Patient Condition Scenarios

Sean is a 2 YO male who presents w/ a dozen shallow, ulcerative lesions in his mouth. His father says he was a little feverish prior to the lesions developing in his mouth. Sean doesn't sit still during PE and seems to be in slight pain from the lesions. You notice he is also drooling a bit and his submandibular lymph nodes seem slightly enlarged. What is your dx and tx for Sean? What is the etiology?

Sean has herpetic gingivostomatitis, a condition probably passed on to him by a relative w/ a cold sore. It is typically caused by HSV1. Tx is topicals for pain and you tell his dad that the lesions generally resolve in 1-2 wks but he may get cold sore outbreaks from time to time. You also advise plenty of hydration and soft, non-acidic foods.

Sierra is a 55 YO female who presents w/ hearing loss and tinnitus in her left ear and she said she's been experiencing some tingling on that side of her face as well. PE shows that she is less responsive to light touch on the left side of her face. Weber shows that she lateralizes sound to her left ear and Rinne confirms that she hears sound better via air conduction. What is your dx and tx for Sierra? What nerves have been affected? What type of hearing loss is she experiencing?

Sierra has an acoustic neuroma, a benign tumor that is compressing her trigeminal and vestibulocochlear nerves, causing sensorineural hearing loss. Tx can typically involve observation, but since she's having symptoms that are reducing her QOL, surgery to excise the tumor or radiation if the tumor is small are options that can reduce her sxs.

Betty is a 72 YO female who presents w/ irritation and pain in her left eye. She said it's worse when the wind is blowing when she's outside and her vision in that eye has gotten worse. PE shows a lower left lid that has curled inward toward her eye and is crusting slightly. What is your dx and tx?

Betty has entropion, a condition that is commonly caused by weakness d/t aging. You refer her to ophthalmology for likely surgery to tx the condition.

Billy is a 8 YO male who presents w/ 3 small lesions near his mouth. His father says that this happened once a year ago, but resolved so they never brought Billy in, but since the lesions are back in the same place, he got worried. PE shows 3 erupted blisters that are crusted over and have bright red rim. What is your dx and tx for Billy? What is the etiology?

Billy has cold sores caused by the Herpex Simplex Virus, most likely HSV1 (HSV2 favors the genitals). Dx is typically clinical and tx may involve oral acyclovir to speed recovery, although the virus won't be fully eliminated from the body. If Billy's discomfort isn't too great, he can also wait for the lesions to self-resolve if he prefers.

Blake is a 52 YO male who calls your office after losing a tooth. He says he took a bite of his steak, felt a weird sensation, pulled the fork back out, and found the tooth embedded in the meat. He wants to know what to do next. What do you tell him?

Blake has a tooth avulsion. You tell him to briefly rinse the tooth under cold water. If he's able, he should reposition the tooth in his mouth, or he can put some gauze in the socket. If he doesn't put the tooth in his mouth, he should store it in milk or saline, but NOT in plain water. You tell him he needs to get to the dentist ASAP - w/in the hour. They'll evaluate and tx him there. You also rx him systemic abx and ask him to come in for a tetanus booster.

Bob is a 65 YO male who presents with a drooping upper lid of his left eye. He had surgery on that eye 8 months ago. PE shows a left upper lid that sits halfway over the left eye. Visual testing shows decreased acuity but his neurological exam is otherwise normal. What is your dx and tx? What muscles are involved?

Bob has ptosis, drooping of the upper eyelid, likely d/t his recent surgery. This condition affects the levator muscles of the eye. You refer Bob to ophthalmology where he will likely receive a second surgery - blepharoplasty.

Brad is a 22 YO male who presents w/ a swollen lump on lateral left eyelid. He said he's had these before but this is the worst one yet. You notice his left eye is tearing and the lid is swollen and erythematous around the lump, which is TTP. How do you dx and tx? What is the most likely etiology?

Brad has an external hordeolum, or stye, a blockage of the accessory glands of Zeis or Moll, MC caused by S. aureus. Tx is to use warm, moist compresses on the affected eye 4-6 times/day.

Damien is a 32 YO male who presents pain in his left eye and a gritty sensation. He said it's been bothering him since he got back from the beach last night. He said he's been rubbing his eye, trying to get the "junk" in his eye out. PE shows a red, tearing left eye. To inspect more closely, you apply topical anesthesia, which he says totally relieves the pain. You evert his lid and see nothing, but on fluorescein exam, you notice ice rink sign. What is your dx and tx for the pt?

Damien has a conjunctival foreign body that has caused a corneal abrasion. Tx is removal w/ a moistened cotton-tip applicator or eye spud. You also rx abx drops d/t corneal involvement and make sure that Damien's tetanus vaccinations are up to date.

Dan is a 48 YO male who presents w/ pain and double vision in his left eye following a racquetball accident. He forgot his goggles at home but wanted to play the match anyways. He took a ball directly to his face. PE shows swelling, ecchymosis, and limited upward gaze. You order a CT - what characteristic sign do you see? What is your dx and tx for Dan? What pt education is important?

Dan has a blowout fracture, caused by the direct blow to his orbit. CT shows a characteristic teardrop on his lower left orbit. You rx prophylactic abx and arrange an ophthalmology consult for the next day. You tell Dan not to blow his nose and to ice and elevate his head when he goes to bed to decrease swelling.

Deirdre is a 9 YO female who presents w/ a red, irritated right eye for the past 2 days. She says she feels like she has sand in her eye when she blinks and it itches sometimes and makes her vision blurry. PE shows a purulent discharge coming from the eye and erythema. What is your dx and tx? What is the etiology? How does it differ from the other two MC etiologies?

Deirdre has bacterial conjunctivitis, the MC cause of eye redness d/t the infection of the conjunctiva that typically initially affects a single eye and presents w/ purulent discharge. Viral conjunctivitis has a more watery discharge and allergic conjunctivitis has a stringy discharge and cobblestoning within the lid. Tx is Cip 0.3% eyedrops.

Francis is a 62 YO female who presents w/ a loose front tooth. She says she took a bite of an apple and felt the tooth shift and was able to wiggle it just a bit afterward. PE shows the tooth is slightly loose but not displaced. What is your dx and tx for Francis?

Francis has a subluxated tooth. Because it's not displaced, you tell Francis that it should heal itself and become reaffixed into place. If it doesn't improve or gets worse, you tell her you can refer her to a dentist. If the tooth were displaced, it would require emergent tx to reposition the tooth and splint it.

Gabby is a 35 YO male who presents w/ "bumps" on her vulva that started accumulating over the past month. She has no other sxs except slight itching. She has a Sohx of 4 sexual partners in the past 6 months. PE shows small, flesh colored papules on her vulva, some of which have coalesced into a cauliflower-like plaque. How do you do dx and tx Gabby? How do you confirm your dx? What is the etiology?

Gabby has condyloma acumulata, or genital warts caused by one of the many human papilloma viruses. It is a sexually transmitted infection. You can confirm your dx using a pap smear or acetic acid testing. Tx options include cryotherapy, electrocautery, shave debulking, or imiquimod. Genital warts are difficult to treat and you tell Gabby that after the outbreak is cleared, she will still carry the virus. You tell Gabby she should inform her sexual partners so they can get tested for HPV as well.

Garrett is a 43 YO male who presents w/ a new mass on the angle of his jaw that's been growing over the past couple months. He says the lump is painful and as its grown he's lost some sensation on that side of his face. PE shows a hard mass just in front of his ear on his jaw. What diagnostics do you perform? What is your dx and tx?

Garrett has a parotid tumor, a salivary gland tumor. Most are benign, but Garrett's sxs of pain and numbness suggest cranial nerve involvement and malignancy. You perform an FNA and order a CT scan. You also refer Garrett to head/neck surgery and oncology.

