle. Hyphema is blood, hypopyon is pus in the anterior chamber, behind the cornea. Iritis gives perilimbal injection
What is the treatment of choice for a patient presenting with acute facial nerve paralysis, and painful vesicular lesions of the ipsilateral pinna? (A) Antibiotics (B) Antifungals (C) Beta blockers (D) Oral corticosteroids (E) Ear drops
(D) The patient has Ramsay-Hunt syndrome which is most appropriately treated with oral corticosteroids, antiviral medications, and pain medications.
A 35-year-old man presents with a sudden marked decrease in hearing in his left ear. There is no history of trauma, otorrhea, or vertigo. The physical examination appears to be normal except for the tuning fork tests. The Weber test lateralizes to the better ear and the Rinne test shows that air conduction is better than bone conduction bilaterally. After confirming findings with an audiometric evaluation, what is the most appropriate therapy? (A) Broad-spectrum antibiotic (B) Nasal steroids (C) Decongestant (D) Oral steroids (E) Antihistamines
(D) Weber testing lateralizing to the good ear suggests a sensorineural hearing loss. The cause is unknown, but generally thought to be viral or vascular. The only therapy shown to be efficacious for sudden onset sensorineural hearing loss is oral corticosteroids given as soon as possible. None of the other listed treatments is efficacious for sensorineural hearing loss and only serve to delay appropriate treatment.
A 14-year-old is seen for several severe nosebleeds in the past few weeks. There is a large reddish-brown mass within the left posterior nasal cavity. What is the most likely diagnosis for this mass? (A) Blood clot (B) Inverting papilloma (C) Hemorrhagic polyp (D) Septal hematoma (E) Juvenile angiofibroma
(E) A nasal mass in a postpubescent male (13-21 years) is typical of juvenile angiofibromas, which are benign vascular tumors. They tend to present in adolescent males. The patient usually presents complaining of severe unilateral epistaxis and obstruction. Any biopsy done should be in the OR based on the possibility of severe hemorrhage.
Your patient is a 39-year-old second grade teacher who states that she developed acute hoarseness 3 days ago. Prior to that, she had a cold, the symptoms of which are improving. There is no history of smoking or other tobacco use. What is the most important intervention for the patient at this time? (A) Discuss that due to her occupation, she is at increased risk of leukoplakia of the vocal cords (B) She should be placed on an antibiotic as she most likely has a bacterial infection (C) Discuss her increased risk of vocal cord paralysis (D) Recommend the patient be placed on a course of oral steroids with a taper (E) Advise the patient to avoid singing or shouting until her normal voice returns
(E) Acute laryngitis is a common cause of hoarseness and often persists for a week or more after resolution of other symptoms of an upper respiratory infection. The patient should be warned to avoid vigorous use of the voice such as singing, shouting, or excessive talking until their voice returns to normal, since persistent use may lead to the formation of traumatic vocal fold hemorrhage, polyps, and cysts. Leukoplakia is related to tobacco and alcohol use, along with dental irritation. Most cases of laryngitis are viral in etiology and this patient's symptoms were resolving, therefore antibiotic treatment is not indicated. Laryngitis is not a risk factor for vocal cord paralysis. There are many causes of vocal cord paralysis, but laryngitis, even if protracted is not one of them
A 45-year-old woman suddenly experiences severe pain in the right eye along with blurred vision, nausea, and vomiting. Intraocular pressure is 58 mm Hg and there is a moderately dilated right pupil, decreased visual acuity, shallow anterior chamber, and steamy cornea noted during physical examination. Based on this information, what is the most likely diagnosis? (A) Retinal detachment (B) Retinal artery occlusion (C) Uveitis (D) Primary open angle glaucoma (E) Primary acute angle closure glaucoma
(E) Based on the patient's symptoms, abnormal findings on eye examination and the significantly elevated intraocular pressure of 58 mm Hg (normal being 10-21 mm Hg), the diagnosis is acute angle closure glaucoma. This is an ophthalmic emergency. Retinal artery occlusion and detachment are painless and the fundoscopic findings are different.
