PAeasy EENT

Which of the following examinations is a major component of routine monitoring of chronic, open angle glaucoma?
A Pupillary response
B Corneal reflex testing
C Visual field testing
D Accommodation
E Visual acuity
Visual Field Testing
Tonometry, gonioscopy, monitoring of the disc-to-cup ratio, and visual field examination are the routine exams done when monitoring primary open angle glaucoma.

A 30-year-old African-American man is admitted to the hospital to undergo stapedectomy for the treatment of otosclerosis. He had been experiencing increased hearing loss in the right ear over the past few years. His mother had suffered from the same condition when she was in her 40’s and had been successfully operated upon. You do an assessment using the Weber and Rinne tests.

Question
What do you expect to find?

Answer Choices
1 Bone conduction of the affected side is greater than air conduction
2 Bone conduction of the affected side is equal to air conduction
3 Air conduction of the affected side is greater than bone conduction
4 Sound lateralizes to the unaffected ear
5 Bone conduction of the unaffected ear is greater than air conduction

Explanation
The correct response is bone conduction of the affected side is greater than air conduction.Otosclerosis is a pathological condition of the middle-ear in which there is a formation of spongy bone near the footplate of the stapes. As it advances, it causes progressive fixation of the stapes footplate. Therefore, the sound transmission by air conduction from the stapes via the oval window to the perilymph of the inner ear is reduced.

Weber tuning fork test is performed by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone is heard. The fork stimulates both inner ears equally. A patient with a unilateral conductive hearing loss hears the tone louder in the affected ear and a patient with a sensorineural loss hears the tone louder in the unaffected ear. In otosclerosis the sound lateralizes to the affected ear.

The Rinne tuning fork test compares air to bone conduction. The stem of the vibrating tuning fork is placed on the mastoid process first and then the tines of the tuning fork are held in front of the ear and the patient is asked which stimulus is perceived better. In a healthy individual, the tone is heard longer and louder by air conduction, whereas with a conductive hearing loss, it is the other way around. Therefore, in otosclerosis the bone conduction is better than air conduction (BC>AC). With a sensorineural hearing loss, both receptions are reduced, but in the same ratio.

A 16-year-old girl has just been diagnosed with severe allergic rhinitis caused by ragweed and dust mite. She is a candidate for allergy immunotherapy, which will involve weekly subcutaneous delivery of the offending allergens in increasing concentrations.

Question
What is the ultimate goal of this type of immunotherapy for this patient?

Answer Choices
1 Immunity
2 Hypersensitization
3 Immune suppression
4 Hyposensitization
5 Eradication of infection

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

A 44-year-old man presents for follow-up of poorly controlled type I diabetes mellitus, which was diagnosed 32 years ago. What change on his funduscopic examination would indicate a need for urgent referral to an ophthalmologist?

Answer Choices
1 Blot hemorrhages
2 Cotton wool spots
3 Microaneurysms
4 Neovascularization
5 Flame-shaped hemorrhages

Explanation
Neovascularization is the hallmark of proliferative diabetic retinopathy. New vessels can appear at the optic nerve and the macula as a result of retinal hypoxia. They are susceptible to rupture, resulting in vitreous hemorrhage, retinal detachment, and blindness. Proliferative retinopathy requires urgent referral to an ophthalmologist and is usually treated with pan retinal laser photocoagulation.The risk of developing diabetic retinopathy is related to the extent of glycemic control and the duration of diabetes. It is classified as nonproliferative and proliferative.

Blot hemorrhages, cotton wool spots, and microaneurysms are indicative of nonproliferative diabetic retinopathy, which is usually seen 10 to 20 years after the onset of diabetes. Nonproliferative retinopathy does not always progress to proliferative retinopathy, but if it becomes extensive, it can result in retinal ischemia, which increases the likelihood of proliferative disease.

Flame-shaped hemorrhages are indicative of hypertensive retinopathy.

A 4-year-old boy accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The child is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Pulse is 94/min; BP is 110/70 mm Hg, and temperature is 101 F.

Question
What is the next best step to confirm the diagnosis?

Answer Choices
1 Direct fiberoptic laryngoscopy in the operating room
2 Indirect laryngoscopy
3 Examination with tongue depressor
4 Lateral neck radiograph
5 Complete blood count (CBC) and blood culture

Explanation
Direct fiberoptic laryngoscopy is the correct answer. The patient has symptoms of acute epiglottitis, a diagnosis that can be made on clinical grounds. The next step is direct fiberoptic laryngoscopy performed in a controlled environment – usually the operation theater – in order to visualize and culture the edematous larynx, as well as to secure the airway through placement of an endotracheal tube1.Direct visualization in the examination room with tongue depressor or indirect laryngoscopy is not recommended because of the high risk of immediate laryngospasm and complete airway obstruction1.

Lateral neck radiograph usually reveals an enlarged edematous epiglottis (thumbprint sign). Laboratory investigations like complete blood count (CBC) typically reveal elevated leukocytes with neutrophil predominance, and blood cultures are usually positive1. These investigations assist the diagnosis but may delay the critical step of placing the endotracheal tube1.

A 35-year-old woman presents with a 24-hour history of purulent drainage and erythema of her right eye. After a brief physical examination, cultures of the drainage are taken and she is started on a medication prophylactically that would cover the most common bacterial causes of conjunctivitis (including sexually transmitted diseases).

Question
On what medication, in either an oral or topical form, would she most likely be started?

Answer Choices
1 Erythromycin
2 Tetracycline
3 Bacitracin
4 Olopatadine
5 Acyclovir

erythromycin
Explanation
Erythromycin ophthalmic ointment, applied 2 – 4 x daily, is a treatment option for non-sexually transmitted bacterial conjunctivitis. If trying to cover all bacterial etiologies of conjunctivitis, then erythromycin can be given in the oral form in order to include good coverage for both gonococcal conjunctivitis and chlamydial conjunctivitis. If the erythromycin ophthalmic ointment were to be prescribed in a patient with a sexually transmitted bacterial conjunctivitis, there may still be a partial or complete resolution of symptoms. Erythromycin, in either the topical or oral form, has a good chance of treating any bacterial cause of conjunctivitis until the culture results confirm the etiologic agent.Tetracycline 250 mg po 4 x daily for 3 weeks is a good treatment choice for chlamydial conjunctivitis should the cultures reveal this as the cause; however, it would not be a good prophylactic choice while waiting for lab results.

Bacitracin ophthalmic ointment applied 2 – 4 x daily for 5 days is a good treatment option for patients with bacterial conjunctivitis that is not from a sexually transmitted disease. In these cases, the most common etiologic agent is Staphylococcus aureus.

Olopatadine is an antihistamine ophthalmic solution that is used in the treatment of ocular itching associated with allergic conjunctivitis. It would not be of any help in a patient with bacterial conjunctivitis, regardless of the etiology.

Acyclovir is an antiviral that is prescribed 400 mg po 5 x a day for 7 days in cases of herpetic viral conjunctivitis. It would not be of any help in a patient with bacterial conjunctivitis, regardless of the etiology.

A 28-year-old woman presents with an itchy throat, prolonged sneezing episodes, watery red eyes, and inflamed nasal membranes. Her temperature is normal and a throat culture is negative. She is most likely suffering from allergic rhinitis. Her physician will most likely prescribe diphenhydramine. To what class of compounds does the drug of choice belong?

Answer Choices
1 Antihistamine (H1)
2 Cathartic
3 Opioid analgesic
4 Prostaglandin
5 Antihypertensive

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

A 17-year-old boy was in your clinic 4 days ago for evaluation of a 101.8° F fever and was diagnosed with acute pharyngitis. You prescribed penicillin VK 250 mg TID for 10 days. The patient returns today because his sore throat is now worse. He has not been able to drink fluids, and he has excruciatingly severe pain with swallowing. You recognize the muffled “hot potato” voice. On re-examination, you identify a right medial deviation of the soft palate with a 4+ right tonsillar swelling.

Question
What is the most likely diagnosis?

Answer Choices
1 Oral candidiasis
2 Peritonsillar abscess
3 Laryngitis
4 Mononucleosis
5 Dental abscess

Explanation
This patient is clearly suffering from a peritonsillar abscess. This occurs when an active infection penetrates the tonsillar capsule and then involves the surrounding tissue. These patients will have a severe sore throat, odynophagia, trismus, deviation of the soft palate, and an abnormally muffled voice (i.e., a ‘hot potato voice’).Oral candidiasis (or thrush) does not present with the symptoms described in the scenario. Typically, oral candidiasis is painful and appears as creamy-white, curd-like patches; overlying erythematous mucosa can be found virtually anywhere in the oral cavity. The white patches can easily be wiped off when attempted.

Laryngitis is lower on the differential diagnosis list because it usually presents with the primary symptom of hoarseness. Laryngitis frequently occurs approximately 1 week after the occurrence of an upper respiratory viral infection that has since resolved.

A dental abscess would cause severe, persistent, throbbing toothache, sensitivity to hot and cold temperatures, sensitivity to biting or chewing, fever, possibly noticeable swelling in the face or cheek, or even lymphadenopathy relating back to the site of the abscess. The symptoms of a dental abscess do not match the clinical scenario presented.

Mononucleosis also presents somewhat differently than the scenario above, making it a less likely diagnosis. Malaise, fever, sore throat (sometimes exudative), lymphadenopathy, palatal petechiae, and even splenomegaly are found in patients with mononucleosis.

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

Answer Choices
1 Fleischer’s rings
2 Kayser-Fleischer rings
3 Rust rings
4 Arcus juvenilis
5 Pinguecula

Explanation
The correct answer is Kayser-Fleischer rings, which are the result of accumulation of copper in the cornea and the most unique sign of Wilson’s disease. Wilson’s disease is an inherited disorder of copper toxicity due to a genetic defect in copper transport. Beginning at birth, copper is not secreted into the bile or incorporated into the copper protein ceruloplasmin, resulting in low serum levels of ceruloplasmin. Symptoms and signs develop between 5 – 40 years of age as copper accumulates in the liver, brain, cornea, kidney, and reproductive organs. 50% of patients present with hepatitis; 40% present with neurological manifestations (tremor, speech disorders, dysphagia, incoordination), and 5 – 10% first present with Kayser-Fleischer rings (a brown-yellow ring in the cornea around the iris from copper deposits), amenorrhea, miscarriages, or hematuria. Diagnosis in confirmed by Kayser-Fleischer rings on slit-lamp examination in the presence of a low serum ceruloplasmin. AST and ALT levels are often elevated; serum copper is low; 24-hour urinary copper excretion is elevated. Treatment is lifelong chelation or oral zinc and a low copper diet.Keratoconus is a bulging of the cornea to form a cone, and the classic sign is Fleischer’s rings, which is an iron colored ring surrounding the cone. This progressive bulge is due to a weakness in the cornea and often occurs bilaterally beginning at 10 – 20 years of age. There are frequent changes in visual acuity necessitating repeated prescription changes, and contacts provide better correction than glasses. Corneal transplant may be necessary if corrective lenses are not adequate.

Arcus juvenilis is a gray or white arc around the peripheral cornea similar to arcus senilis in adults. It occurs in younger adults and is often associated with high blood cholesterol.

A metallic foreign body lodged in the cornea can quickly result in a single, small diameter rust ring that requires ophthalmologic intervention with a rust ring drill for removal.

A pinguecula is a raised, yellowish discoloration on the bulbar conjunctiva at the 3 o’clock or 9 o’clock position of the sclera-corneal junction. It is a benign growth; it is due to an accumulation of conjunctival tissue that can be the result of chronic actinic irritation.

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

Staphylococcus aureus
Explanation Staphylococcus aureus is a gram-positive staining cocci that is catalase positive, coagulase positive, and frequently beta hemolytic on blood agar. It is probably the 2nd most common bacterial isolate of human infections behind Escherichia coli and the most common cause of bacterial endophthalmitis. The organism has been described as an etiologic agent of many infections, including but not limited to, conjunctivitis, endocarditis, septicemia, abscesses, and urinary tract infections. The conjunctivitis caused by Staphylococcus aureusis usually characterized as non-severe where there is little to no lid edema, scant purulent discharge, and normal cornea; however, in some cases the presentation can be severe.
Chlamydia trachomatis is an obligate intracellular parasite with a unique biphasic life cycle. It does not gram stain, and laboratory procedures used for diagnosis include isolation in tissue culture, EIA detection of antigen, immunofluorescent staining, cytologic examination for intracytoplasmic inclusions, and by the demonstration of nucleic acid by direct hybridization or by amplification techniques. It can cause inclusion conjunctivitis and ocular trachoma. The inclusion conjunctivitis presents as an acute follicular conjunctivitis and is usually self-inoculated from an infected genitourinary site. The patient frequently complains of a foreign body presence in the eye. These symptoms are usually unilateral, and in the first 2 weeks, there is a mucoid discharge that becomes purulent.Pseudomonas aeruginosa is a gram-negative rod, non-lactose fermenting, oxidase-positive motile bacteria. Pathogenesis is due to its minimal nutritional requirements, relative resistance to antibiotics, and a host of other invasive and toxinogenic substances that it produces. It can cause a keratitis that is rapid in its development. The infection is usually the result of a previous injury to the eye, which causes an interruption in the epithelial surface and allows bacterial invasion of the underlying stroma. Scrapings from the floor of the ulcer exhibiting gram-negative rods are strongly indicative of Pseudomonas aeruginosa and should necessitate treatment.