Glen is a 42 YO male who presents w/ redness along the gum line and swelling for the past two days. He says his gums were bleeding when he brushed his teeth before coming here. He just got back from a long weekend at his cabin and he forgot his toothbrush at home, so he made sure he brushed before this appointment. PE confirms redness and swelling along the gumline and signs of recent bleeding. What is your dx and tx for Glen?

Glen has gingivitis, a common disease that occurs when you don't brush or floss regularly, like Glen at his cabin. You tell him that if he keeps brushing and flossing now, his sxs should resolve.

Greg is a 62 YO male who presents w/ headache, fever, and neck pain for the past 8 hours. He says he's been feeling more nauseated since this morning. He has a hx of HIV/AIDS and he says he hasn't taken his ART in the past 5 years. During the exam you notice that he immediately closes his eyes when you use your penlight to check PERRLA. What tests would you perform during PE? What imaging do you order? How do you dx and tx Greg?

Greg has meningitis, you suspect caused by Cryptococcus neoformans d/t his sensitivity to light and his HIV+ status. You perform Brudzinski's and Kernig's to support your ddx. You also order a CT, and you can confirm your dx w/ a culture or microscopy using a blood sample. You rx amphotericin B and flucytosine to tx the infection, to be followed by a course of fluconazole. You also discuss the need to resume ART w/ Greg.

Gwen is a 24 YO female who presents w/ constant sneezing, congestion, and itchy nose for the past three weeks. She recently adopted a cat from Kenzie and has a hx of asthma. PE shows pale, edematous nasal mucosa, conjunctival erythema, tearing, and wheezing. You also notice folds beneath her lower lids. What are these called? What is your dx and tx for Gwen?

Gwen has allergic rhinitis, likely d/t pet dander from her cat. The lines you noted beneath her eyes are called Dennie-Morgan lines. Tx involves environmental controls (vaccuming, cleaning frequently, humidifier) as well as nasal corticosteroids - e.g. flonase. If this doesn't help, you suggest taking a second generation antihistamine like loratadine. She is very insistent about keeping the cat, so if they tx's don't help, you can refer her to an allergist and discuss allergen immunotherapy.

Janine is a 48 YO woman who presents w/ bilateral hearing loss that started one day ago. She was dx'd w/ meningitis 2 days ago and given gentamicin. Rinne shows that air conduction is better than bone conduction in both ears. She is responding well to her meningitis tx and her other sxs align with those of a person in recovery. What is your dx and tx for Janine? What type of hearing loss is Janine experiencing?

Janine has sensorineural hearing loss caused by ototoxicity, most likely d/t the gentamicin. You stop the medication and replace it w/ a different abx, but unfortunately the damage she's already suffered is likely permanent.

Jill is a 32 YO female who presents w/ painful urination for the past 2 days. She says she "always feels like she has to go" and never feels like she is fully emptying her bladder. She rates the pain a 5 and says the discomfort bothers her more than anything. You get a urine sample from her and see that it is cloudy. When you order a UA, what is the most likely etiology for her condition? What is your dx and tx for Jill? What other conditions can the bacteria in Jill's urine cause?

Jill has a urinary tract infection most likely caused by E. Coli. Tx options include ciprofloxacin or bactrim. E. Coli is also a common culprit of food poisoning that can cause enterotoxigenic (traveler's) diarrhea, enterohemorrhagic diarrhea that can lead to HUS, and enteroinvasive diarrhea.

Joanie is 32 YO female who presents w/ an eruption of "spots" on her left leg that started to appear a month ago. Joanie is HIV+ but stopped ART when she lost her job and her insurance a year ago. PE shows a crop of nontender, dark brown, macular lesions on her left leg. What is your dx and tx for Joanie? What causes this condition?

Joanie has Kaposi sarcoma, a type of cancer that forms in the lining of blood vessels and presents superficially as macules. It is caused by HHV8 and is frequently seen in HIV patients. Dx can be confirmed via biopsy of the macules, and additional testing may be done to dx the tumor(s) internally. It is important that Joanie starts taking her ART again. If she doesn't have a new job or insurance, you should direct her toward a community health worker who can provide her with resources to ensure she is treated. This may be the only tx required, but Joanie should follow-up regularly to track the progress/remission of the sarcoma when she has started therapy again.

Joe is an 8 YO male who presents w/ difficulty swallowing. He currently has a URI. PE reveals a midline anterior neck mass that is somewhat tender and swollen located at the hyoid. What imaging do you order? How do you dx and tx?

Joe has a thyroglossal duct cyst, a typically benign neck mass MC in children. You order a US to confirm your dx. You rx abx to tx the infection and you refer to ENT/surgery to discuss surgical removal of the cyst to prevent further infection. You reassure Joe and his parents that the mass is typically benign.

Luther is a 14 YO who presents w/ a single lesion in his oral mucosa. He says it's painful and "stingy" but he doesn't have a fever. It developed after he bit his cheek last week. PE confirms a single lesion on his buccal mucosa - white in the center with a red rim. How do you dx and tx?

Luther has an aphthous ulcer, or canker sore, possibly d/t biting his cheek. You tell him the lesion is self-limiting and he should treat w/ a topical anesthetic or allum for the pain until it resolves.

Aaron is a 5 YO male who presents w/ thick, swollen upper eyelids. He is a refugee from rural South Sudan who moved here recently with his parents. PE shows white lines on Aaron's inner eyelids. What condition are you concerned that Aaron has? How do you tx?

Aaron has trachoma, an infection caused by Chlamydia trachomatis that is frequently transmitted between people by flies. You rx oral azithromycin to treat the infection. However Aaron's eyelids are already showing signs of scarring, so you refer him to ophthalmology for monitoring and further assessment.

Alex is a 47 YO male who presents w/ mild fever, fatigue, and myalgias. He recently returned from a camping trip in Colombia. You notice that his upper left arm has localized swelling around a healing scratch. He says he scraped his arm on a branch when they were hiking early on in the trip. What tests do you order? What is your dx and tx for Alex? What are the etiology and vector? What is one possible complication you are concerned about?

Alex has Chagas disease, an infection caused by the parasite Trypanosoma cruzi that is transmitted through the feces of the triatomine bug. You suspect that the bug fed and and defecated on Alex while he was sleeping outside camping and that the feces got into his wound leading to infection. Tx is elimination of the parasite via benznidazole, although this drug is difficult to get. You tell Alex that you are concerned about possible heart complications in the future - e.g. cardiomyopathy, arrhythmias, and cardiac arrest and you'll want to monitor him for any sxs from this point on.

Andrea is a 12 YO female who presents w/ blurred vision and and floaters in her right eye. She has a recent hx of juvenile RA. PE shows no redness and Andrea reports no pain in her eye. You examine her right eye w/ a slit-lamp and see leukocytes in the aqueous humor and choreoretinal inflammation. What is your dx and tx for Andrea?

Andrea has posterior uveitis, a complication of her juvenile RA. Tx involves topical steroids, possible oral or injected steroids, and referral to an ophthalmologist. You also talk with her and her parents further to assess if her juvenile RA is being managed properly.

Angela is a 37 YO female who presents w/ pain, photosensitivity, and blurred vision that has developed over the morning and afternoon. She says she noticed some discomfort last night, but the pain got significantly worse over the course of today. She wears contact lenses and said she's been reusing the same pair until her new ones arrive. PE shows a white spot on the cornea and fundoscopic exam shows iritis. What is your dx and tx for Angela? What is the most likely etiology?

Angela has a corneal ulcer, likely d/t wearing her lenses for an extended period of time. Because she's a contact lens wearer, the likely cause is pseudomonas. You take a swab to culture to be sure. Tx is ofloxacin drops (2 gtts q 30 minutes while awake day 1, 2 gtts hourly while awake days 2-10). You tell Angela she needs to keep her lenses out while she gets tx'd and you also refer her urgently to ophthalmology.