A 48-year-old male patient is diagnosed with shingles involving cranial nerve V. During the examination you note that the tip of his nose is involved. At this point, it is crucial to rule out involvement of: (A) The opposite pinna (B) Nasal septum (C) Ipsilateral epitrochlear node (D) Tympanic membrane (E) Cornea
(E) Involvement of the tip of the nose with herpes virus is known as Hutchinson's sign. It is suggestive of involvement of the cornea with herpes and urgent referral to an ophthalmologist is recommended. The patient has shingles (herpes zoster) which follows dermatomes and is generally unilateral. Ruling out involvement of the nasal septum is not crucial. Involvement of the tip of the nose or lid margins should lead one to suspect corneal involvement. Tympanic membrane involvement is not crucial to rule out and is not related to herpes zoster ophthalmicus
Your patient is a 35-year-old male who recently underwent restoration of teeth #28, 29, and 30. He has a 24-hour history of fever, dysphagia, odynophagia, and drooling secondary to inability to swallow his own secretions. Examination of the patient shows a toxic-appearing male with trismus, edema of the neck, and submandibular area along with poor dentition, foul smelling breath, and gingivitis. The tongue, which is painful for the patient to move is displaced posteriorly, and a temperature of 103°F is noted. What is the most likely diagnosis? (A) Sialadenitis (B) Peritonsillar abscess (C) Retropharyngeal abscess (D) Epiglottitis (E) Ludwig's angina
(E) Ludwig's angina, most likely secondary to dental infection is a cellulitis of the floor of the mouth which if left untreated could completely obstruct the airway. The submental, sublingual, and submandibular spaces are infected bilaterally. Patients usually present with poor dental hygiene, dysphagia, odynophagia, trismus, and edema of the upper midline neck and the floor of mouth. Clinical examination reveals edema of the entire upper neck and floor of mouth. Infection progresses rapidly and can posteriorly displace the tongue, causing airway compromise. The appropriate plan includes CT of the neck, IV antibiotics, and preparation for intubation.
A 14-year-old boy presents to follow-up on unilateral tonsillitis from a previous visit. He was previously treated with a 10-day course of amoxicillin. Over the last 6 weeks, since finishing his antibiotics, his right tonsil has continued to enlarge. Other than the enlarged right tonsil, the pharynx is normal without exudate or inflammation. Careful palpation of the oropharynx reveals a nontender right tonsil 50% larger than the left tonsil. There is nontender right cervical adenopathy. Complete blood cell count and differential is within normal limits. What is the most appropriate management for this patient? (A) Reassure the patient and his mother that this is normal after tonsillitis and the tonsil will return to normal size as the patient gets older. (B) Order a monospot. (C) Order a soft tissue lateral radiograph to rule out a retropharyngeal abscess. (D) Prescribe an alternative antibiotic and schedule routine follow-up. (E) Obtain an urgent surgical consult for tonsillectomy
(E) Lymphoma may present as unilateral tonsillar enlargement. The rapidly enlarging tonsil and lack of other infectious symptoms suggests a malignant process. Performing a tonsillectomy will provide a biopsy specimen
You are seeing a 19-year-old male for follow-up from urgent care where he was seen 2 days earlier with a sore throat. The patient is febrile (102°F), has a muffled (hot potato) voice, and extreme difficulty opening his mouth (trismus). He opens it just far enough for you to note uvular deviation. What is your diagnosis? (A) Torus palatinus (B) Gingival hyperplasia (C) Koplik spots (D) Ranula (E) Peritonsillar abscess
(E) Trismus and muffled or "hot potato" voice developing in a patient with a sore throat are the clues to the diagnosis. Along with the uvular deviation, this trio provides a classic description of a peritonsillar abscess. Palatal tori are completely benign midline palatal masses that are asymptomatic. Koplik spots are pathognomonic for measles. Gingival hyperplasia is seen on the gingiva and an oral ranula produces swelling of the floor of the mouth that is usually nonpainful. Speaking, chewing, breathing, and swallowing may be affected because of the upward and medial displacement of the tongue.
A 44-year-old male presents with unilateral hearing loss, tinnitus, unsteadiness, and imbalance which has been slowly developing over the last few months. You appropriately order an audiogram and find a unilateral sensorineural hearing loss with poor speech discrimination. What is the most likely cause of the patient's hearing loss? (A) Megaloblastoma (B) Impacted cerumen (C) Otosclerosis (D) Labyrinthitis (E) Acoustic neuroma
(E) Vestibular schwannoma or acoustic neuroma causes asymmetric (unilateral) sensorineural hearing loss, tinnitus, and disequilibrium. The audiometric findings of sensorineural hearing loss with poor speech discrimination along with tinnitus and unsteadiness should cause one to obtain an MRI with gadolinium enhancement as soon as possible to rule out acoustic neuroma or schwannoma of the vestibular nerve. There is no condition known as megaloblastoma. Impacted cerumen may cause mild dizziness and possibly conductive hearing loss. Otosclerosis has a hereditary disposition and conductive hearing loss. Labyrinthitis is not associated with hearing loss.