Haemophilus aegyptius is a gram-negative coccobacillus, non-motile, fastidious bacteria requiring the presence of special factors for its growth on agar media. These factors are hemin and nicotinamide adenine dinucleotide, which are present in chocolate agar but not on other isolation media. The organism is indigenous to humans. It is an important cause of a purulent conjunctivitis called “Pink Eye” and can occur in outbreaks because of its contagious nature. The diffuse pink color of the sclera and the presence of a serous or purulent discharge are virtually diagnostic of Haemophilus aegyptius infection. Leukocytosis is absent. The infection is not acute in presentation.

Bacillus cereus is a gram-positive (or gram-variable) rod that is aerobic, spore-forming, and is ubiquitous in nature. Bacillus cereus is an important cause of food poisoning. It has also been recognized as an ocular pathogen. The ocular infection is acute in presentation and requires aggressive intervention to save the eye. The presence of progressive corneal deterioration and ring abscess formation is a complication of panophthalmitis caused by Bacillus cereus. Except for infections with Pseudomonas aeruginosa, this finding is almost pathognomonic of Bacillus cereus. Because of the seriousness of the infection, early diagnosis is important. Patients presenting with ocular infections after trauma or in the setting of drug abuse should arouse suspicion.

Acanthamoeba is a free-living amebae that can cause granulomatous amebic encephalitis and keratitis. It can not be cultured by routine culture methods. Detection is usually made by observing the free living motile organisms in a wet prep preparation. Acanthamoeba keratitis is a slow-developing corneal infection that occurs in healthy people and is usually associated with contact lens wearers. Symptoms include blurred vision, conjunctivitis, tearing, severe pain to the eye, and photophobia. The keratitis achieves an advanced stage in several days to several months and can exhibit patchy stromal infiltrates and dendriform epithelial involvement without frank corneal ulceration in its early stages.

Candida albicans is a yeast. Yeasts appear on gram stain as large gram-positive organisms, approximately 3-5 times larger than gram-positive cocci, and are nonhemolytic on blood agar. They are aerobic and generally grow well on most non-selective agar media. Endophthalmitis due to yeast is generally a common and serious complication of intravenous drug use. Candida albicans is the most common fungal cause. It is usually of hematogenous origin where the patient has infective endocarditis or some other infective process occurring. The symptoms are blurred vision, decreased vision, white cotton appearing exudative lesions in the choroid and retina with vitreous haziness, and eye pain. A definitive diagnosis is made by obtaining vitreous fluid for gram stain and culture.

A 61-year-old woman presents a 1-week history of intermittent episodes of feeling like she was spinning. She states the episodes are brief; however, they occur 2 – 3 times per day. It is worse when she turns to her right side while lying in bed. Even when she is not dizzy, she feels off balance. She denies tinnitus, decreased hearing, fever, syncope, nausea, vomiting, diplopia, or any other related symptoms. During the Dix-Hallpike maneuver, the patient exhibits nystagmus, with her eyes beating upward and torsionally when the right ear is turned downward. The nystagmus diminished with each time the maneuver was performed.

Question
Based on the above description, what is the most likely diagnosis?

Answer Choices
1 Benign Paroxysmal Positional Vertigo
2 Labyrinthitis
3 Meniere’s Disease
4 Vestibular Schwannoma
5 Brainstem Infarction

Benign Paroxysmal Positional Vertigo
Explanation
Benign Paroxysmal Positional Vertigo (BPPV) is the correct answer; episodes of BPPV are brief in nature and occur with change in position. People often feel off balance even when an episode is not occurring. BPPV does not typically cause hearing loss. The Dix-Hallpike maneuver elicits an episode of vertigo, with nystagmus being noted during the exam. The nystagmus diminishes with each maneuver due to fatiguability.Labyrinthitis is incorrect; labyrinthitis is usually caused by an infection, which the patient did not have. Labyrinthitis often includes hearing loss and or tinnitus.

Episodes often last days or weeks.

Meniere’s disease is incorrect; vertigo with Meniere’s disease usually lasts from 20 minutes to 24 hours in duration. Sensorineural hearing loss and tinnitus are also common features. Typical onset is usually between 20 – 40 years old.

Vestibular schwannoma is incorrect; most people with this have hearing loss and or tinnitus. True spinning vertigo is uncommon with this disorder. People do have unsteadiness with walking. Some other symptoms can include paresthesia, hypesthesia, facial paresis, and taste disturbances. Symptoms are slow onset.

Brainstem infarction is incorrect; patients present with sudden onset of symptoms, and the symptoms persist for days to weeks. Nystagmus has central characteristics versus the above patient, which showed peripheral characteristics. This would also have associated neurological signs and symptoms.

A 1.5-year-old boy presents with a squint in the left eye. His mother informed you that the child’s eyes were quite normal until about 2 months ago, when she noticed asymmetric movements of her son’s eyes. She also felt that the child could not see properly with his left eye. There is no history of trauma to the eye. Child was born at full term and his growth and development were within normal limits. Eye examination showed both eyeballs were equal in size. There was loss of vision in the left eye and a convergent squint in the same eye. Fundus examination showed absence of red reflex in the left eye, and instead a white pupillary reflex (leukocoria) was seen. X-ray of the skull showed calcification within the globe.

Question
What is the most likely diagnosis?

Answer Choices
1 Retinal detachment
2 Congenital cataract
3 Retinoblastoma
4 Congenital glaucoma
5 Persistent hyperplastic primary vitreous

Retinoblastoma
Explanation
The most likely diagnosis is retinoblastoma, as it is the most common primary ocular tumor in children below 5 years of age. 90% of cases are diagnosed below 3 – 4 years of age. The index case is a 1.5-year-old boy who has presented with a recent appearance of squint and absence of normal red reflex in the left eye, replaced instead by a white pupillary reflex (leukocoria). This is due to reflection of light from the white-colored tumor and loss of vision in that eye. The diagnosis is further supported by calcification seen in the globe in the X-ray of the skull. Fundoscopy may show the tumor as a white mass, which may be small and flat or may be large and protuberant. Orbital inflammation, hyphema, and irregular pupil are seen in advanced stages of the disease. Retinoblastoma gene is a recessive gene located on the chromosome13 at the 13q 14 regions, and the tumor may arise from any of the nucleated layers of the retina.Besides direct observation, ultrasonography or CT scan may help to confirm the diagnosis and demonstrate calcification within the mass. As biopsy can lead to the spread of the tumor, histopathological confirmation of the tumor can be made only after removal of the affected eye

Retinal detachment in infants and children more commonly occurs due to trauma, secondary to other abnormalities like myopia, or after cataract surgery. It can also occur in diabetes, sickle cell disease, and retinopathy of prematurity. Presenting signs can be loss of vision, secondary strabismus (squint), nystagmus, and leukocoria (white pupillary reflex). Calcification seen on an X-ray of the skull in retinoblastoma is absent in retinal detachment. Also ultrasonography and neuroimaging may be required to establish the cause of detachment.

Congenital glaucoma (elevated intraocular pressure) usually manifests during the first 3 years of life. The classical triad of symptoms of congenital glaucoma are epiphora (excessive lachrymation), photophobia (sensitivity to light), and blepharospasm (squeezing of the eyelids). These symptoms are due to corneal irritation. As the cornea and sclera are more elastic during early childhood, the elevated intraocular pressure therefore leads to expansion of the eyeball, including the cornea, and development of buphthalmos (ox eye), which means a large eye. This leads to corneal edema and conjunctival congestion. The cornea may become cloudy. There is no white pupillary reflex or calcification in the globe seen on an X-ray of the skull.

A cataract is an opacity in the lens and may cause significant impairment of vision. It may be an isolated defect or may be a part of a generalized disorder. Common causes are intra uterine infections like rubella, cytomegalovirus infection, toxoplasmosis, metabolic disorders like galactosemia, and chromosomal disorders like trisomy 13, 18, and 21. Trauma to the eyeball is a major cause of cataract in children. The red reflex may be absent or may be irregular or there may be a white pupillary reflex. The retina and the blood vessels may not be visualized due to the lenticular opacities. Nystagmus may be present. Poor visual fixation, squint, and poor social smile may be seen later on. Calcification in the globe is not present in cataract.

Persistent hyperplastic primary vitreous (PHPV) is caused by persistence of portions of the fetal hyloid vascular system and the associated fibromuscular tissue. The condition is usually unilateral, and the affected eye is smaller than normal. The anterior chamber is shallow, and the lens is also smaller than normal. Other presenting signs are white pupillary reflex (leukocoria) strabismus and nystagmus. The course is progressive and outcome is poor.

The major complication is spontaneous intraocular hemorrhage, swelling of lens caused by rupture of posterior capsule, and glaucoma. Sometimes the distinction between PHPV and retinoblastoma can be difficult. Ultrasonography and CT scan can be useful diagnostic aids that may show calcification within the mass in the case of retinoblastoma.

A 48-year-old Caucasian woman with multiple comorbidities presents with worsening hearing loss and tinnitus in her right ear. She states this first began about 3 months ago and was initially bearable; it has now progressed to where she cannot hear anything out of her right ear, and the tinnitus is unrelenting and constant. The patient is worried because she is now experiencing balance and coordination issues. An MRI is ordered on the patient, and it reveals the following results.

Question
Considering the diagnosis, as well as the fact that this patient is a poor surgical candidate, what would be a reasonable treatment option at this time?

Answer Choices
1 Gamma knife radiosurgery
2 Chemotherapy
3 Linear accelerator radiation therapy
4 Proton beam therapy
5 Observation only

Gamma knife radiosurgery
Explanation
Vestibular schwannoma, which also sometimes is referred to as an acoustic neuroma, are one of the most common intracranial tumors encountered in clinical practice. More than likely these occur as unilateral lesions; only rarely can these occur as bilateral masses. Although growth of these lesions is overall slow, the increased size can eventually cause such symptoms as unilateral hearing loss and deterioration of speech discrimination. Tinnitus will also be seen in these patients and as the tumor increases in size more central nervous system components are affected. This will cause loss of balance, coordination, vertigo, facial numbness, facial weakness, or even dysphagia. Typically these lesions are diagnosed via MRI or even a CT scan.Treatment options usually are initially centered on surgical removal; however, our patient is not a candidate for a surgical procedure at this time. Other options would be radiosurgery, or specifically Gamma Knife radiosurgery is recommended. Gamma Knife radiosurgery is seen as an acceptable alternative for microsurgery for non-surgical candidates with similar tumor control rates to those having the surgical intervention.

Linear accelerator radiation therapy is another type of radiotherapy used to treat cancers; however, this type is not indicated in the treatment of a vestibular schwannomas.

Proton therapy, or proton beam therapy, is yet another type of radiotherapy; however, it is not a type that is specifically used in the treatment of schwannomas.

Observation only would not be appropriate for this patient currently as she is having significant symptoms currently that are interfering with her every day and quality of life.

Chemotherapy is not used for treating schwannomas.

A 78-year-old Caucasian man presents with unilateral painless loss of vision in the right eye of 3 hours duration. Examination reveals an elderly gentleman who is anxious but in no acute distress. Visual acuity is light perception only in the right eye and 20/30 in the left eye. Pupillary examination is significant for an afferent pupillary defect on the right side. Penlight examination of the eyes is otherwise unremarkable. Retinal examination of the right eye reveals a cherry-red spot. Retinal examination of the left eye is unremarkable.

Question
What disease process most likely accounts for the patient’s presentation?

Answer Choices
1 Adult-onset Tay-Sach’s disease
2 Open angle glaucoma
3 Central retinal artery occlusion
4 Trauma
5 Cataract

Explanation
This case represents the classic presentation of a central retinal artery occlusion, namely acute, unilateral, painless, loss of vision as well as a cherry-red spot on fundus examination.Tay-Sach’s disease is a lysosomal storage disease found predominantly in Ashkenazi Jews. Infants with this fatal neurodegenerative disease do have a cherry red spot on retinal examination. An adult-onset form of Tay-Sach’s disease is rare but does exist. Onset of symptoms is in the 3rd or 4th decade of life; however, it is characterized by neurologic deterioration and cherry-red spots would be bilateral. Although this patient does have a cherry-red spot, there is nothing in the presentation to suggest Tay-Sach’s disease.