Anika is a 12 YO female who presents w/ a sore throat, fever, and persistent fatigue for the past month. She came in 2 weeks ago and was tested for strep, but it came back negative. Her doctor thought a viral infection would've cleared by now, but it hasn't. PE shows exudative tonsils and cervical lymphadenopathy. You palpate her abdomen and both her liver and spleen feel enlarged. What is your dx and tx for Anika? What is the etiology? What would happen if you tx'd her w/ penicillin?

Anika has pharyngitis associated with mononucleosis caused by Epstein-Barr virus (HHV4). If you rx'd penicillin, it would give her a characteristic rash (which you wouldn't, knowing that it's viral). Tx is symptomatic, you recommend ibuprofen or acetaminophen and you tell her to get lots of rest and fluids. It will likely take her 3+ months to fully recover.

April is a 27 YO female who presents w/ nasal congestion for the past 7 days. She said she was using over-the counter decongestant that helped about 2 weeks ago, but then the congestion came back, no matter how much decongestant she used. What med is she using? What is your dx and tx?

April has rhinitis medicamentosa, d/t her overuse of Afrin (oxymetazoline). You suggest that she stop using the med and her sxs should resolve in 2-3 wks. She might try a second generation oral antihistamine like loratadine to address her sxs now.

Ari is a 52 YO male who presents w/ irritation and dryness in his right eye. He recently lost 40 lbs. PE shows an everted lower lid. What is your dx and tx for Ari?

Ari has ectropion, an eversion of the lower lid that is a possible complication of weight loss. You recommend OTC drops for the dryness and you refer him to ophthalmology for likely surgery.

Arnold is a 68 YO male who presents w/ 9 round, dry, numb lesions on his trunk that are hypopigmented in the center. You ask him about his travel history and he says he used to serve the people in Kalaupapa, Hawaii every summer for years when he was younger, but as the population began to dwindle, he stopped going, around 10 years ago. What disease do you think Arnold might have? What is the tx? What is the etiology?

Arnold has leprosy, or Hansen's disease, an infection caused by Mycobacterium leprae. He very likely acquired it working at the leper colony every summer in Hawai'i. Tx is very effective and typically involves dapsone w/ rifampicin for 1-2 years.

Arthur is a 42 YO male who presents w/ bilateral hearing loss that's worsened over the past couple months. He's been a bouncer at a music venue since he was 24. He says he often has high-pitched ringing in his ears and often has trouble hearing patrons in the club when music is playing. What is your dx and tx for Arthur? What would you see on his audiogram? What type of hearing loss is he experiencing? What is the etiology?

Arthur has noise-induced hearing loss caused by exposure to loud music on a daily basis at work. The loud music damages the hair cells in the inner ear over time, causing sensorineural hearing loss. An audiogram would show a characteristic notch around 4000 Hz. There is no treatment for this type of hearing loss, but you tell Arthur he should use earmuffs or ear plugs at work to prevent further damage and hearing loss.

Arya is a 28 YO female who presents w/ jaw pain. She said it hurts most when she moves her jaw and sometimes it clicks or locks up. PE shows no significant findings, but you do hear her jaw pop while she speaks to you. What is your dx and tx for Arya?

Arya has temporomandibular joint disorder. You advise her to take NSAIDs and avoid chewy foods like bread, taffy, carrots, etc. You refer her to a dental specialist for further evaluation and tx.

Brandon is a 14 YO male who presents w a rash on his groin that's been growing for the past week. He says it itches and burns. You notice he's wearing a jersey and he says that ultimate frisbee practice started a month ago, so he wears his under armor and jerseys all the time so he doesn't have to change after school. PE shows a red rash that looks particularly irritate in the crease of his groin. The edge looks raised and scaly. How do you dx and tx? How do you confirm your dx? What is the etiology?

Brandon has tinea cruris, or jock itch, a fungal infection caused by dermatophytes that Brandon has been fostering by wearing tight under armor all day. You can confirm your dx w/ KOH prep. You suggest txing w/ an OTC antifungal cream. If this doesn't work you can rx an oral antifungal like fluconazole.

Brenna is a 25 YO female who presents w/ a mass in her mouth. She said it hurts when food rubs against it and it bleeds frequently. PE shows a raised, reddish nodule that bleeds when you palpate it. What is your dx and tx for Brenna?

Brenna has an oral pyogenic granuloma, a benign growth. You take a biopsy to confirm the dx. You refer her to the dentist for removal of the lesion- possibly curretage or cautery.

Carey is a 62 YO female who presents w/ dry eyes and a foreign body sensation. She has a hx of Sjoegren's syndrome. PE shows her eyes are erythematous and you notice she's squinting against the sunlight coming through the window. What PE test do you perform? What is your dx and tx?

Carey has keratoconjunctivitis sicca, or dry eyes, secondary to her Sjoegren's. You can perform Schirmer's test to measure her tear production. Tx involves, hot compresses, artificial tears, lubricating ointments, Restasis, and/or topical steroids.

Carla is a 5 YO female who presents with a mass above her right eye. The lump is painless, moveable, firm, and slightly discolored. She has no other sxs or findings. How do you dx and tx?

Carla has a periorbital dermoid cyst, a mass caused by entrapment of organic material in the deep epithelium. Tx is surgical resection.

Carolyn is a 24 YO female who presents w/ a painless mass on her posterior left shoulder that has been growing slowly over the past 4 months. She says it's now making it difficult to sit back in chairs or on the couch. PE shows the mass is soft, fatty, and mobile. How do you dx and tx?

Carolyn has a lipoma, a benign tumor. Because it is affecting her quality of life, you refer her to surgery for removal, but you caution her that they can recur.

Charlie is a 32 YO male who presents w/ " a really weird whitish pink spot" in his eye. He spends a lot of time outside - he is an avid surfer. PE shows an elevated plaque that extends from his medial eye into his cornea. You note the lesion is vascular. You test his visual acuity and note that it is unaffected by the lesion. How do you dx and tx?

Charlie has a pterygium, or surfer's eye, a nodule of the conjunctiva that crosses the limbus and extends into the cornea that can be associated w/ increased exposure to UV light and wind. Because it's not affecting his vision, you tell Charlie you want to observe it for now. If it become irritates or affects his vision he can have it surgically removed, but it may recur.

Claire is a 44 YO female who presents w/ worsening dyspnea and a cough with clear sputum for the past 4 weeks. She is HIV+ but never started ART. PE shows she has a low-grade fever - 99.6 - and her respiratory rate is 22. How do you dx and tx Claire? What imaging do you order? How do you confirm your dx? What is the etiology?

Claire has pneumocystic pneumonia, an infection caused by Pneumocystis jirovecii fungus that has a typically insidious onset in HIV/AIDS pts. You can confirm your dx w/ a culture from Claire's sputum. You also take a chest x-ray to see where her lungs are infected. Tx involves TMP-SMX. You also discuss the importance of starting ART w/ Claire.

Clarice is a 48 YO female who presents w/ a lump in her eyelid that developed over the past 2 weeks. PE shows a firm, pea-like nodule w/in her lid. It isn't tender and you notice no tearing. What is your dx and tx? What gland is involved?

Clarice has a chalazion, a granulomatous inflammation of the meibomian gland that blocks its drainage duct. You tell Clarice that it may spontaneously resolve and since it's not causing her pain you'd like to observe it for a while. If it doesn't get better, you can refer to an ophthalmologist for surgical removal and possibly steroid injection.

Clark is a 45 YO male who presents w/ tooth pain. He said he recently got a filling and it hurt when he bites down. You perform a thermal test and find he is sensitive to cold in that tooth. You see no other abnormalities. What is your dx and tx for Clark?

Clark has reversible pulpalgia, probably caused by hyperocclusion from his new filling. You tell him to take NSAIDs for the pain and you refer him to his dentist for possible alteration to the filling.

A coworker of yours asks your opinion about the pt she is seeing. Clem is a 62 YO male who presents w/ headache, blurred vision, and blind spots. She performed a fundoscopic exam and found a blurred optic disc and venous engorgement. She knows this is abnormal, but doesn't know what it means. What sign did your coworker uncover on exam? What are 2 possible conditions it might indicate? What test is now contraindicated? What is the overall goal of tx for this pt, regardless of underlying cause?