A 12-year-old girl was seen a week ago with an upper respiratory infection, which has failed to improve. She now presents with an elevated temperature (101.4°F), bilateral facial pain, congestion, and purulent nasal drainage. At this point what is the most appropriate therapy? (A) 10 days of amoxicillin (B) Sinus CT (C) 10 days of ciprofloxacin (D) Warm facial compresses and sinus washes (E) 10 days of cefaclor
. (A) The patient has developed acute sinusitis secondary to her previous upper respiratory infection and amoxicillin is the first-line antibiotic recommended. Based on the history and PE findings, CT is not needed at this time. Oral ciprofloxacin is not indicated in pediatric patients for sinusitis; the only indication for which a fluoroquinolone (i.e., ciprofloxacin) is licensed by the U.S. Food and Drug Administration for use in patients younger than 18 years are complicated urinary tract infections, pyelonephritis, and postexposure treatment for inhalation anthrax. Cefaclor is not indicated for sinusitis. Although warm facial compresses and sinus washes are helpful adjunct treatments, an antibiotic is indicated in this patient.
After a recent bout of gastroenteritis characterized by vomiting and diarrhea, a 60-year-old male patient presents with bright red blood visible on the lateral right sclera. Blood pressure is normal as is his visual acuity. What is your treatment plan? (A) Emergency consultation with an ophthalmologist (B) Computed tomography (CT) scan to rule out intracranial hemorrhage (C) Provide reassurance to the patient; no treatment is needed (D) Complete intraocular examination with dilation (E) Complete blood cell count and bleeding studies
. (C) A subconjunctival hemorrhage is associated with acute onset of symptoms, the patient is usually alarmed. The hemorrhage was brought on by vomiting associated with the acute bout of gastroenteritis, but may sometimes appear spontaneously, or after a cough or a sneeze. The patient has a subconjunctival hemorrhage and no emergent consultation is needed. CT is unnecessary. Extensive examination is not required. With hemorrhage limited to the conjunctiva, no further evaluation of coagulation is needed.
A 5-year-old patient in your pediatric practice is seen with her parents who states there is a 2-day history of fever (101°F), sore throat, and tearing and mild erythema of both eyes. She has been swimming in a public pool. There is scant exudate present bilaterally and a large amount of watery discharge. There are conjunctival and pharyngeal mucosa follicles present. Nontender preauricular adenopathy is present. What is the most appropriate treatment for this patient? (A) Oral antibiotics (B) Topical or systemic antiviral medications (C) Symptomatic treatment only (D) Ocular antihistamines for treatment of allergies
. (C) Viral conjunctivitis is usually self-limited and treated symptomatically with antipyretics as needed. Topical antibiotics, while indicated for bacterial conjunctivitis are not indicated for viral conjunctivitis. Topical acyclovir is sometimes indicated in the treatment of herpes viral conjunctivitis, characterized by unilateral pain, injection, mild photophobia, and mucoid discharge and photophobia. The patient in question did not exhibit these symptoms. If the patient notes itchy eyes, consideration might have been given to ocular antihistamines.
Your next patient is a 26-year-old otherwise healthy male who suffered a nondisplaced nasal fracture 3 weeks ago. He now presents with clear right-sided rhinorrhea. He states that his nose has healed completely and feels fine at this time. He states that he is experiencing short gushes of salty tasting liquid from his right nostril several times a day. Sometimes he can produce the liquid by leaning forward. What test should be run on this patient? (A) "Bull's eye" test (B) Specific gravity (C) Gram stain (D) Culture and sensitivity (E) Glucose dipstick
E) Injuries to the nasal bone and nasal process of the frontal bone may lead to a fracture through the cribriform or ethmoid bones. Cerebrospinal fluid (CSF) is typically unilateral and comes in short rapid gushes, or as a steady flow. CSF contains glucose which can be easily measured with a urine glucose dipstick.