Open angle glaucoma is a chronic, slowly progressive condition that would not be expected to cause acute visual loss. The patient gives no history of trauma and no evidence of trauma is seen on examination. A cataract, or opacification of the lens, would not be expected to cause acute visual loss.

A 27-year-old woman presents with a 3-day history of left eye pain. The patient notes sensitivity to light, and she comments that her eye throbs in pain at night. On physical examination, you note a redness and loss of visual acuity.

Question
What would be an appropriate treatment for this patient?

Answer Choices
1 Cool compresses and artificial tears
2 Cortisporin ointment
3 Dexamethasone and homatropine ophthalmic drops
4 Oral acyclovir
5 IV acetazolamide

Dexamethasone and homatropine ophthalmic drops
Explanation
The correct response is dexamethasone and homatropine ophthalmic drops.The clinical picture is suggestive of uveitis. Patients with uveitis usually note redness, pain, photophobia, and visual loss. Treatment is with topical steroids and a dilating agent to relieve the discomfort. There are multiple causes of uveitis, but it is primarily immunogenic.

Cool compresses and artificial tears are not effective treatment for uveitis.

Cortisporin is effective against bacterial conjunctivitis. Patients typically present with a copious discharge in the affected eye with mild discomfort. There is no loss of visual acuity.

Oral acyclovir is used in the treatment of herpes simplex keratitis. Dendritic ulcer is seen on staining with fluorescein, which is not seen in this patient.

IV acetazolamide is used in the treatment of acute angle-closure glaucoma. Patients typically present with rapid onset of severe eye pain, profound visual loss, and halos around lights. The symptoms of severe eye pain, profound vision loss, and halos around lights are not seen in this patient.

An 84-year-old man presents to the emergency room with 2.5-hour history of painless, progressive vision loss in his right eye, which began while he was reading. He denies any other symptoms. Past medical history is positive for hypertension and a cardiac dysrhythmia.

Physical exam findings include a BP of 180/110; other vital signs are normal, and the left eye non-reactive to light. Marcus Gunn pupil (afferent pupillary defect) is seen; funduscopic exam reveals a pale retina with a red spot. The rest of the physical exam is normal. What is the most likely cause of vision loss in this patient?

Answer Choices
1 Retinal vein occlusion
2 Retinal detachment
3 Angle closure glaucoma
4 Central retinal artery occlusion
5 Branch retinal artery occlusion

Central Retinal artery occlusion
Explanation
Central retinal artery occlusion (CRAO) interferes with the major supply of blood to the retina, causing vision loss. In 25% of individuals, the macula is supplied by the cilioretinal arteries, sparing some central vision in the event of CRAO. The occlusion is principally caused by thrombus, thromboembolia, cholesterol plaques, calcium, or vasospasm. The patient notes a sudden, painless, monocular vision loss; the physical examination reveals a problem in the visual afferent way, and the funduscopic examination shows the red spot, which is the pigment of the choroid showing through the macula. Treatment consists of decreasing intraocular pressure in order to increase the pressure gradient in the artery and force the embolus to dislodge, restoring vision. Application of digital pressure, carbonic anhydrase inhibitors, beta-blockers, and paracentesis of the anterior chamber are some of the methods used for this purpose.Retinal vein occlusion should be considered in the differential; it is characterized by preservation of some vision, and it rarely shows a red spot in the retina at the funduscopic examination.

Retinal detachments often cause prodromal symptoms, such as flashing lights, floating ‘spider webs’, and the sensation of ‘having a curtain drawn up or down’ over the visual field. The funduscopic exam reveals an undulating, pale, detached retina.

Acute angle-closure glaucoma is characterized by severe ocular pain and blurred vision, rather than loss of vision.

A 58-year-old Caucasian man presents with a bleeding mole on his face. The mole is located on his left cheek has been present for the past several years but has started to spontaneously bleed over the last 3 months. The patient denies any other moles with the same characteristics and just wants it taken care of so it is not as bothersome. The patient denies weight loss, night sweats, or fevers; he has no recent changes in his appetite or sleeping issues. He is a farmer and owns over 100 acres that he plants and harvests yearly and has done so for the past 40 years. On physical examination, you find a 3 cm pink papule that is pearly in appearance and possesses a telangiectatic characteristic to it. Central ulceration is present.

Question
Given the history and physical exam findings, what is the most likely diagnosis for this patient?

Answer Choices
1 Malignant melanoma
2 Squamous cell carcinoma
3 Basal cell carcinoma
4 Benign nevi
5 Actinic keratosis

basal cell carcinoma
Explanation
The patient in this clinical case scenario most likely has basal cell carcinoma (BCC). BCC is a common skin cancer that arises from the basal layer of the epidermis. BCC is particularly common in Caucasians and has a 30% higher incidence in men than in women. BCC incidence also increases with age, with persons aged 55-75 having a 100-fold higher incidence than those under 20.BCC clinically presents in four or so different clinical types, the nodular form being the most common (making up 60% of the BCC cases). Nodular BCC is described as a pin or flesh-colored papule that is pearly or translucent and evidence of a telangiectatic vessel within the papule. Ulceration is common, sometimes referred to as a “rodent ulcer.” The other types of BCC include superficial, morpheaform, other subtypes, and even several BCC syndromes.

Squamous cell carcinoma of the skin typically appears as small, red, conical, hard nodules that occasionally will ulcerate. The presence of a pearly appearance helps distinguish BCC from squamous cell, although the two malignancies present in the same patterns.

Malignant melanoma of the skin is described as being a flat or raised pigmented lesion. The mnemonic of the “ABCD” rule is what is used to help screen suspicious lesions: Asymmetry, Border irregularity, Color variegation, and Diameter > 6 cm.

Benign nevi are common, but any skin lesion that has an ulcer and tendency to bleed should be urgently evaluated to rule out the worst-case scenario.

Actinic keratosis is also an incorrect choice. These are generally small (0.2 cm-0.6 cm) macules or papules that could be flesh color, pink, or even slightly hyper pigmented; however, they will feel like sandpaper and are generally tender when palpated. The clinical scenario does not match this description.

A 66-year-old woman presents with an acute closed-angle glaucoma attack. She is experiencing excruciating pain in her left eye, vision loss, vision field defect, nausea, and vomiting. She is given 4% pilocarpine. What is the primary purpose of pilocarpine administration?

Answer Choices
1 Antiemetic effect
2 Control of increased intraocular pressure
3 Restoration of peripheral vision
4 Improvement of vision
5 Pain relief

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

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

Answer Choices
1 Hairy leukoplakia
2 Atrophic glossitis
3 Hairy tongue
4 Geographic tongue
5 Candidiasis

geographic tongue
Explanation
A geographic tongue is a benign condition with unknown cause; it is characterized by a map-like pattern of smooth, red areas that do not have papillae as well as rough areas that still have papillae.Atrophic glossitis (or smooth tongue) presents as having a smooth surface due to papillae loss. The loss may indicate deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron.
Candidiasis is an infection that may cause the tongue to have a white coating, which can be scraped, and a sample can be analyzed for the presence of Candida.

Hairy leukoplakia may be seen in people infected with HIV and AIDS. It is characterized by raised areas that are whitish-tan in color that have a feathery appearance. It is different from candidiasis of the tongue in that hairy leukoplakia cannot be scraped off.

A ‘hairy tongue’ is not actually due to hair growth on the tongue; it consists of elongated papillae that have the appearance of grayish-black hair to the naked eye. This condition may be caused by antibiotic use, or there may not be any reason.

A 73-year-old African-American man presents for a routine follow-up since being diagnosed with glaucoma. His ophthalmologist has started him on a topical carbonic anhydrase inhibitor (dorzolamide) in order to lower eye pressure by decreasing aqueous humor production. What is the site of action of this drug?

Answer Choices
1 Trabecular meshwork
2 Canal of Schlemm
3 Corneal endothelium
4 Ciliary body epithelium
5 Retinal pigment epithelium

Ciliary body epithelium
Explanation
The correct response is the ciliary body epithelium.Aqueous humor is produced in the epithelium of the ciliary body; it travels through the pupil into the anterior chamber and drains through the trabecular meshwork into the canal of Schlemm. A topical drug which decreases aqueous humor production would be expected to act at the ciliary body epithelium.

The trabecular meshwork and canal of Schlemm are part of the outflow pathway of aqueous humor; they are not involved in aqueous humor production.

The corneal endothelium and retinal pigment epithelium are not involved in aqueous humor production.

A 66-year-old man presents with sudden onset of brief episodes of blindness in his right eye, with complete recovery of vision within 24 hours. The event is described as a shade coming down across his field of vision, and it is not painful.

Question
What is the most common underlying condition leading to the event described above?

Answer Choices
1 Migraine headaches
2 Lower extremity deep venous thrombosis
3 Carotid stenosis
4 Sickle cell disease
5 Acute angle-closure glaucoma

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

A 55-year-old man presents with intermittent vertigo, tinnitus, and progressive hearing loss over the last 4 years. What will an MRI of the head most likely show?

Answer Choices
1 No abnormalities
2 Acoustic neuroma
3 Aneurysm
4 Stroke
5 Hemorrhage

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

A 42-year-old man presents with a 24-hour history of severe vertigo, tinnitus, hearing loss, nausea, and vomiting intermittently; episodes last at least 30 minutes at a time. After a thorough history and examination, the patient is diagnosed with Ménière’s disease.

Question
What medication is he most likely to be given to treat the acute symptoms?

Answer Choices
1 Hydrochlorothiazide/triamterene (Dyazide/Maxzide)
2 Meclizine (Antivert)
3 Diazepam (Valium)
4 Acetazolamide (Diamox)
5 Dimenhydrinate (Dramamine)

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

Meclizine (Antivert) is not the correct answer, as this is an antihistamine medication that can be used for maintenance and long-term prevention of recurrent attacks.

Acetazolamide (Diamox) is not the correct answer, as this is another diuretic medication choice that can be used for maintenance and long-term prevention of recurrent attacks.

Dimenhydrinate (Dramamine) is not the correct answer, as this is another antihistamine medication that can be used for maintenance and long-term prevention of recurrent attacks.

A 2-week-old female infant is seen for her newborn well baby exam after a normal birth and delivery. She has been nursing well, has regained her birthweight and her development appears normal for her age so far. Physical examination is normal with the exception that ophthalmoscopic evaluation reveals a faint white reflex in her right eye.

What is the most likely diagnosis?

Answer Choices
1 Retrolental fibroplasia
2 Phakomata
3 Retinitis Pigmentosa
4 Retinoschisis
5 Retinoblastoma

retinoblastoma
Explanation
Retinoblastoma is the most common primary malignant intraocular tumor of childhood. It usually appears quite early in the first 5 years. Leukocoria, a white or Cat’s eye reflex in the pupil is the most frequent finding. There may also be strabismus due to vision impairment. Ocular inflammation, intraocular hemorrhage, glaucoma or heterochromia iridis may be seen. On fundoscopic exam, the tumor may appear as a small to large white mass depending on its stage. Primary treatment includes enucleation, though smaller tumors diagnosed at an earlier stage may be amenable to newer alternative treatments such as cryotherapy and photocoagulation.Though leukocoria may be seen in retrolental fibroplasia or advanced stage of retinopathy of prematurity it is predominantly a disorder in preterm, low birthweight infants who received supplemental oxygen in the newborn period. These infants are susceptible due to the immaturity and subsequent damage of developing retinal vasculature. If the retina goes through various stages to ischemia and neovascularization, leukocoria may be seen representing retinal detachment and a subsequent membrane formation.

Phakomata are retinal findings hallmarking hamartomatous disorders such as tuberous sclerosis. The distinctive ocular lesion is a yellowish multinodular cystic lesion arising from the retina or disc. Similar lesions can occur in neurofibromatosis.

Retinitis pigmentosa is a progressive degeneration of the retina. It is characterized by pigmentary changes, arteriolar attenuation, some degree of optic atrophy and progressively deteriorating visual impairment. Granularity or mottling of the retinal pigment pattern or distinctive focal pigment aggregates can be seen fundoscopically.

Retinoschisis is a congenital disorder involving splitting of the retina into an inner and outer layer. Usually good vision is maintained. An elevation of the inner layer of the retina can be seen.