Clem has papilledema, which indicates he has increased ICP. This can be a sign of brain tumor, pseudotumor cerebri, intracranial hemorrhage, brain injury, malignant HTN, and many other diagnoses. You tell your coworker she should order a CT and NOT order a lumbar puncture, as it could cause herniation. Ultimately, Clem should receive tx that can reduce his ICP (e.g. mannitol), as well as tx for the underlying cause of his papilledema.

Colton is an 80 YO male who presents w/ headache, myalgia, and chills for the past 3 days. He said he also recently started coughing and feeling short of breath. He just got back from a 2-wk cruise up the Norwegian coast - he said it was beautiful but cold, so he was in the ship's hot tub every night to warm up before bed. He is in otherwise good health and isn't on any meds. He has no allergies. How do you dx and tx Colton? What is the etiology? How do you confirm the dx? What imaging might you order?

Colton has Legionnaire's disease, a type of pneumonia caused by Legionella pneumophilia that he likely contracted from the hot tub on his cruise ship. You can confirm your dx w/ a UA to look for antigens. You may also take a chest X-ray to see how the infection has progressed to his lungs. Tx is erythromycin.

Colton is a 62 YO male who presents w/ hoarseness, dyspnea, cough, and weight loss that began 6 months ago. He has a hx of smoking and alcohol use. PE shows hard, swollen lymph nodes and laryngoscopy reveals a mass inside his larynx. What imaging do you order? What is your dx and tx? What is the likely etiology?

Colton may have laryngeal cancer, most commonly a squamous cell carcinoma. This is highly correlated w/ a hx of smoking and drinking. You order a CT or MRI to get better visualization. Tx will involve surgical resection, if possible, and maybe chemotherapy and/or radiation. This cancer will also require close f/u and you recommend that Colton abstain from drinking and smoking from this point on.

Dennis is a 58 YO male who presents w/ a painful rash that began yesterday on is posterior and anterior upper, left trunk. He said the area felt "numb and tingly" two days ago, but he figured it would go away. PE shows two crops of vesicles on an erythematous base. Dennis is extremely sensitive to touch during the examination and rates his pain an 8. How do you dx and tx Dennis? What is the etiology?

Dennis has herpes zoster, or shingles, an infection caused by the varicella zoster virus and typically presents w/ a dermatomal rash. Because Dennis saw you so soon after his sxs began, you rx Acyclovir to help resolve the rash sooner. You also suggest capsaicin topical cream and rx Neurontin to help w/ his pain.

Derek is a 17 YO male who presents w/ a painful, "leaky" eye following a stab wound directly to his eye this morning. PE shows he has reduced visual acuity, leaking aqueous humor, a prolapsed iris, and a teardrop pupil. What is your dx and tx for Derek? What test must you NOT perform?

Derek has a ruptured globe, caused by the stabbing wound. You give him a metal eye shield to protect his eye. It is critical that you do not perform tonometry and put any additional pressure on the globe. You order a CT, put in an emergent consult for ophthalmology, and make sure that Derek is up to date on his tetanus vaccinations. You also rx IV abx to prevent endophthalmitis.

Diane is a 72 YO female who presents w/ a painful, swollen jaw for the past few weeks. She has a hx of osteoporosis and is taking bisphosphonates. PE shows the front of her jaw is swollen and you notice purulent exudates. You palpate and notice her two lower front teeth are loose. What is your dx and tx for Diane?

Diane has osteonecrosis, possibly d/t her bisphosphonates. You discontinue the medication and refer her emergently to the dentist for oral surgery.

Diane is a 26 YO female who presents w/ worsening hearing loss in both ears for the past 2 months and occasional balance issues. She is currently 6 months pregnant. Rinne shows that she hears better via bone conduction. PE shows a rosy glow behind her tympanic membrane. What is your dx and tx for Diane? What is the name for the rosy glow you see? What kind of hearing loss is she experiencing? What characteristic sign would you see on her audiogram?

Diane has otosclerosis, a type of conductive hearing loss that often worsens during pregnancy. The rosy glow you notice behind her tympanic membrane is called a Schwartz sign, and her audiogram would show a characteristic Carhart notch - a dip in bone conduction threshold that occurs near 2000 Hz. Tx is a stapedectomy w/ prosthesis and possibly hearing aids.

Donald is a 22 YO male who presents w/ eye pain in both of his eyes. He said it's hard to open his eyes fully and he's not able to see as well when he's driving or reading. He wears contact lenses - dailies - and he says he frequently sleeps in them and wears them for 3 or 4 days at a time. What exam do you perform next. What do you see/what is your dx? How do you tx Donald?

Donald has corneal abrasions in both of his eyes from sleeping in his contacts and wearing them for longer periods of time than recommended. You are able to visualize the small abrasions using a fluorescein exam. You examine for any foreign bodies/remainder of the contacts left behind and remove them. Because the trauma is minor, you rx topical abx ointment (erythromycin ophthalmic) QID x 3-5 days and advise NSAIDs for pain control.

Donald is a 17 YO male who presents w/ a purulent abrasion on his left arm. He says he got "bad turf burn" when he was tackled during practice 3 days go but he didn't want to stop playing so he didn't wash it until he showered after practice a few hours later. He left it uncovered to "let it breathe" and he's been practicing daily since. It started to hurt more last night. PE shows a raw lesion 2 cm wide that is actively draining. You notice the surrounding skin is warm to the touch. Donald is also slightly febrile - 99.8. You take a sample to culture. What infection are you concerned about? How do you tx?

Donald may have community-acquired MRSA, given the nature of his wound and how he got it. Fortunately, community-acquired MRSA is still sensitive to some oral abx, so you rx clindamycin to treat his infection.

Donna is a 2 day old female who presents w/ no pinna or external opening from her right ear canal. There is no sign of infection and she was born w/ this condition. CT shows no abnormalities of her ear internally. What is this condition called? How does it affect her hearing? What is the tx?

Donna has a congenital condition called anotia, an example of auricular malformation. This condition may or may not create hearing loss for her, and testing her will help determine this. Surgery when Donna is older and her head has developed more (between 4 and 10 years old), is an option to reconstruct/create the pinna on the right side of her head.

Dora is a 11 YO female who presents w/ a new mass on her neck, anterior to the sternocleidomastoid. She currently has a URI. You notice the mass is draining slightly and is soft and not fixed. Dora says it's not painful. What imaging do you order? What is your dx and tx?

Dora has a branchial cleft cyst, a congenital mass. You order an ultrasound to help confirm your dx. Because the cyst is draining, you rx abx and your refer to ENT/surgery to discuss removal to prevent further infection, but you reassure Dora and her parents that the mass is benign.

Dorothy is a 4 YO female who presents w/ lesions in her mouth following a fever and sore throat. Her mother says she hasn't been eating much either. PE shows small grey ulcers on her uvula and soft palate, but none on her gums. How do you dx and tx? What is the etiology? If this disease progressed how would it present/what would it be called?

Dorothy has herpangina, a condition caused by coxsackie viruses. If the disease progresses, it spreads as a rash to the hands and feet, causing hand, foot & mouth disease. Tx is symptomatic and you reassure Dorothy's mother that it should resolve in 7-10 days.

Edith is a 70 YO female who presents w/ high fever, chills, and malaise that began yesterday afternoon and has gotten worse in the past 18 hours. She says that yesterday she thought maybe she was just feeling "a little run down" from the crowds at the mall the day before when she went Christmas shopping, but when it got worse she decided to come in. PE confirms she is febrile - 101.5, and her general appearance is that of an unwell, uncomfortable patient. You notice she has several layers on but still occasionally shivers. You notice that she exhibits rhinorrhea and her throat looks a bit irritated and red. Throughout the visit, she coughs weakly. Edith is an otherwise healthy pt who is only taking alendronate and she has no allergies. How do you dx and tx Edith?