A 23-year-old man presents 2 hours after being involved in a road traffic accident in which he sustained right-sided periorbital injuries. He is seeing double; he denies headache, vomiting, and loss of consciousness. On examination, he is alert and oriented in time, space, situation, and person. His right eye is deviated downwards and temporally.

Question
What finding would you also expect to find in this patient?

Answer Choices
1 Loss of the corneal reflex
2 Ptosis
3 Pupillary constriction
4 Corneal anesthesia
5 Eye adduction

Ptosis
The correct response is ptosis.The clinical picture is suggestive of injury to the oculomotor nerve, which is the 3rd cranial nerve. It innervates the following striated muscles:

Superior rectus
Inferior rectus
Medial rectus
Inferior oblique
Their denervation results in infraduction and abduction of the eye.

The oculomotor nerve also innervates the levator palpebrae superioris and the pupillo-constrictor. Their denervation results in ptosis and mydriasis respectively.

Causes of 3rd cranial nerve palsy include:

Intracranial and intraorbital lesions (e.g., neoplasms)
Head and orbital trauma
Ocular myopathies
Cerebral aneurysms
Transtentorial herniation
Patients usually present with diplopia, which is also known double vision. They may also mention the inability to see with 1 eye if the ptosis is severe enough to cover the pupil. They may also mention blurred vision and a glare in bright lights due to the mydriasis.

Corneal anesthesia with loss of corneal reflex is a result of interruption of the trigeminal nerve supply to the cornea and conjunctiva.

A 34-year-old woman presents to your office to establish care. Her past medical history is significant for gastritis. She has no other medical problems. As part of your new patient assessment, you perform a neurological examination. On confrontation with visual field testing, you note bilateral temporal field defects, specifically a bitemporal non-homonymous hemianopsia. The remainder of your neurological evaluation is unremarkable. What would be your next step in the management of this patient?

Answer Choices
1 Refer the patient to the emergency room for evaluation of a possible stroke
2 Order an outpatient MRI of the brain
3 Check thyroid function tests
4 Check an EKG in your office
5 Consult with ophthalmologist for possible glaucoma

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

While glaucoma can cause visual field defects, a bitemporal hemianopsia suggests a chiasmal lesion. Glaucoma would be unlikely in this setting and with a patient of this age.

A 28-year-old man presents with diplopia and the inability to move the right eye outwards. He was hit by a ball on the right side of his face while playing volleyball 2 hours ago. His symptoms are non-progressive. On examination, his visual acuity is normal in both eyes. Right eye is medially deviated and cannot be moved laterally; otherwise, there is no abnormality detected.

Question
What is the most likely nerve injured?

Answer Choices
1 Abducens
2 Oculomotor
3 Trochlear
4 Facial
5 Trigeminal

Abducens
Explanation
The abducens, or cranial nerve VI, is the most common nerve traumatized in head injuries. It is the only supply to the lateral rectus muscle of the eye, which is responsible for external or lateral deviation of the eye. Injury to this nerve results in esotropia (internal deviation) of the eye and failure to move the eye outwards.The oculomotor, or cranial nerve III, supplies most extraocular muscles except the SO (superior oblique) and lateral rectus. Injury results in external deviation, ptosis, and pupil dilatation.

The trochlear nerve supplies the SO, and an injury to the nerve alone is rare. It results in defective downward and inward gaze.

The facial, or cranial nerve VII, supplies the facial muscles; an injury to the nerve results in facial paralysis (i.e., inability to close the eye, inability to frown with the forehead, and loss of mouth movement with smiling).

The trigeminal nerve supplies the muscles of mastication and sensation of the face. An injury to this nerve results in defective facial sensation and mastication.

A 52-year-old man presents with concerns over hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only 1 side (his left). Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms.

The patient’s past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use.

On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed, and it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells.

Question
After completing treatment for his current condition, what is the best approach for health maintenance of this patient?

Answer Choices
1 Full body bone scans every 2 years
2 Prophylactic antibiotics
3 Serum blood tests of inflammatory markers every 6 months
4 Testing only if the patient reports return of symptoms
5 Yearly head imaging

Yearly head imaging
Explanation
This patient is presenting with a vestibular schwannoma (or acoustic neuroma), affecting his vestibulocochlear nerve (cranial nerve VIII). This is one of the more common benign head and neck neoplasms. A common presentation is unilateral hearing loss and tinnitus. Treatment is typically surgical removal, or possibly radiation therapy. After completing therapy, yearly head imaging is recommended to monitor for recurrence.Full body bone scans every 2 years are not recommended for vestibular schwannomas; they are not likely to metastasize to bone.

Prophylactic antibiotics have no role in the original formation or the recurrence of schwannomas. Some other benign neoplasms in the ear, such as cholesteatomas, are associated with chronic ear infections, but antibiotics are still not helpful after treatment of those growths either.

Serum blood tests of inflammatory markers every 6 months are not helpful for schwannoma monitoring. Schwannomas are not considered an inflammatory disease and typical serum markers (erythrocyte sedimentation rate and C-reactive protein) may be entirely normal in affected individuals.

Testing only if the patient reports return of symptoms is also not appropriate, because of the usual slow-growing nature of schwannomas. Because of very slow hearing loss or balance problems (if the vestibular portion of the nerve is affected), patients with schwannomas may adapt and easily miss these symptoms for years.

A 33-year-old man presents with acute left eye pain. He was working in his garage on a woodworking project, and as he hammered in a nail, he felt that something hit him in the left eye. On examination, you note that the left pupil has a teardrop appearance.

Question
What diagnostic test/procedure will most likely confirm your diagnosis?

Answer Choices
1 Flourescein stain
2 An X-ray of the orbits
3 Test extra ocular movements (EOMs)
4 Check visual acuity
5 Test intraocular pressure

an x-ray of the orbit
Explanation
The clinical picture is suggestive of an intraocular foreign body or penetrating injury to the eye. This is commonly seen in individuals with a history of pounding on metal or using grinding equipment. The patient may give a history of “something hitting my eye” or “something was pulled out of my eye. His pupil is teardrop shaped, indicating penetration of the globe. An X-ray or CT scan of the orbit should be ordered to rule out radiopaque foreign bodies. Referral to an ophthalmologist is recommended.Fluorescein staining is indicated for a corneal abrasion.

To avoid extrusion of intraocular contents, EOMs should not be performed.

Visual acuity should be tested but alterations in visual acuity will not confirm your diagnosis.

Testing intraocular pressure is indicated if you suspect glaucoma.

A 22-year-old woman presents with a 1-day history of foreign body sensation in her right eye. She woke up with pain in the right eye, and she immediately had trouble opening her eye. She wears soft contact lenses and does not remember how long the last pair was in for. She removed her contact lenses the night before the pain started. There was no trauma. Visual acuity was 20/40 O.U. without corrective lenses, and extraocular movements were within normal limits. With fluorescein stain, a defect is noted; it is round and found at the center of the cornea. No foreign bodies are noted.

Question
What intervention is indicated?

Answer Choices
1 Pressure patch
2 Trifluridine drops
3 Ketorolac 0.5% solution
4 Ciprofloxacin 0.3% solution
5 Sulfacetamide 10% solution

Explanation
The correct answer is ciprofloxacin 0.3%; the patient has a corneal abrasion due to contact lenses. Ciprofloxacin covers pseudomonas, and pseudomonas should always be covered when someone gets a corneal abrasion from contact lenses.A pressure patch is never used in someone who gets a corneal abrasion from contact lenses because of the risk of developing infectious keratitis.

Trifluridine drops are used as an antiviral for Herpes Simplex keratitis; they are not used for corneal abrasions.

Ketorolac solution is used to help pain in a corneal abrasion, but it is not the mainstay of treatment.

Sulfacetamide solution is not used for corneal abrasions caused by contact lenses because it does not cover pseudomonas adequately.

A 30-year-old man presents with recurrent vertigo. He gives a history of attacks when rising from bed in the morning and rolling over in bed. He does not have headache, earache, hearing loss, nausea, or vomiting. On examination, external auditory canals are normal. Hearing tests are within normal limits. Pulse is 72/min, and blood pressure is 120/78 mm Hg. Central nervous system examination, including higher functions and mental status, is within normal limits.

Question
What is most likely to be useful in treating the patient’s condition?

Answer Choices
1 Diuretics
2 Methylprednisolone
3 Selective serotonin reuptake inhibitors (SSRIs)
4 Repositioning maneuvers
5 Scopolamine patch

Explanation
The correct answer is repositioning maneuvers. The patient gives a classic history of benign paroxysmal positional vertigo, which most often responds to treatment with repositioning maneuvers that utilize gravity to remove the otoconia (calcium carbonate crystals) from the semicircular canals that are thought to be responsible for causing the condition1.Diuretics are used in cases of vertigo in Meniere’s disease caused by increased endolymphatic pressure1. This patient does not have symptoms of Meniere’s disease, which usually include hearing loss, nausea, and vomiting.

Methylprednisolone is used to treat vertigo caused by vestibular neuritis which is associated with nausea, vomiting, and upper respiratory infections1.

Selective serotonin reuptake inhibitors (SSRIs) are used to treat vertigo in psychosomatic disorders like major depression, anxiety, and panic disorders1. This patient does not have symptoms associated with any of these disorders.

Scopolamine is an anticholinergic medication used to treat vertigo caused by motion sickness1. It causes symptomatic relief, but is not a treatment for vertigo.

A 20-year-old man with no significant past medical history presents with a severe sore throat for the last hour. He reports associated fever, difficulty swallowing, difficulty in opening his mouth, excessive salivation, and a self-described “raspy, harsh voice.” He denies chills, sick contacts, otalgia, myalgias, malaise, rashes, wheezing, shortness of breath, and cough. He also denies smoking, drinking, drug use, or recent sexual activity. His physical exam is notable for a toxic-appearing young male patient with tonsillar hyperemia, swelling of the anterior pillar and soft palate, tender cervical lymphadenopathy, and a small, left-tonsillar abscess. The primary care provider performs an oropharyngeal culture and refers the patient immediately to the emergency room for further treatment.

Question
What is the most likely agent isolated from the oropharyngeal culture performed by the provider?

Answer Choices
1 Corynebacterium diphtheriae
2 Staphylococcus aureus
3 Haemophilus influenzae
4 Streptococcus pyogenes
5 Fusobacterium necrophorium

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

A 55-year-old woman comes to your clinic presenting with episodic vertigo, tinnitus, hearing loss, and ear fullness. Her ear and eye physical examination are unremarkable. You perform a Dix-Hallpike maneuver which is negative. There are no carotid bruits noted on auscultation. Which of the following is the best initial treatment for this patient?
Answer Choices
1 Restrict water intake
2 Diazepam10 mg BID
3 Antibiotics
4 Fluticasone propionate
5 Low sodium diet
Low sodium diet
Explanation The clinical picture is suggestive of Meniere’s disease. The classic syndrome consists of episodic vertigo lasting 20 minutes to several hours associated with fluctuating low-frequency sensorineural hearing loss, tinnitus, and a sensation of aural pressure. The Dix-Hallpike maneuver is a diagnostic maneuver for benign paroxymal positional vertigo. Treatment involves a low sodium diet and diuretics.
Restricting water intake will lead to dehydration and an increase in sodium levels, worsening the symptoms of Meniere’s disease.Diazepam can be used for Meniere’s disease but is usually used for severe vertigo. The question is indicating initial treatment.

Diazepam is used in the treatment of vestibular neuronitis. In vestibular neuronitis, a paroxymal, usually single attack of vertigo occurs without accompanying impairment of auditory functions and will persist for several days to weeks before clearing. Examination reveals nystagmus. These symptoms are not present in this patient.

Antibiotics are not indicated for Meniere’s disease.

Fluticasone propionate is an anti-inflammatory nasal spray used to treat the nasal symptoms of indoor and outdoor nasal allergies and year-round nonallergic nasal symptoms. Fluticasone helps reduce the inflammation that leads to nasal symptoms that include congestion, sneezing, and itchy, runny nose which are not indicated in this patient.

A 26-year-old man presents with an eye issue. He does not wear corrective lenses. The only change of lifestyle that he states is that, a few months ago, he quit his office job and began to “help out a buddy” in the construction business. On physical examination, there is a triangular fold of tissue extending from the medial conjunctiva to the cornea in both eyes.

Question
What is the most likely diagnosis?

Answer Choices
1 Keratoconjunctivitis sicca
2 Pinguecula
3 Chalazion
4 Pterygium
5 Hordeolum

Pterygium
Explanation
The clinical picture is suggestive of pterygium. The common presentation is a fleshy, triangular intrusion of the conjunctiva onto the nasal side of the cornea that is often bilateral. It is usually associated with constant exposure to sand, wind, or sunlight.Keratoconjunctivitis sicca (or dry eyes) is a condition of lacrimal gland hypofunction commonly seen in elderly women.

Pinguecula is a yellow elevated conjunctiva nodule in the area of the palpebral fissure on the nasal side of the eye. It is common in patients over 35 years of age.

Chalazion is a chronic eye stye.

Hordeolum is an acute stye.

A man cannot hear any normal voice sounds spoken from more than 3 feet away. This is consistent with what type of hearing?

Answer Choices
1 Normal hearing.
2 Profound hearing loss.
3 Slight hearing loss.
4 Severe hearing loss.
5 Moderate hearing loss.

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

A 34-year-old man presents due to something being “wrong” with his left ear. He reports his hearing has been gradually declining, but he recently noticed some discomfort and malodorous discharge draining from this ear. He denies any trauma to the ear and any symptoms in his right ear. Upon further questioning, he admits to some tinnitus and mild vertigo. He otherwise feels well. He denies nasal symptoms, headache, sore throat, and fevers.

His past medical history is unremarkable; he has no known medical conditions or history of surgery; he takes no medications and has no allergies. He lives with his wife and 2 children; he works as an office manager, and he denies the use of alcohol, tobacco, and drugs.

On physical exam, his vitals are normal. Examination of the left ear reveals mucopurulent drainage within the external auditory canal. The tympanic membrane is disrupted by a retraction pocket within the upper portion, with some thick yellow debris and a polyp protruding from the pocket. Hearing tests are not performed. The right ear reveals mild tympanosclerosis on the tympanic membrane, but it is otherwise normal. The remainder of the patient’s exam is normal.

Question
What is the most likely diagnosis?

Answer Choices
1 Cholesteatoma
2 Contact dermatitis of the ear canal
3 Labyrinthitis
4 Otitis externa
5 Psoriasis

Explanation
This patient is presenting with a cholesteatoma, which a benign neoplasm of the tympanic membrane. It is considered a complication of chronic otitis media, so this patient could be expected to report a history of frequent otitis media. (The tympanosclerosis on the right is another clue.) The cholesteatoma is an epidermal inclusion cyst. Complications can include infection, and more significantly, erosion into bone and nerve damage.Contact dermatitis of the ear canal can produce local irritation with pain and/or pruritus, and if the inflammation is severe enough, discharge. The hearing loss and the physical exam findings of the pocket and polyp are not associated with contact dermatitis.

Labyrinthitis is a condition that can cause hearing loss, tinnitus, and nausea. The cause is not well understood, but it involves the inner ear, not the tympanic membrane. Ear discharge is not associated with labyrinthitis.

Otitis externa is an inflammatory condition of the ear canal, and can be most commonly caused by fungal or bacterial organisms. It can lead to ear pain and discharge. Typically, it should not causing hearing loss and tinnitus; furthermore, it would not cause the findings on this patient’s tympanic membrane.

Psoriasis is a dermatologic condition that affects skin all over the body. It is typically described as silvery scale over bright red plaques. It can affect the ear canals, causing pain and pruritus, but it does not typically the affect the tympanic membrane.

A 62-year-old woman presents to the Emergency Department with acute unilateral loss of vision for 1 hour. Fundoscopic examination demonstrates vein dilation, intraretinal hemorrhages, and cotton-wool spots with optic disc swelling. Which of the following is the most likely diagnosis?
Answer Choices
1 Macular degeneration
2 Retinal artery occlusion
3 Retinal vein occlusion
4 Diabetic retinopathy
5 Retinal detachment
Explanation Retinal vein occlusion results in acute vision loss with retinal vein dilation, intraretinal hemorrhages, cotton-wool spots, and optic disc swelling on fundus examination.
Macular degeneration does not cause acute vision loss but progressive loss over time and does not result in the findings above. Retinal artery occlusion does not cause retinal vein dilation and causes a classic cherry-red spot at the fovea. Diabetic retinopathy does not cause the constellation of signs noted above. Retinal detachment was not found on fundoscopic examination.

A 64-year-old African-American man presents to the emergency department after he went blind in his right eye “out of the blue” 20 minutes ago. There is no pain associated with his symptoms and he is not nauseated. Past medical history is positive for DMII for the past ten years. The pupil reaction on the left side is normal with pressure of 17mmHg. Right pupil evaluation reveals no reaction to light or accommodation with pressure of 20mmHg. Right eye ophthalmoscopy reveals arteriolar narrowing, vascular stasis, and “boxcar” pattern.

Question
What is the most likely diagnosis?

Answer Choices
1 Occlusion of the central retinal artery
2 Acute glaucoma attack
3 Subconjunctival hemorrhage
4 Retinal detachment
5 Macular degeneration

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

A 17-year-old boy presents with a 1-day history of an extremely painful and pruritic left ear after returning from a trip to the beach over the weekend. Physical examination of the left ear reveals an erythematous external canal without clear visualization of the tympanic membrane. The patient grimaces and expresses a painful sensation when the left pinna is manipulated. Physical examination of the right ear is benign.

Question
What is the most appropriate treatment for the above condition?

Answer Choices
1 Oral ciprofloxacin
2 Fluoroquinolone ear drops
3 Anti-pseudomonal IV antibiotics for 6 weeks
4 Acyclovir in combination with oral corticosteroids
5 Saline flushes of the ear canal

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

An anti-viral agent, such as acyclovir, can be used in combination with oral corticosteroids for Ramsey-Hunt Syndrome (herpes zoster affecting the geniculate ganglion).

Saline flushes are not helpful in the treatment of otitis externa.

A 40-year-old man presents with a painless, circular, 7-millimeter spot inside his mouth; he noticed it 2 days ago. His medication list includes propranolol for hypertension. He is a known alcoholic. The diagnosis of leukoplakia of the buccal mucosa is made. The physician adopts a ‘watch-and-wait’ attitude; however, after 2 weeks the lesion is still present and unchanged.

Question
What is the best course of management?

Answer Choices
1 Continue to observe and reassure the patient
2 Discontinue propranolol
3 Order a fluorescent antinuclear antibody test (FANA)
4 Perform a biopsy of the lesion
5 Treat with oral nystatin

Explanation
The correct response is that you should perform a biopsy of the lesion.Leukoplakia is a white keratotic lesion seen on mucous membranes. Irritation from various mechanical and chemical stimuli, including alcohol, favors development of the lesion. Leukoplakia can occur in any area of the mouth, and it usually exhibits benign hyperkeratosis on biopsy. On long term-term follow-up, 2% to 6% of these lesions will have undergone malignant transformation into squamous cell carcinomas.

Oral nystatin would not be appropriate treatment because this lesion is not typical of oral candidiasis. Candidal lesions usually are multiple and spread quickly when left untreated. A fluorescent antinuclear antibody test is also not indicated, as the oral lesions of lupus erythematosus are typically irregular, erosive, and necrotic. An idiosyncratic reaction to propranolol is unlikely in this patient.

A 9-year-old boy presents to the emergency department with acute onset of 90 minutes of fever, sore throat, and labored breathing. IV access and oxygen therapy are both initiated in preparation for diagnostic testing. The physician assistant in the emergency department is concerned that he might have epiglottitis.

Question
What finding on lateral neck radiograph would support this diagnosis?

Answer Choices
1 Narrowing of the trachea
2 Foreign body in the trachea
3 Soft tissue mass in the nasal cavity
4 Narrowing of the esophagus
5 Thumb-like projection superior to the larynx

Explanation
Thumb-like projection superior to the larynx is the correct answer, as this is the description that is often used for an edematous epiglottis seen with epiglottitis. The epiglottis is a flap of tissue at the entrance of the larynx that points upwards while a person is breathing and folds down while swallowing. This mechanism prevents food from entering the trachea rather than the esophagus while eating. Epiglottitis can be life threatening and is an infection of the epiglottis that can lead to obstruction of the airway. It is commonly caused by H. influenza type B, group A Streptococcus, pneumococcus, or staphylococci. The classic thumb sign is usually seen on a lateral neck radiograph, which is essentially a swollen epiglottis seen on X-ray.Narrowing of the trachea is not the correct answer, as this is not typically seen on the neck radiograph of a patient with epiglottitis. A patient with croup (an upper respiratory viral illness characterized by a barking cough, stridor, and fever) can have narrowing of the trachea on a lateral neck radiograph.

Foreign body in the trachea is not the correct answer. A lateral neck radiograph would show a foreign body in the trachea if one was lodged there, and this would not be associated with epiglottitis.

Soft tissue mass in the nasal cavity is not the correct answer. The epiglottitis is soft tissue, but is not located in or near the nasal cavity. A patient with a nasal polyp may have a soft tissue mass in their nasal cavity on lateral neck radiograph.

Narrowing of the esophagus is not the correct answer. Narrowing of the esophagus can occur with an esophageal stricture, but is more commonly diagnosed with a barium swallow or endoscopy. Narrowing of the esophagus can be seen on a neck radiograph in a patient with esophageal cancer, as well.

A 40-year-old man with a past medical history of hepatitis C presents with burning and pain of his oral cavity, which has been associated with a pruritic rash of the flexor aspect of his left wrist. The physical exam is remarkable for violaceous, shiny, and polygonal papules arranged as lines and circles on his wrist. These papules range in size from 1 mm to 1 cm in diameter, and have fine, white lines on them. In the oral cavity, a reticular, white, lacy pattern is visualized, as seen in the image.

Question
What is the most appropriate first-line pharmacological treatment of this patient’s oral lesions?

Answer Choices
1 Clobetasol propionate (Temovate) gel
2 Cyclosporine (Sandimmune) capsules
3 Soriatane (Acitretin)
4 Nystatin oral suspension
5 Doxycycline (Vibramycin) oral suspension

Cyclosporine (Sandimmune) capsules
Explanation
This patient most likely has lichen planus with cutaneous and oral involvement. It is an inflammatory mucocutaneous condition that usually exhibits a distinctive morphology and is associated with hepatitis C. The classic appearance of skin lesions includes violaceous polygonal flat-topped papules and plaques, commonly occurring at the wrist. For lichen planus of the oral mucosa, topical steroids are usually tried first. Treatment with steroids is especially indicated in ulcerative forms of oral lichen planus.Topical and systemic cyclosporin has been tried with some success; however, a randomized double-blind study indicated that topical cyclosporin was a less effective and much more costly regimen than clobetasol.Newer topical calcineurin inhibitors have replaced topical cyclosporin for the treatment of lichen planus.

If corticosteroid resistance occurs, other treatment options using oral or topical retinoids are available. One controlled trialdemonstrated efficacy of treatment with a dosage of 30 mg daily of soriatane (acitretin) once daily for 8 weeks. When prescribing any retinoid, however, physicians must be familiar with the risk profile because of the severe teratogenicity associated with this class of drugs.

Nystatin and vibramycin suspensions are not indicated, as this patient is not experiencing a fungal or bacterial infectious process.

Using the Weber and Rinne tests, a left-sided conduction hearing loss will manifest as what?

Answer Choices
1 Sound lateralization to the right on the Weber test, and left-ear sound longer through bone in the Rinne test
2 Sound lateralization to the right in the Weber test, and left-ear sound longer through air in the Rinne test
3 Sound lateralization to the left in the Weber test, and left-ear sound longer through bone in the Rinne test
4 Sound lateralization to the left in the Weber test, and left-ear sound longer through air in the Rinne test
5 No sound lateralization in the Weber test, but sound longer through bone in the Rinne test

Sound lateralization to the left in the Weber test, and left-ear sound longer through bone in the Rinne test
Explanation
In the Weber test, sound lateralizes to the impaired ear in conduction hearing loss, and to the good ear in unilateral sensorineural hearing loss. In the Rinne test, sound is heard longer through bone in conduction hearing loss, and it is heard longer through air in sensorineural hearing loss. Therefore, in left-sided conductive hearing loss, sound will lateralize to the left in the Weber test, and left-ear sound will be heard longer through bone in the Rinne test.
A 72-year-old man presents with a neck mass. Examination reveals a mass within a multinodular goiter. The patient undergoes a fine needle aspiration, which reveals cancerous cells.
Question
What is the most aggressive type of thyroid cancer?Answer Choices
1 Papillary carcinoma
2 Follicular carcinoma
3 Medullary carcinoma
4 Anaplastic carcinoma
5 Squamous cell carcinoma

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

A 62-year-old man presents with a 1-month history of mouth pain and non-healing white patches on his mouth. He denies infection and recent trauma to the area. Past medical history is significant for diabetes mellitus, hypertension, osteoarthritis, and gonorrhea, which was treated 6 months ago. Social history is positive for a 20-pack year smoking history and cocaine abuse; he quit both approximately 10 years ago. On examination, leukoplakia is present, as seen in the image. The patient is referred for biopsy.