Edith has influenza, a viral illness she likely contracted from someone when she was shopping at the mall. Because Edith is an elderly patient and is seeing you w/in 48 hours of onset, you prescribe Tamiflu to help reduce her sxs, prevent the spread of the flu, and prevent complications. If Edith has a spouse or family member living at home with her, you can talk to her about having that person watch her for worsening sxs that may require hospitalization as well as offering to prescribe tamiflu for that person prophylactically. If Edith lives alone, you may recommend admitting her to the hospital for observation to ensure she responds to tx.

Elaine is a 45 YO female who presents w/ white lesions in her mouth that have developed over the past 6 months. She has a hx of smoking for the past 20 years. PE shows a white mucosal plaque on her lower gums. It isn't TTP and can't be rubbed off. You take a sample to biopsy. What is your dx and tx for Elaine?

Elaine has oral leukoplakia, likely d/t her hx of chronic smoking. Biopsy will show if she has early signs of cancer. You tell her that the plaques will likely resolve if she stops smoking. If her biopsy shows signs of cancer, you can refer her to a surgeon for removal of the patches.

Harold is a 6 YO male who presents w/ ear discomfort for the past 5 days. He says his ears "feel full." Harold has a hx of URIs. PE shows that his tympanic membrane has a yellow coloration but is otherwise normal. How do you dx and tx Harold?

Harold has Eustachian tube dysfunction, characterized by the yellow tint to his tympanic membrane that indicates effusion. You rx a steroid nasal spray (like nasonex) and tell Harold's parent that he should also use saline rinses. If the sxs don't improve or other sxs develop, you can refer him to ENT for tubes or myringotomy.

Heath is a 50 YO male who presents w/ a "spot in his right eye" that he noticed 2 days ago. He said it doesn't hurt or cause him any pain, but he's worried that it's something cancerous. PE shows a small, elevated nodule in his right conjunctiva. There are no signs of inflammation. What is your dx and tx?

Heath has a pinguecula, a typically asymptomatic nodule in the conjunctiva. It is benign, but may become problematic if it becomes inflamed. You tell Heath you want to wait and observe it, and that he should come back if he develops any new sxs or notices any changes in the nodule.

Hilda is a 62 YO female who presents w/ pain and redness in her left eye. She said being in the sun has become unbearable and she's been wearing sunglasses everywhere. PE shows an erythematous left eye w/ tearing. You note a few small vesicles around her left eye as well. What exam do you perform and what do you see? What is your dx and tx? What is the etiology?

Hilda has Herpes Simplex Keratitis, caused MC by HSV1. Fluorescein exam reveals dendritic corneal ulcers - a hallmark of Herpes infection. Tx is oral acyclovir, cycloplegic drops, topical antivirals (trifluridine), and referral to an ophthalmologist

Joey is a 32 YO male who presents w/ a plugged feeling in his ears that he's had ever since he got back from his trip diving the Great Barrier Reef. He thought it would resolve but it's lasted for 3 days now. PE is normal and you tell Joey he has nothing to worry about, his ear will return to normal eventually. What is the cause of Joey's complaint? What recommendations do you make?

Joey's ears are feeling plugged due to barotrauma from scuba diving that introduced negative pressure external to the middle ear. To try to "pop" his ear, he can chew gum, yawn and swallow frequently, or try to the Valsalva maneuver. Eventually, they should re-equilibrate.

Jonas is a 2 YO male who presents w/ fever, stridor, and a barking cough for the past 4 days. Prior to that, his parents say he had a stuffy nose. They think he might have picked it up at daycare. PE confirms his fever and you notice sternal retractions as well. What is your dx and tx for Jonas. What is the most likely etiology? If you took an x-ray, what would you see?

Jonas has croup, a viral infection MC caused by parainfluenza virus. Dx is typically clinical, but if you took an x-ray, you would see Steeple sign - subglottic narrowing that causes he sxs. You tell his parents to tx w/ humidity, ibuprofen, and fluids to start, but if it worsens you can tx nebulized epinephrine and/or dexamethasone.

Julia is a 7 YO female who presents w/ crackling and fullness in her right ear as well as difficulty hearing for the past 4 days. Her mother says she knows you won't give antibiotics because it's probably viral and it's only been a couple days, but this is the 3rd time Julia has experienced this in the past four months and she's wondering if there's any solution besides waiting and giving her daughter ibuprofen. PE confirms your suspicion: you see effusion and a dull tympanic membrane, but no purulence. What does Julia have? How might you tx her differently this time?

Julia has acute otitis media and it is likely viral as her mother suspected. Because this is her third episode in the past 6 months, you tell Julia and her mother that you could insert PE tubes to assist drainage and prevent future recurrences.

Julian is a 57 YO male who presents w/ a new mass on his neck laterally. During PE you notice that the mass pulses, and you can hear a bruit. As you palpate the mass, you note that it is mobile horizontally but not vertically. What is this sign called? What imaging do you order? What is the layman's term for this condition? What is your dx and tx for Julian?

Julian has a paraganglioma, or potato tumor, a vascular tumor that MC occurs in the carotid body where Julian's is located. The ability to move the tumor horizontally but not vertically is known as Fontaine's sign. You order and MRI to visualize the mass better. Tx is surgical removal.

Kailey is a 3 YO female who presents with a sudden fever, sore throat, and drooling that began in the middle of the night last night and quickly got worse. You note stridor during her PE and her throat is very red and swollen. What are your next steps? What is your dx and tx? What would you see on X-ray? What is the MC etiology?

Kailey has epiglottitis, a viral infection MC caused by H. influenzae that causes cellulitis of the epiglottis and surrounding tissues. This is a life-threatening condition and your next step is to ensure her airway stays open. You refer Kailey urgently to the ED via ambulance where she will receive IV abx and will have a tracheostomy set at her bedside. It is important to keep her calm throughout this. X-rays aren't typically taken because they take too long, but they would show thumbprint sign.

Kara is a 45 YO female who presents w/ high fever, pain behind her eyes, and nausea for the past 2 days. She returned recently from a trip to Puerto Rico w/ her husband. PE shows that she has a high-grade fever of 104 F and a petechial rash on her neck and arms. You insert a BP cuff on her arm and inflate it for 5 minutes then deflate it. What test are you performing? What are you looking for? What is your dx and tx? What is the etiology? What is the vector?

Kara has dengue fever, a viral infection transmitted by the Aedes aegypti mosquito. You are performing a tourniquet test on Kara, and you're looking for the formation of 10 + new petechiae in one square inch on her arm, below where the tourniquet was placed. Tx is supportive.

Karen is a 45 YO female who presents for her annual physical. She has a hx of Graves' disease but is otherwise healthy. Upon examination of her throat, you notice a hard nodule on the thyroid. You ask Karen to swallow and feel that the nodules moves up and down as she swallows. Karen has no other signs or sxs. What tests might you run? What is your dx and tx for Karen?

Karen has a thyroid nodule. You order TSH, and T3/T4 labs as well as an ultrasound of her thyroid to help confirm the dx. If these tests suggest the nodule is benign, tx will be observation.

Kathy is a 33 YO female who presents w/ bright red blood in her left eye. She said she went to bed last night and her eye looked normal, but she woke up, it looked like this but doesn't hurt. PE shows blood surrounding (but no passing beyond) her iris. Visual acuity is intact and Kathy has no other findings. What is your dx and tx for Kathy?

Kathy has a subconjunctival hemorrhage, a MC spontaneous condition. Tx is reassurance - you tell Kathy that it should resolve by itself.

Kendra is a 35 YO female who presents w/ hearing loss in her left ear that's developed over the past 2 weeks. She has also noticed some drainage from the ear. She has a hx of recurrent otitis media infections. Weber lateralizes sound to the left ear. Rinne shows she is able to better hear the tuning fork placed behind her left ear than next to it. Otoscopy shows a pearly substance just behind her tympanic membrane. What is your dx and tx? What kind of hearing loss is Kendra experiencing? What would an audiogram show?