Question
What is the strongest risk factor for the most likely diagnosis?

Answer Choices
1 Age
2 Male gender
3 Recent history of gonorrhea
4 Tobacco use
5 Cocaine use

tobacco use
Explanation
Tobacco use and alcohol use are the strongest risk factors for oropharyngeal cancer. The patient has non-healing areas of leukoplakia, which is suggestive of malignancy. Squamous cell carcinoma is the most common type of oropharyngeal cancer, and approximately 75% of patients will have a history of tobacco and/or alcohol abuse.Oropharyngeal cancer is more common with increased age and male gender, but tobacco use is a stronger risk factor.

Recent history of gonorrhea is incorrect. While human papillomavirus (HPV) is strongly associated with oropharyngeal cancer, gonorrhea is not a risk factor.

Cocaine use is not associated with the development of oropharyngeal cancer.

A 74-year-old man presents with a 1 ½-hour history of severe pain and blurred vision in his left eye. Upon examination, his left eye is erythematous with a steamy cornea and a nonreactive, dilated pupil. An ophthalmologic consult is ordered, and tonometry is completed, revealing an elevated intraocular pressure and a confirmed diagnosis of acute angle-closure glaucoma.

Question
What will be the definitive treatment for this patient?
Answer Choices
1 Left laser peripheral iridotomy
2 Bilateral laser peripheral iridotomy
3 IV acetazolamide
4 Oral glycerol
5 Topical timolol 0.25%

Bilateral laser peripheral iridotomy
Explanation The correct answer is bilateral laser peripheral iridotomy. This is a procedure during which a puncture-like opening is made near the base of the iris in order to decrease intraocular pressure in patients with angle-closure glaucoma. While there are various medications used to treat acute episodes, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. If this occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally.Left laser peripheral iridotomy is not the correct answer. While there are various medications used to treat acute episodes of angle-closure glaucoma, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. Narrow anterior chambers always occur bilaterally. If acute angle-closure glaucoma occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally as opposed to being done in JUST the affected eye.

IV acetazolamide is not the correct answer. This medication is given in episodes of acute angle-closure glaucoma in order to decrease the intraocular pressure. It is typically given in a single 500mg IV dose followed by 250mg orally 4 times daily. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient’s underlying issue is narrow anterior chambers.

Oral glycerol is not the correct answer. This medication is an osmotic diuretic that can be given 1-2 g/kg in order to decrease a patient’s intraocular pressure during an acute episode of angle-closure glaucoma. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient’s underlying issue is narrow anterior chambers.

Topical timolol 0.25% is not the correct answer. This medication is a topical β-adrenergic blocking agent used twice daily chronically in patients who have chronic glaucoma. The disorder does not require the acute lowering of intraocular pressure such as angle-closure glaucoma. Topical timolol would not be effective in lowering intraocular pressure in patients with angle-closure glaucoma.

A 3-year-old girl presents with a 5-day history of purulent, foul-smelling nasal discharge. She is otherwise well-appearing, and her mother reports that she has not had any cough, fever, or other illness symptoms recently. She has been eating and sleeping normally. She is playful and “acting like herself”. She stays with a babysitter during the day. Her mother also mentions that the discharge seems to only come from one nare.

Question
What is the most likely diagnosis?

Answer Choices
1 Foreign body
2 Seasonal allergies
3 Sinusitis
4 Trauma (nose-picking)
5 Viral URI

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

Nose-picking is more likely to lead to epistaxis than to purulent discharge.

A 16-year-old girl presents with throat pain. Her sore throat was first noticed when she woke up this morning. The patient has a temperature 102 degrees F. On examination, the pharyngeal mucosa is erythematous, with yellow exudate. She has tender anterior cervical lymphadenopathy.

Question
What organism is the most likely cause of her condition?

Answer Choices
1 Group A streptococcus
2 Corynebacterium diphtheriae
3 Adenovirus
4 Rhinovirus
5 Candida albicans

Explanation
Group A streptococcus is the correct response. Group A streptococcus is the most common cause of bacterial pharyngitis. The patient has presence of fever, exudate and tender anterior cervical adenopathy, which are all highly suggestive of bacterial pharyngitisCorynebacterium diphtheriae is an incorrect response. Corynebacterium diphtheriae is an uncommon cause of sore throat. It would present with a gray pseudomembrane on examination of the throat.

Adenovirus and rhinovirus are incorrect responses. Viral pharyngitis does not typically present with exudate or tender anterior cervical adenopathy.

Candida albicans is an incorrect response. Candida albicans of the throat typically presents with thin exudate, but it is not common unless a patient is immunocompromised or has had recent antibiotic treatment.

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

Answer Choices
1 Oral amoxicillin
2 Intramuscular amoxicillin
3 Intramuscular ampicillin
4 Oral ampicillin
5 Needle aspiration

Oral amoxicillin for otitis media
Explanation
The correct response is oral amoxicillin.The diagnosis in this case is acute otitis media (inflammation of the middle ear), which is a common childhood infection. Infants and children are at highest risk for otitis media; incidence rates are 15 – 20%, with peaks occurring from 6 – 36 months and 4 – 6 years of age. Children who develop otitis media in the 1st year of life have an increased risk of recurrent acute infection or chronic disease.

In the usual course, a child suffering an upper respiratory infection for several days suddenly develops otalgia, fever, and hearing loss. The characteristic features include a bulging, opaque, erythematous tympanic membrane with impaired mobility. Purulent otorrhea may be present, but earache and fever are not always present. Any child with a ‘fever of undetermined origin’ must also be evaluated for a middle ear infection.

Bacteria are the primary agents of otitis media. The most common causes in all age groups are Streptococcus pneumoniae (25 – 40% of cases), followed by Haemophilus influenzae (15 – 25% of cases). In addition, Gram-negative bacilli cause about 20% of otitis media in neonates; however, these bacteria are rarely found in older children with otitis media. Less common causes include group A Streptococci and Branhamella catarrhalis. Staphylococcus is a less common cause of chronic otitis media.

Normally, children will improve clinically within 48 hours after antimicrobial therapy. If there is no improvement, the possibility of a resistant organism must be suspected; trimethoprim-sulfamethoxazole, or erythromycin and sulfonamides may be given. The antibiotic of choice is amoxicillin orally; it is effective for both S. pneumoniae and H. influenzae.

There is no added advantage of intramuscular injection over oral amoxicillin. An increasing percentage of H. influenzae and Moraxella catarrhalis strains have now become beta-lactamase producing and, therefore, ampicillin-resistant. Some resistant cases may benefit from a change of antibiotics to erythromycin or sulfonamides.

Needle aspiration of the middle ear is only rarely necessary, as in the case of a critically ill child or a child who fails to respond to standard antimicrobial therapy.

A 12-year-old female presents to the office with an acute sore throat. The patient is experiencing great pain when swallowing. Even the swallowing of her own saliva causes intense pain. An examination of the throat reveals an enlarged and erythematous epiglottis. A special throat culture request was made in consideration to the finding of acute epiglottitis. The patient was discharged and treated with ampicillin. The next day the culture was significant for 4+ of a gram-negative coccobacillus that only grew on chocolate agar media. The cause of this acute epiglottitis is:
Answer Choices
1 Streptococcus pneumoniae
2 Staphylococcus aureus
3 Streptococcus pyogenes
4 Haemophilus influenzae
5 Candida albicans
H Influenzae
Explanation Streptococcus pyogenes is a gram-positive coccus, catalase negative, beta hemolytic on blood agar, appearing as chains on gram stain. Definitive identification to distinguish it from other beta hemolytic streptococci is the detection of its specific “A” antigen by latex agglutination techniques. It is associated with streptococcal pharyngitis, scarlet fever, streptococcal pyoderma, necrotizing fascitis, and streptococcal toxic shock syndrome. Bacteremia is uncommon. They are universally sensitive to penicillin.
Streptococcus pneumoniae is a gram-positive lancet-shaped coccus that is catalase negative and occurs in pairs. It is a common cause of otitis media in children. It is also a major cause of meningitis in elderly people and especially those that have underlying conditions, are malnourished, or are alcoholics. The organism is alpha hemolytic on blood agar.Staphylococcus aureus is a gram-positive coccus, catalase positive, and coagulase positive, predominantly beta hemolytic on blood agar, appearing in characteristic grape clusters on gram stain. Staphylococcus aureus can cause a variety of infections. In children with reactive tonsils, this can be a source of infection, leading to severe tonsillitis. A semisynthetic penicillin is the treatment of choice.

Haemophilus influenza is a gram-negative coccobacillus. It is also a major cause of meningitis. It occurs mostly in young infants and children where it can also cause a severe epiglottitis that can necessitate intubation. When it occurs in adults, it is usually due to an underlying condition, such as paranasal sinusitis, remote head trauma, or otitis. The organism will not grow on blood agar and requires the presence of growth factors (hemin and NAD) for growth.

Candida albicans is a yeast. Yeast appears on gram stain as large gram-positive organisms approximately 3-5 times larger than gram-positive cocci. They are aerobic and generally grow well on most nonselective agar media. The organism is a major cause of throat infections in the immunocompromised, such as patients with HIV. When causing an infection in the throat, it is called “thrush.”

What is the most frequent malignant neoplasm involving the larynx?

Answer Choices
1 Adenocarcinoma
2 Squamous cell carcinoma
3 Squamous papilloma
4 Metastatic tumor from another site
5 Fibrosarcoma

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

Squamous papillomas are exophytic benign neoplasms that may arise in any age group.

A 28-year-old woman presents with an itchy throat, prolonged sneezing episodes, watery red eyes, and inflamed nasal membranes. Her temperature is normal and a throat culture is negative. She is most likely has allergic rhinitis. Which of the following factors is a major disadvantage of the drug diphenhydramine?

Answer Choices
1 Weight gain
2 Sedation
3 Constipation
4 Jaundice
5 Addiction

Sedation
The H2 receptor is involved in stimulating gastric acid secretion from parietal cells in the gastric mucosal glands. It also has a cardiac stimulatory effect. H2 receptor activity is expressed by activation of adenylate cyclase and concomitant increased cAMP levels. The H3 receptor seems to be active mainly in the CNS, where it may be involved in modulating histamine neurotransmission at some presynaptic membranes.Histamine itself has no therapeutic applications, but compounds that block its actions at the H1 receptor (H1 receptor antagonists; antihistamines) are very important clinically. There are many kinds of H1 blockers from several different chemical classes. Some are listed in Figure I6.10 below.

H1 blockers do not have any effect on the formation or release of histamine from storage sites. They compete with histamine for receptor sites on target cells. H1 receptor blockers do not serve as histamine agonists due to the differences between their structures. Some H1 blockers may also show some affinity for the serotonin, adrenergic, and cholinergic muscarinic receptors. H1 blockers competitively inhibit the effects of histamine. All show varying degrees of sedative and anti-motion sickness effects in the CNS. Since some may act at other receptors (noted above), they may block muscarinic, α-adrenergic, and serotonin receptor mediated effects.

During a routine physical exam, a 16-year-old boy notes a painful lesion on the inside of his cheek. A round whitish-gray ulcer with an erythematous surrounding halo is noted on exam. The lesion is tender to the touch. The patient denies any medical, surgical, sexual, or social history. What is the primary diagnosis?

Answer Choices
1 Mucous patch due to syphilis
2 Tori mandibulares
3 Caviar lesions
4 Aphthous ulcer
5 Leukoplakia

Aphthous ulcer
Explanation
This lesion is likely an aphthous ulcer, also known as a canker sore. An aphthous ulcer is a painful, round whitish-gray ulcer that has a classic red surrounding halo. It is self-limiting, and it will heal within 1 – 1.5 weeks.Second-stage syphilis presents as a mucous patch that is gray in color, raised, oval-shaped, and may be distributed in multiple areas in the oral cavity. Syphilis needs to be treated by penicillin.

Caviar lesions are varicosities found on the dorsal side of the tongue only. This type of lesion does not have any significance clinically, and no intervention is needed.

Tori mandibulares are benign, painless bony projections found on the inner side of the lower teeth. The mucosa covering these tori are of normal color and appearance.

Leukoplakia is characterized by non-tender white patches found in the inside of the mouth. Biopsy is necessary to determine malignancy.

A 36-year-old woman presents with a small and irregular right pupil. On exam, you note that the pupil does not respond to direct or consensual light stimuli; however, it becomes smaller during an accommodation testing. What is the most likely diagnosis?

Answer Choices
1 Transient ischemic attack (TIA)
2 Retinal artery occlusion
3 Retinal vein occlusion
4 Tertiary syphilis
5 Herpes simplex keratitis

Explanation
The clinical picture is suggestive of tertiary syphilis; more specifically, it is likely tabes dorsalis. The pupil describe here is the Argyll Robertson pupil. The pupil reacts poorly to light, but it reacts well to accommodation.Signs and symptoms seen in a TIA include temporary weakness and heaviness of the contralateral arm, leg, or face. There may be monocular vision loss in the eye contralateral to the affected limbs, which are not described in this patient.

Retinal vein or artery occlusion will produce sudden vision loss, which is not described in this patient.

Herpes simplex can involve the eyes, but the patient will develop keratitis (cornea inflammation) with impaired vision, and dendritic ulcers can be seen with fluorescein stain.

A 15-year-old boy presents to your office for evaluation of a lesion on the side of his upper lip. The lesion appears on the outer edge of the upper lip. It appears as a small, well-circumscribed elevation with crusting. You tell the patient that the diagnosis is herpes simplex. What type of lesion is this?

Answer Choices
1 Vesicle
2 Bulla
3 Nodule
4 Pustule
5 Tumor

Vesicle
Explanation
A vesicle is a circumscribed elevation of the skin less than 1 cm in diameter. It contains fluid.Bullae are larger than vesiclesand are produced by factors that include chemicals, friction, and heat.

A nodule is a solid lesion larger than 1 cm in diameter. It consists of inflammatory cellular infiltrates or neoplasms.

Pustules are circumscribed accumulation of pus in the skin. The lesion may or may not be raised.

Tumors vary in size and are new skin growths composed of skin and subcutaneous tissue. They may be malignant or benign.

A 42-year-old man presents for evaluation of a growth on his tongue. He thinks that the lesion has been present for a few months, and it has not changed; however, he generally prefers to avoid health care, and he has not been concerned. He is only here at the urging of his family member. The patient denies oral symptoms and changes in taste sensation; he states that he generally feels fine. The patient denies the use of chew tobacco and cigarettes.

On physical exam, there is a white patch of tissue, which does not scrape off; there is a ‘shaggy’ appearance on the left lateral tongue. No erythema is noted. No other lesions are identified. The remainder of his exam is normal.

A biopsy of the lesion is obtained. The pathology shows hyperkeratosis, “balloon” cells in the upper cell layer, and Epstein-Barr virus (EBV) in the basal epithelial cells.

Question
What is the most likely diagnosis?

Answer Choices
1 Geographic tongue
2 Oral candidiasis
3 Oral hairy leukoplakia
4 Oral lichen planus
5 Squamous cell carcinoma

Oral Hairy Leukoplakia
Explanation
This patient has oral hairy leukoplakia, which is often associated with HIV-infection or other immunocompromised states (such as post-transplant). It is rare in immunocompetent individuals. The oral hairy leukoplakia is a benign neoplasm of the tongue; in and of itself, it is not of great significance. However, due to its association with an immunocompromised state, it can be a harbinger of a more significant condition.Geographic tongue is a benign condition of the tongue; it affects the epithelium. It typically presents with erythematous patches, with white, rounded borders. Lesions can change size, patterns, and locations. Patients may be asymptomatic or experience burning or oral discomfort.

Oral candidiasis (thrush) is a fungal infection of the oral mucosa. Typically, affected individuals note oral pain or discomfort. There may be white plaque with surrounding or underlying erythematous tissue. Biopsy is not typically necessary for diagnosis; this patient’s biopsy would have indicated fungal organisms if he had thrush.

Oral lichen planus can present with white ‘lace-like’ patches, but it typically presents with oral pain.

Squamous cell carcinoma can present in a variety of lesions (plaques, ulcerations, erosions, papules). Any persistent oral lesion should be biopsied to evaluate for possible malignancy. This patient’s biopsy did not indicate malignancy.

A 40-year-old man presents with burning and pain of his oral cavity; the burning and pain have been associated with a pruritic rash of the flexor aspect of his left wrist. He denies a history of smoking, drinking, or illicit drug use. The physical exam is remarkable for violaceous, shiny, and polygonal papules that are arranged as lines and circles on his wrist. These papules range in size from 1 mm to 1 cm in diameter, and they have fine, white lines on them. In the oral cavity, a reticular, white, lacy pattern is visualized, as seen in the image.

Question
What is correct regarding this condition?

Answer Choices
1 The use of imaging study modalities are required for diagnosis
2 Systemic antifungal pharmacotherapy is curative in a majority of patients
3 The patient’s oral lesion is a premalignant mucosal finding caused by carcinogen exposure
4 It is a cell-mediated immune response that is associated with hepatitis C and primary biliary cirrhosis
5 The most common causes are iron, folic acid, vitamin B12, and riboflavin deficiencies

It is a cell-mediated immune response that is associated with hepatitis C and primary biliary cirrhosis

Explanation
This patient most likely has lichen planus with cutaneous and oral involvement. It is an inflammatory mucocutaneous condition that usually exhibits a distinctive morphology; it is associated with hepatitis C virus infection, chronic active hepatitis, and primary biliary cirrhosis. The classic appearance of skin lesions includes violaceous polygonal flat-topped papules and plaques, commonly occurring at t the wrist. Wickham’s striae may also be found; these are white lines found within papules.

No imaging studies are necessary for lichen planus.

Lichen planus is not a fungal disease process; therefore, antifungal agents are not appropriate treatment.

Unlike leukoplakia or erythroplakia, the oral finding in this patient is not a premalignant finding.

Nutritional deficiencies commonly contribute to angular chelitis and atrophic glossitis, not lichen planus.

A 29-year-old woman presents with slowly progressive right-sided hearing loss, tinnitus, and continuous vertigo. Her Weber test reveals lateralization to the left ear.

Question
What is the recommended next step?

Answer Choices
1 Observation
2 Tympanostomy tube placement
3 MRI
4 Angiography
5 Referral for hearing aid

MRI
Explanation
MRI is the correct response. The presentation of slowly progressive sensorineural hearing loss, vertigo, and tinnitus is suggestive of acoustic neuroma, which is a benign tumor on the 8th cranial nerve. Diagnosis is made through MRI.Observation is an incorrect response. While acoustic neuroma is a benign tumor, its growth can impinge on vital structures. MRI should be obtained in this patient.

Tympanostomy tube placement is an incorrect response. Tympanostomy tubes are placed for recurrent otitis media.

Angiography is an incorrect response. Angiography has no role in this patient’s diagnosis.

Referral for hearing aid is an incorrect response. While the patient is suffering from hearing loss, the cause should be investigated before referring her for a hearing aid.

A 28-year-old woman with a past medical history of well-controlled asthma presents with recurrent sneezing episodes, nasal itching, congestion, and headache. Her physical exam reveals post-nasal drip, a transverse nasal crease, and bilateral infraorbital cyanosis.

Question
What additional findings support an allergic etiology of this patient’s presentation?

Answer Choices
1 Associated manifestations, including malaise, body aches, and cough
2 Pale, bluish nasal mucosa upon speculum examination
3 Provocation by changes in temperature or exposure to odors and chemicals
4 An erythematous and edematous nasal septum and turbinates
5 The presence of fever and copious, purulent green nasal discharge

Pale, Bluish nasal mucosal upon nasal speculum examination
Explanation
This patient’s past medical history and current presentation are remarkable for allergic rhinitis. Signs and symptoms include sneezing paroxysms, nasal, ocular, or palatal itching, clear rhinorrhea, nasal congestion, pale, bluish nasal mucosa, transverse nasal crease, infraorbital cyanosis (allergic shiners), and serous otitis media.Viral rhinitis is often associated with other manifestations of viral illness, which can include headache, malaise, body aches, and cough. Nasal drainage in viral rhinitis is most often clear or white and can be accompanied by nasal congestion and sneezing. The nasal septum and turbinates are typically erythematous and edematous.

Patients with vasomotor rhinitis present with symptoms of nasal obstruction and clear nasal drainage. The symptoms are often associated with changes in temperature, eating, exposure to odors and chemicals, or alcohol use. Some clinicians suggest that abnormal autonomic regulation of nasal function leads to vasomotor rhinitis.

The presence of fever in conjunction with copious, purulent green nasal discharge should raise suspicion for underlying infection, especially bacterial rhinosinusitis.

A 70-year-old man presents with paralytic strabismus with maximal esotropia as he gazes to the left.

Question
Which of the following nerves is most likely affected in this case?
Answer Choices
1 Left fourth cranial nerve
2 Left sixth cranial nerve
3 Right fourth cranial nerve
4 Right sixth cranial nerve
5 Right third cranial nerve

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

A 2-year-old girl is brought to an otolaryngologist by her mother for chronic ear infections. The patient is otherwise healthy, with the exception of recurrent episodes of otitis media (OM). Examination and history show that the child has had average growth and development; she has not had invasive infections, skin disorders, or hospitalization. The child’s mother is concerned about the risk of hearing loss and its effects on development. What statement about hearing loss and OM is most accurate?

Answer Choices
1 Hearing loss does not result from OM, except in rare cases
2 Sensorineural, but not conductive hearing loss, is associated with OM
3 Hearing loss during OM may adversely affect cognition and language
4 Van der Hoeve syndrome, a sequela of OM, can cause hearing loss
5 Hearing loss associated with OM is always conductive and temporary

Hearing loss during OM may adversely affect cognition and language

Explanation
Conductive and sensorineural hearing loss are complications of chronic otitis media (OM). Acute and chronic suppurative OM usually results in conductive hearing loss. Chronic infection may result in conductive hearing loss from a perforation of the tympanic membrane; however, sensorineural hearing loss can occur, especially when herpes zoster is the etiologic agent. Cholesteatoma increases the probability of labyrinthitis, which carries a high risk for sensorineural hearing loss. Van der Hoeve syndrome is a constellation of symptoms including hearing loss, but is unrelated to OM.

Hearing impairment is a risk factor for impaired speech and language development, particularly if it occurs early in life. In cases where hearing loss due to chronic OM is reversed surgically, it is likely that young children will compensate and catch up to peers. In cases where OM is either undiagnosed or untreated, long-term developmental and social problems may result. Because otitis media is often associated with hearing loss, most clinicians have been eager to treat the condition to restore hearing to normal, thereby preventing any long-term problems.

A 35-year-old woman presents with slowly progressive right-sided hearing loss, tinnitus, and continuous vertigo. Patient’s Weber test reveals lateralization to the left ear.

Question
What is the most likely cause of this patient’s symptoms?

Answer Choices
1 Vestibular neuronitis
2 Meniere’s disease
3 Acoustic neuroma
4 Labyrinthitis
5 Benign paroxysmal positional vertigo

Explanation
Acoustic neuroma is a benign tumor of the VIII cranial nerve. While these tumors are benign, their growth can lead to sensorineural hearing loss, vertigo, and tinnitus. Because the tumor is slow growing, symptoms typically have a gradual onset. Diagnosis is made by MRI.In vestibular neuronitis, patients present with paroxysmal episodes of vertigo without hearing loss. The patient may also have nystagmus.

Meniere’s disease also presents with vertigo, sensorineural hearing loss, and tinnitus; however, these symptoms are typically episodic in nature, whereas the symptoms of acoustic neuroma are continuous.

Labyrinthitis presents with an acute onset of continuous vertigo, hearing loss, and tinnitus. Symptoms gradually improve over several weeks, though hearing may remain impaired following recovery. Acoustic neuroma has a gradual onset, and symptoms will not improve until the tumor is treated.

Patients with benign paroxysmal positional vertigo have recurrent episodes of brief vertigo without hearing loss; the vertigo is related to changes in head position. There is no associated hearing loss.

A 32-year-old woman presents with a 3-day history of irritation, burning, itching, and redness of both eyelids. She denies fever, visual changes, and photophobia. On physical examination, you note the presence of scales clinging to the eyelids bilaterally.

Question
What is the proper management in this case?

Answer Choices
1 Daily cleaning with a damp cotton applicator and baby shampoo
2 Short-term oral antibiotic therapy for 7 days
3 Short-term oral corticosteroid therapy for 14 days
4 Topical corticosteroid eye drops for 10 days
5 Prompt ophthalmologist referral

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

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

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

A woman presents with an otherwise healthy 12-month-old boy because she notice that he has crossed eyes that are different colors. His mother has been smoking for about 10 years, and she smokes during the pregnancy. She remembers that her brother died when he was 3 because he had a tumor in both his eyes. Physical exam reveals heterochromia iridis and leukocoria.

Question
What is the main risk factor for the condition of this child?