Kendra has a cholesteatoma, a condition that can follow frequent otitis media infections. Hearing tests shows that her hearing loss is conductive. An audiogram would show normal hearing in her right ear and reduced air conduction in her left ear. Tx involves abx (e.g. ciprodex), aeration under microscopy, and weekly cleaning. If this is ineffective, surgery can be an option.

Kenny is a 48 YO male who presents w/ a red patch in his mouth that's been growing over the past 4 months and just won't go away, no matter what he tries - gargling w/ salt water, orajel, etc. He says it sometimes bleeds and it makes chewing difficult at times. He has a hx of smoking and alcohol abuse. PE shows a velvety red patch on the floor of his mouth. What is your next step? What is your dx and tx for Kenny?

Kenny has oral squamous cell carcinoma, likely d/t his hx of smoking and drinking. You take a biopsy for histology and you recommend that he avoid smoking and drinking moving forward. You refer him to oncology for further evaluation and treatment, pending the results of the biopsy.

Klaus is a 4 YO male who presents w/ reduced vision in his left eye. He has no pain and no other significant sxs. He was recently dx'd w/ myopia and given corrective glasses. His parents say his vision has improved overall but his left eye seems to lag. PE confirms reduced visual acuity in his left eye and you notice esotropia in that eye as well. He often squints w/ his left eye. What do his myopic hx and strabismus indicate could be a cause of his vision loss? How do you tx Klause?

Klaus has amblyopia, a loss of vision d/t abnormal development in his left eye that leaves his vision poor even after correcting for his myopia. His recent glasses will likely improve his amblyopia, but you also suggest PT to retrain his extraocular muscles and you suggest that he wears a patch over his right eye to incentivize his left eye to be strengthened and trained by his brain.

Kyle is a 35 YO male who presents w/ a persistent fever and chills for the last month and persistent fatigue. He has a history of IVDU for the past several years and has lost 15 lbs since his physical 1 year ago, though he hasn't changed his diet or exercise habits. PE confirms that he is febrile - 100.5 degrees, and you note swollen lymph nodes. He is currently on no medications and has no allergies. What lab and what test would you run? If the results confirm your ddx, what is your dx and tx

Kyle has HIV. You could confirm with HIV antibody testing and you take a blood sample for a CD4 count to determine his baseline. Given his current state it's very possible that he has AIDS - CD4 < 200. You would also run follow up tests following a positive HIV antibody test to determine the type of HIV, if he has the HLA-B*5701 allele, to determine his viral load, and possibly screening for STIs, HBV, and HVC. You would want to run baseline labs as well (CBC, BUN, etc.) to identify any comorbidities. If Kyle can commit to lifelong therapy, you would start him on ART - e.g. Biktarvy, a single pill he would take daily. Depending on his CD4 count, you may also treat him prophylactically to prevent certain other opportunistic infections. You refer Kyle to psych to address the emotional trauma of the dx, and also encourage him to treat his addiction. You impress upon him the importance of informing any sexual partners or people w/ whom he shared needles of his status so they can also be tested.

Kyle is a 32 YO male who presents w/ high fever, headache, and nausea following his return from Kenya. His roommate says he's been having spasms every day since the other sxs started. PE shows that his vitals are Temp 103.3 F, HR 105, RR 20, and BP 130/90. You also notice a petechial rash on his back that he wasn't aware of and when you palpate his abdomen the you note hepatomegaly. Labs show mild coagulopathy and elevated BUN and creatinine and anemia as well as parasitemia. What is your dx and tx? What is the etiology and what is the vector?

Kyle has malaria, contracted during his visit to Kenya. This parasitic infection is caused by 5 species of plasmodium, in his case most likely P. falciparum. The parasite is transmitted by the bite of the female Anopheles mosquito. Tx is Malarone and probably admission for the next few days, given Kyle's severe fever and spasms.

Lauren is a 32 YO female who presents fever, headache, and joint pain for the past 4 days. She recently returned from a trip to Cuba. She says she knows it could just be flu, but she requests a Trioplex Real-Time RT-PCR assay. She and her husband are trying to get pregnant. What disease is she concerned about? What is the vector? What is tx if she tests positive?

Lauren is worried she may have contracted Zika virus, a disease transmitted by the Aedes aegypti mosquito, on her recent trip to Cuba. The assay she requested can determine if she's been exposed to the virus. If she is infected, tx is supportive/symptomatic and she should wait at least 6 months before attempting to conceive.

Leah is a 27 YO female who presents w/ a slight cough and tightness in her throat, but no difficulty breathing. She is 8 months pregnant and otherwise healthy. PE shows swelling at the base of her neck but no other significant signs or sxs. What labs/imaging do you order? What is your dx and tx?

Leah has a goiter, likely brought on by pregnancy. You order TSH and T3/T4 labs as well as a thyroid US. Because they sxs are not extreme and you believe the goiter will resolve after Leah gives birth, you tell her you want to observe the goiter, but that she should come back immediately if her sxs worsen or change.

Lindsey is a 42 YO female who presents w/ a bulging left eye. She says it also feels dry and irritated. PE shows a bulging left eye and you notice she has difficulty closing her lid around her eye when she blinks. An exophthalmeter measurement shows her left eye is out of position in its orbit. What is the most likely etiology for this condition? What is your dx and tx?

Lindsey has proptosis, or exophthalmos, a condition of unilateral or bilateral bulging eyes that is MC seen in adults who have underlying Graves' disease. Tx for Graves' may involve radioactive iodine therapy, beta blockers, and/or anti-thyroid medication (e.g. Tapazole). Typically, the proptosis resolves when the Graves' disease has been tx'd. If it does not, you can refer her to ophthalmology for further evaluation and possible surgery to tx the eye condition.

Madison is an 18 YO female who presents with a painful, "bloody right eye" following a hit to her face. She was standing on the sideline at her ultimate game and didn't see the disc fly out of bounds - it hit her directly in her right eye. PE shows blood in the anterior chamber that nearly covers her pupil. What is your dx and tx? What pt education is important?

Madison has a hyphema, d/t the trauma to her eye. You tell her to elevate the head of her bed to 45 degrees and you give her a protective eye shield to wear. You know here eye is painful, but you tell her not to use ASA or NSAIDs. You rx dexamethasone gtts to decrease inflammation and mydriatic gtts (e.g. cyclopentolate) to dilate and temporarily paralyze her right pupil.

Maggie is an 80 YO who presents w/ worsening hearing loss over the past several months. She is otherwise healthy and has no allergies and isn't taking any medications. She hears you speak during the whisper test, but isn't sure what you've said. She has no lateralization w/ the Weber test and Rinne shows that air conduction is louder than bone conduction. You refer her for an audiogram, which shows bilateral hearing loss at higher frequencies. What is your dx for Maggie? What type of hearing loss is she experiencing? How do you tx?

Maggie has presbycusis, or age-related hearing loss. The damage is sensorineural and unfortunately can't be reversed w/ treatment but you tell Maggie that a hearing aid may help her accommodate the hearing loss.

Mandy is an 8 YO female who presents w/ fever, headache, and sore throat for the past 3 days. Her father says that she hasn't been eating much because it hurts to swallow. PE confirms she has a fever- 100.4 and her throat is bright red w/ exudates. You see petechiae on her palate as well. You run a rapid test and it comes back positive. What did you test for? What is your dx and tx? If you'd noted a sandpaper-like rash on Mandy's skin, what would your dx be?

Mandy has bacterial pharyngitis, and you ran a rapid strep test, confirming the cause to be GABHS. If you'd found a sandpaper-like rash on Mandy's skin, your dx would be Scarlet fever. Tx can be natural course - allow the infection to resolve on its own - or you can rx penicillin.

Marian is a 25 YO female who presents w/ acute, throbbing pain in her left mouth for the past 3 days. She says it radiates to her ear. She's tried taking tylenol and ibuprofen but neither helped her pain. She had her wisdom teeth removed 4 days ago. PE shows an exposed bone in the socket where her left wisdom tooth was and you notice a fetid odor. What is your dx and tx for Marian?

Marian has dry socket, a post-extraction complication d/t loss of clot. Tx involves anesthesia, irrigation, packing, and pain meds and you refer her to the dentist for this.

Maurice is a 62 YO male who presents w/ pain and swelling in his jaw that has worsened over the past month. He is only recently insured after being homeless and jobless for several years and this is his first checkup in several years. You notice severe swelling and redness of his gumline, which has receded, as well as excessive buildup of plaque and tartar. What is your dx and tx for Maurice. What other health concerns might you have?

Maurice has periodontitis, a consequence of untreated gingivitis. You tell Maurice you want to refer him to the dentist for evaluation and a care plan, but you stress the importance of oral hygiene moving forward. You tell him that oral health has systemic consequences and could increase his risk of cardiovascular issues so want to see him back in 2 weeks to see how he's doing and you put him in touch with a community resource officer to help him find the resources he may need.

Max is a 32 YO male who presents w/ pain around his left eye and intermittent blurred vision for the past 2 hours. PE shows he has injected conjunctiva and his left-pupil is mid-dilated and non-reactive. His visual acuity is decreased compared to his right eye and tonometry shows an IOP of 22 mmHg. What is your dx and tx for Max? What nerve is affected? What canal is being impaired?

Max has acute angle-closure glaucoma, caused by sudden increase in IOP that damages the optic nerve and is associated w/ impaired drainage of the aqueous humor through trabeculae and the canal of Schlemm. Tx is IV acetazolamide to reduce the production of aqueous humor and pilocarpine drops to constrict the pupil and relieve the obstructed outflow. You may also rx an osmotic diuretic and a topical steroid drop. You should tx for pain as well and refer to ophthalmology for anterior chamber paracentesis. Definitive tx is laser peripheral iridotomy.

May is an 48 YO female who presents w/ congestion and discharge on the left side of her nose that's been worsening for the past 2 weeks. She says that it's hard to breathe through her nose on that side and also hard to smell. She has a hx of allergic rhinitis and asthma. PE shows a mobile, nontender, pedunculated mass inside of her left nostril and clear discharge. What is your dx and tx? If the discharge was blood-tinged, how would your dx change?

May has a nasal polyp, a benign mucosal protrusion of unknown etiology. You tell her it's benign so you can continue to observe it over time and you recommend that she uses nasal corticosteroids (e.g. Flonase) to tx her sxs. If these don't work, you can rx an oral or injectable steroid or she can consult an ENT about polypectomy to remove the mass.

Melissa is a 22 YO female who presents w/ a new, slowly growing patch on the sole of her left foot. She's concerned it's melanoma. She recently returned from a trip to Bali where she camped daily and ran barefoot on the beach every morning. Melissa has a hx of hyperhidrosis. PE shows the rash is scaling slightly and dark brown in color. It is flat and has irregular edges. What test do you perform? What is your dx and tx? What is the etiology?

Melissa has tinea negra, a fungal infection caused by Exophiala werneckii that she likely acquired in the warm climate of Bali You confirm your dx w/ a KOH prep of a scraping from the lesion. Tx is topical ketoconazole.

Micah is 14 YO male who presents w/ pain in his mouth. He got in a fight at school today and took a punch to the mouth. He says it hurts tremendously somewhere on the upper right side of his mouth if he bites or clenches his jaw You notice his gums and buccal mucosa are bleeding near the site of the trauma. You see a well defined crack down the middle of one of his right molars. What might help with his pain? What is your next step? Is this a dental emergency?

Micah has a complete tooth fracture, caused by the trauma from the fight. Removement of the fragments may help w/ his pain. You suggest NSAIDs for pain and you refer him to the dentist for evaluation ant tx - possible filling or crown. This is considered a dental emergency if the pulp of the cracked tooth is exposed.

Michael is a 40 YO male who presents w/ headache and fatigue for the past week. He is HIV+ but is not currently on ART. PE confirms he is febrile - 100.7 - and you notice he is jaundiced and his abdomen is TTP. What test do you perform to dx? How do you dx and tx? What causes this condition?

Michael has a cytomegalovirus, an opportunistic infection associated w/ HIV that is caused by a herpes virus and is impacting his liver. You can confirm this dx by PCR. If you can convince Michael to begin ART, that would be beneficial for his long term health and you should do so. You rx additional antiviral meds to tx the CMV.

Miranda is a 35 YO female who presents w/ a needle in her eye. She said she was carrying her cross-stitch with her down the stairs when she tripped and the needle ended up in her eye. It appears to be embedded at least 1 inch. How do you image the injury? What is your dx and tx?

Miranda has an intraocular foreign body. Ideally you take a CT to image the needle, but an x-ray will also work since the object is metallic. (Do NOT take an MRI). Tx is broad-spectrum IV abx and an immediate ophthalmology consult.

Mischa is a 33 YO female who presents with cracking at the corners of her mouth for the past week. She says they start to heal overnight, but when she wakes up and starts talking and eating they get irritated again. PE shows crusted cracks bilaterally on her mouth with some scabbing/signs of recent bleeding. What is the mostly likely etiology? What is the dx and tx?

Mischa has angular cheiilitis, an inflammation of the corners of her mouth, most likely caused by a yeast infection. You tell Mischa that she can wait a bit longer to see if it resolves by itself, or she can use an OTC antifungal like Lotrimin to ease the sxs.

Patience is a 52 YO female who presents w/ congestion and rhinorrhea for the past week. She says she doesn't have any itching or sneezing. She notices it's been more prevalent as the weather has gotten colder this week - when she first steps into the cold air her sxs worsen. She went to a bonfire last night as well and found that her sxs were exacerbated by the smoke. PE shows normal appearing nasal mucosa. You take a sample of her nasal secretions and find normal IgE levels and normal eosinophils. What is your dx and tx for Patience?

Patience has vasomotor rhinitis, a poorly understood condition. You tell her that tx is difficult - she should avoid known triggers as much as possible, humidify in the winter and use nasal saline spray. She can also consider nasal antihistamines like Afrin, nasal steroid spray like flonase, or anticholinergic nasal sprays. If these don't improve her sxs, you can refer her to ENT.

Paulo is a 6 YO male who presents w/ a cough for the past 3 days. His mother says he also developed a rash on his face yesterday, and he had a fever but it's started to fade. The family recently returned from a trip to Brazil to visit Paulo's grandparents there. You note that Paulo's vaccinations aren't up to date. PE shows an erythematous maculopapular rash on Paulo's face that seems to be spreading down his neck. In his mouth you notice clustered white lesions on his buccal mucosa. How do you dx and tx Paulo? How do you confirm your dx? What are the lesions in Paulo's mouth called? What is the etiology?

Paulo has measles, an infection caused by Measles morbillivirus that he likely acquired during his trip to Brazil. Dx is typically clinical but you can confirm w/ serology. The enanthem in his mouth is referred to as Koplik spots. The infection is typically self-limiting in 10-12 days and you recommend OTC drug for any pain (e.g. acetaminophen). You encourage Paulo's mother to update his vaccinations to prevent future infections.

Peter is a 35 YO male who presents w/ fever, malaise, and diarrhea for the past 2 weeks. He is HIV+ but doesn't take his ART consistently. You notice that he's lost 5 lbs since his last visit, and his CD4 count is lower than his last visit. You take a sputum culture and and stain the bacteria, but find that they are neither strongly gram + or -. What is your suspected dx? How do you tx? What bacteria are responsible?

Peter has Mycobacterium Avium Complex, an atypical mycobacterial infection caused by M. avium and M. intracellulare. MAC is a common OI in HIV+ pts w/ reduced immunity. You start him on azithromycin to tx the infection and discuss the importance of adhering to his ART to prevent future OI's as well as creating resistant HIV.

Rachel is a 14 mo old female who presents w/ fever, swollen eyelids, and swollen lymph nodes for the past two days. Her parents say that this morning the fever had dropped, but then they noticed she was also developing a rash on her stomach and brought her in.. She has no known allergies and is otherwise in good health. PE confirms she is febrile - 100.4 - and you note bilateral palpebral edema. The rash on her stomach consists of a patch of pink macules and papules surrounded by white halos. What is your dx and tx for Rachel? How do you confirm? What is the etiology?

Rachel has roseola, or sixth disease, an infection caused by HHV6 (MC) or HHV7 (rare). You can confirm the infection w/ serologic testing, but dx is commonly clinical. Tx is supportive as the infection is self-limiting.

Tanya is a 48 YO female who presents w/ episodes of "the room spinning around me" that last for at least half an hour and often longer. They started a month ago and occur at least a couple times a week. She said she also experiences low-pitched ringing at times and hearing loss in her left ear. What is your dx and tx for Tanya? What kind of hearing loss is she experiencing? What would her audiogram look like? What is the etiology?

Tanya has Meniere's disease, a condition caused by excessive endolymph in the inner ear. Her hearing loss is unilateral sensorineural and her audiogram would show more difficulty hearing at lower frequencies in the affected ear. You rx Meclizine to help reduce the spinning sensations and you refer her to rehab to help improve her balance. You may also recommend a hearing aid to improve her hearing. If these measures don't help, you can suggest a Meniett device to apply pulses the inner ear through a ventilation tube.

Theresa is a 16 YO female who presents w/ reddened eyelids off and on for the past month. She has a hx of rosacea. PE shows red, swollen eyelids with some crusting between the lashes. You notice she is wearing mascara and eyeliner. What is your dx and tx? What is the MC etiology?

Theresa has blepharitis, an inflammation of the upper eyelid that can accompany rosacea and is MC caused by S. aureus. It is also caused by poor eyelid hygiene. You tell Theresa that she may want to take a break from eye makeup until the infection resolves and she should use warm, moist compresses on her eyes to help w/ the sxs. Since she also has rosacea, you rx doxycycline PO to help clear the infection.

Thomas is a 44 YO male who presents w/ a swollen neck that began this morning. He is a post-op pt at your hospital and was recovering well from an appendectomy but the pain meds have killed his appetite and he hasn't been eating or drinking much. PE shows a firm, swollen, tender parotid gland and he is slightly febrile and diaphoretic. Labs show that urinary amylase is elevated. What is your dx and tx for Thomas?

Thomas has parotitis, an inflammation or the parotid gland. Tx involves encouraging him to eat and hydrate properly as well as IV abx.

Toby is 37 YO male who presents w/ painful, swollen red skin around his right eye that's progressed over the past 36 hours. He has a recent history of acute sinusitis. PE shows that he is slightly febrile - 99.8 and you observe edema and erythema surrounding his right eye. You notice his right eye is bulging and he is not able to track smoothly with that eye. What imaging do you order? What is your dx and tx? Name one of the MC etiologies.

Toby has orbital cellulitis, likely d/t infection spreading from his sinuses. You order a CT to confirm your dx - you will be able to see an inflammatory mass w/in the orbit. The MC causes are S. aureus, S. pneumoniae, and H. flu. Tx is broad spectrum IV abx and an emergency surgical consult.

Todd is a 47 YO male who presents w/ erythema and tearing in his left eye. He says that bright lights are painful and he's been wearing sunglasses frequently. PE shows localized erythema in his red eye with no discharge. You ask if the eye feels irritated and he says no. What is your dx and tx for Todd?

Todd has episcleritis, an idiopathic inflammation of the episclera. Tx is reassurance - the condition should resolve in 1-2 wks. In the meantime, Todd can you NSAIDs, if he'd like.

Tory is a 28 YO female who presents w/ acute pain in her right jaw for the past week and a weird taste in her mouth. PE shows a fluctuant mass along her lower right gum line, purulent exudate in the same area and a very decayed, discolored-looking tooth. You palpate the area and it is extremely tender. What is your dx and tx for Tory?

Tory has a dental abscess, caused by an untreated cavity. Tx is abx to tx her oral infection and you suggest NSAIDs for the pain but you tell her it is important that she get a dental consult ASAP for I&D and further tx.

Tricia is a 27 YO female who presents w/ a fever and a productive cough for the past two weeks. She recently returned from volunteering in a refugee camp for 4 weeks in South Sudan. You note that she's lost weight since she left for the trip, but she thinks that's because she was so active while she was on the trip. You notice light pink spots when she coughs into a tissue. How would you dx and tx Tricia? What test could confirm your dx? What is the etiology? What imaging might you want to perform?

Tricia has tuberculosis, a bacterial infection caused by Mycobacterium tuberculosis and transmitted via respiratory droplets. You could confirm the dx w/ a tuberculin test, but given her sxs you may want to start tx immediately - a long course of abx - first line is Isoniazid. Because her sxs are pulmonary (coughing up blood), you may also want to take a chest x-ray to visualize the progression of the disease in her lungs.

Tristan is a 7 YO male who presents w/ a red, swollen lump near the medial corner of his right eye. His mother said it started to appear 2 days ago and keeps getting worse. PE shows an erythematous, tender bump just medial to his left eye and you see slight drainage of pus from his right tear puncta. How do you dx and tx? What are the MC etiologies?

Tristan has dacrocystitis, an inflammation of the lacrimal drainage system that is MC caused by Staph and Strep infection. You take a sample of the pus to be cultured and you start Tristan on Augmentin PO. You also refer him to ophthalmology for potential surgery/probing to reopen the blocked area.

Troy is a 32 YO male who presents w/ hoarseness for 2 days. He said he was at a Viking's game 2 nights ago with friends and he noticed the hoarseness the next morning. He's worried he caught something from the crowd. Laryngoscopy shows diffuse erythema, edema, and engorged vocal cords. What are two possible etiologies? What is your dx? How do you tx?

Troy has laryngitis. It may be d/t cheering throughout the game or a viral infection, most likely rhinovirus, influenza, adenovirus, or coxsackie virus. Tx is reassurance and rest. You tell Troy to gargle with saltwater and use a humidifier and drink lots of water.

Nora is a 73 YO female who presents w/ sudden floaters in her visual field and flashing lights in her left eye. She says she feels like a dark curtain has been pulled over the left periphery of her left eye. She has a hx of myopia. Fundoscopic exam shows a wrinkled retina. What is your dx and tx for Nora? How do you know this isn't vitreous separation?

You suspect that Nora has a retinal detachment in her left eye. Both her age and her myopia are predisposing factors. You don't think this is vitreous separation because Nora described a "black curtain" over part of her visual field. You refer her to ophthalmology for a dilated, indirect fundoscopic exam. If they confirm, tx will be surgery to reattach the retina to the underlying layers - either laser photocoagulation for small tears or scleral buckling for a larger detachment.

Clarissa is a 5 YO female who presents for her physical. When you look inside her mouth, you notice some discoloration on the tops of a few of her teeth. You notice she's drinking apple juice from her sippy cup. You ask her mother about it and she says it's the only thing she can get Clarissa to drink lately. You notice no other abnormalities, but you suggest that Clarissa should go to the dentist and stop drinking juice, or at least not drink so much. Her mother asks if it's a big concern since Clarissa hasn't lost any teeth yet. What is your concern for Clarissa? What is your response to her mother? What would tx for Clarissa's issue be?

You're worried that Clarissa has dental caries d/t drinking so much juice (so much sugar). You tell her mother that poor health of primary teeth can lead to poor health of permanent teeth, so it's important to take care of them. You refer them to a dentist for possible filling and closer evaluation by a dentist.