Answer Choices
1 Heredity
2 Leukocoria
3 Smoking
4 Heterochromia iridis
5 Strabismus

heredity
Explanation
The correct response is heredity.The child most likely has inherited retinoblastoma. Retinoblastoma is a rapidly developing cancer that generally affects children under the age of 6. It is most commonly diagnosed in children aged 1 – 2 years. Genetic counseling is especially important when more than 1 family member has had the disease or if the retinoblastoma occurs in both eyes.

Leukocoria is seen as a whitish color behind the pupil, which is usually black. It is a sensitive test best done by looking at the “red reflex.” Normally, red reflection often occurs in people’s eyes when taking flash photographs. Dimming the room lights and using a flashlight to shine light directly into the child’s eyes can also elicit the red reflex. With leukocoria, also known as “cat’s eye,” red reflex is absent. This abnormality is present in approximately 60% of all children with retinoblastoma. Keeping in mind that retinoblastoma is the third most common cancer overall affecting children, red reflex is a useful screening tool. It is a sign and not a risk factor for the disease.

Although smoking can affect pregnancy and a child, in this particular case, heredity is probably the main risk factor.

Heterochromia iridis is a relatively late symptom caused by the tumor invasion and/or neovascularization. It is a symptom, not a risk factor.

Crossed eyes, or strabismus, which occurs as a result of visual loss, is a common sign of retinoblastoma. That is the reason funduscopic examination through a well-dilated pupil must be performed in all cases of childhood strabismus. Strabismus is usually secondary to macular involvement. It is also a sign and not a risk factor for the disease.

A 37-year-old man presents with headache, malaise, and nasal congestion. He reports his symptoms started with what he believed to be a common cold, which occurred about 2 weeks ago. However, he has begun feeling much worse over the last 5 days. He describes severe facial pain when he bends to tie his shoes. He admits a very mild nonproductive cough, but he denies shortness of breath, fever, and chills. He has tried multiple over-the-counter cold remedies without relief.

His past medical history is unremarkable, with no known medical conditions, no history of surgery, no regular medications and no allergies. He works as a welder, but denies known occupational respiratory exposures. He denies use of alcohol, tobacco, and drugs.

On physical exam, his temperature is mildly elevated at 99.9 °F (37.7 °C), and other vitals are normal. His voice has a nasal quality and an occasional mild cough is noted throughout the exam. On HEENT exam, he demonstrates some tenderness over the left frontal region. Green nasal discharge with boggy nasal mucosa is present bilaterally. Mild injection is seen in the posterior nasopharynx. The remainder of his exam is unremarkable.

Question
What organism is most likely implicated with this patient’s current condition?

Answer Choices
1 Candida albicans
2 Clostridium difficile
3 Escherichia coli
4 Francisella tularensis
5 Haemophilus influenzae
6 Pseudomonas aeruginosa

Haemophilus Influenzae

Explanation
This patient presents with a classic acute bacterial rhinosinusitis (sinus infection). The most common causative organisms are Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis. Viruses and anaerobes can also be implicated as causes. Haemophilus influenzae is a Gram-negative bacterium. It is important for clinicians to understand the basic underlying etiology of common infections in order to select appropriate empiric antibiotic therapy. Because of difficulty in obtaining sinus cultures without nasal contamination, culture and identification of sinusitis-causing organisms is rarely done in clinical settings.

Candida albicans is a common fungal organism. It is typically responsible for vaginal yeast infections and thrush. It does not usually cause sinusitis.

Clostridium difficile is a Gram-positive, anaerobic bacillus. It can be a causative organism in diarrheal illnesses and colitis, and it is often considered a nosocomial (hospital-acquired) infection. It is not linked with sinusitis.

Escherichia coli is a Gram-negative bacterium commonly found in the gastrointestinal tract. It is part of the normal GI flora, but can contribute to infection in other systems, such as the urinary tract. It is not usually found in the sinuses.

Francisella tularensis is a Gram-negative bacterium that causes tularemia (also known as “rabbit fever”). It is carried by various vectors (ticks, rabbits, and rodents). Tularemia can cause various systemic symptoms, such as fever, malaise, fatigue, aches, and swollen lymph nodes.

Pseudomonas aeruginosa is a Gram-negative bacterium that can be found in infections throughout several body systems. It can cause pneumonia, skin infections, as well as gastrointestinal and urinary tract infections. However, it is typically associated with some type of inoculation or immunocompromising condition (e.g., burns, post-catheter, puncture wounds, neutropenia, ventilator use, etc.). This patient history does not suggest any unusual etiology for his sinusitis. Pseudomonas aeruginosa is an unusual and rare cause of sinus infection.

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

Answer Choices
1 Augmentin
2 Cephalexin (Keflex)
3 Ciprofloxacin
4 Mupirocin (Bactroban)
5 Erythromycin

Erythromycin
Explanation
The clinical picture is suggestive of a streptococcal bacterial infection. Penicillins are the 1st-line antibiotics in the treatment of strep pharyngitis. Since the patient is allergic to penicillins, erythromycin is an effective alternative and has no allergic cross-reactivity with the penicillins.Augmentin contains amoxicillin, a member of the penicillin family with allergic cross-reactivity; it is contraindicated for patients allergic to penicillin.

Cephalexin, a cephalosporin, can be used to treat strep throat. However, approximately 7% of patients who are allergic to penicillin are also allergic to cephalosporins. Therefore, compared to erythromycin, use of this agent poses a slightly higher risk of causing an allergic reaction in this patient.

Ciprofloxacin is effective against Gram-negative organisms. Since streptococcal species are Gram-positive, it would not be an appropriate treatment in this scenario.

Mupirocin is a topical antibiotic and is not indicated in the treatment of strep throat.

A 42-year-old man presents with a 10-day history of worsening headache, stuffy nose, greenish nasal discharge, and a low grade fever. He has body aches and facial pain, as well as a dry cough. He denies shortness of breath, abdominal pain, nausea, or vomiting. He is a non-smoker, has no significant past medical history, and is only taking acetaminophen. On exam, he has a temperature of 100.9° F taken orally. Pulse is 86/min, BP is 120/76 mm Hg left arm sitting, and SPO2 is 94% on room air. Lungs are clear and abdomen normal. Nasal mucosa appears boggy, and there is tenderness with palpation over the facial bones (maxillary area). Pharynx is without exudates.

Question
What component of the history prompts you to consider giving antibiotics for treatment of this condition?

Answer Choices
1 Facial pain, body aches, and a SPO2 of 94%
2 Length of time the symptoms have been present
3 Boggy nasal mucosal with facial tenderness
4 Low grade fever
5 Headache and body aches

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

A 24-year-old man presents with a painless, localized swelling of his left lower eyelid; it has developed over a period of weeks. He is seeking medical attention because it is now producing a foreign body sensation in his left eye; it is also hindering his path of vision. On physical examination, his visual acuity is normal; there is no evidence of injection or discharge. You palpate, and you observe a nontender, localized nodule on the lower eyelid.

Question
What is the most likely diagnosis?

Answer Choices
1 Keratitis
2 Chalazion
3 Malignant melanoma
4 Blepharitis
5 Ectropion

Chalazion
Explanation
Chalazion is the correct response. Chalazion is a granulomatous inflammation of the meibomian gland, and it has the typical presentation of being a hard, nontender swelling of either the upper or lower lid. It is sometimes accompanied by redness and swelling of the adjacent conjunctiva.Blepharitis is the incorrect choice; typically, blepharitis is a bilateral condition of general inflammation of the eyelid skin, eyelashes, and associated glands. Characteristics of blepharitis include red-rimmed eyes as well as scales on the eyelashes. Tears may even have a greasy distinction to them.

Ectropion is also an incorrect choice. Ectropion is the outward turning of the lower lid. This is not what was described in this case.

Keratitis is also incorrect; it produces a painful eye, a hazy-appearing cornea as well as evidence of an ulcer or even an abscess in this area; hypopyon is also possible in patients who have keratitis.

Malignant melanoma can have a presentation in the ocular area that is somewhat like the one described in this case; however, it is not a common presentation.

A 52-year-old man presents with a concern of hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only 1 side (his left). Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms.

The patient’s past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use.

On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed; it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells.

Question
What choice represents the best intervention for this patient’s current condition?

Answer Choices
1 Referral for chemotherapy
2 Referral for electroencephalography
3 Referral for surgery
4 Referral for unilateral hearing aid
5 Referral for ventricular shunt

Referral for surgery
Explanation
This patient is presenting with a vestibular schwannoma (or acoustic neuroma), which is affecting his vestibulocochlear nerve (cranial nerve VIII). This is one of the more common benign head and neck neoplasms. A common presentation is unilateral hearing loss and tinnitus. Treatment is typically surgical removal; another possibility is radiation therapy. Of the choices listed, referral for surgery is the best option; if he turns out to be a poor surgical candidate, radiotherapy should be discussed.This patient should not be referred for chemotherapy. Schwannomas are not typically responsive to chemotherapy, so doing so could delay appropriate treatment.

If the patient was describing seizures, the provider should refer for electroencephalography (EEG), especially as some brain tumors are associated with seizures. However, this patient denied other neurological symptoms and has been clearly shown to have an intracranial mass. Referral for EEG would also delay definitive treatment.

A referral for unilateral hearing aid would not fix this man’s hearing loss; the treatment of his brain tumor would be delayed.

A referral for ventricular shunt should be done for patients with hydrocephalus. Shunts have no role in schwannoma treatment.

A 42-year-old man presents with a 3-day history of, as he puts it, “not being able to hear in my right ear”. He is otherwise healthy, and he is not taking any medications. There is not a history of trauma. On physical exam, the whisper test is decreased on his right; the Weber test lateralizes to the right ear and the Rinne test is as follows: right ear bone conduction is greater (lasts longer) than air conduction; left ear air conduction lasts longer than bone conduction.

Question
What is the most likely diagnosis?

Answer Choices
1 Right ear sensorineural hearing loss, possibly due to Meniere’s disease
2 Left ear sensorineural hearing loss, possibly due to Meniere’s disease
3 Left ear conductive hearing loss, possibly due to middle ear disease
4 Right ear sensorineural hearing loss, possibly due to acoustic neuroma
5 Right ear conductive hearing loss, possibly due to cerumen impaction

5 Right ear conductive hearing loss, possibly due to cerumen impaction

Explanation
Hearing loss can be recognized at the bedside as either sensorineural or conductive through the Rinne and Weber tests. In this case, the Rinne test bone conduction (BC) lasts longer than air conduction (AC) in the right ear ( affected ear) and the Weber test lateralizes to the right ear (affected ear). Normally AC lasts longer than BC because of the amplifying effects of the eardrum and middle ear. If BC is longer than AC, the patient is likely to have conductive deafness. Both tests in this patient indicate a conductive hearing loss in the right ear, probably produced by cerumen impaction; there is no apparent evidence of middle-ear disease. In sensorineural hearing loss, both AC and BC are equally diminished.

Right ear sensorineural hearing loss due to Meniere’s disease is incorrect. The patients Rinne and Weber test results indicate conductive hearing loss confined to the right ear not sensorineural hearing loss. There is no evidence of Meniere’s disease.

Left ear sensorineural hearing loss due to Meniere’s disease is incorrect. This patient’s hearing tests indicate a conductive hearing loss in the right ear. In sensorineural hearing loss both AC and BC are equally diminished. Symptoms of Meniere’s disease are not present.

Left ear conductive hearing loss due to middle-ear disease is incorrect. The patient’s hearing tests indicate a conductive hearing loss in the right ear not the left.

Right ear sensorineural hearing loss due to acoustic neuroma is incorrect. There is no evidence of sensorineural hearing loss or acoustic neuroma in this patient.

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

Question
What is the most likely diagnosis?

Answer Choices
1 Acute angle-closure glaucoma
2 Chronic glaucoma
3 Cataract
4 Acute uveitis
5 Acute conjunctivitis

Acute closed angle glaucoma
Explanation
Acute angle-closure glaucoma is frequent among the older age group and in Asians. Essential for diagnosis is rapid onset of severe pain and profound vision loss/blurring with halos around lights. On physical exam, a fixed and dilated pupil as well as red eye with a steamy cornea is the hallmark.Chronic glaucoma is usually an insidious onset of bilateral loss of peripheral vision.

Cataracts usually present as gradually progressive and non-painful; there are clear corneas, normal pupil size, and normal light reaction.

Acute uveitis presents with blurred vision; the cornea is clear, and the affected pupil is small with poor papillary light response.

Acute conjunctivitis presents with copious discharge; it does not impact vision. There is a clear cornea, normal pupil size, and normal papillary light reaction.

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

Aspirin
Explanation
Aspirin should be avoided in this patient. Given the description of pale swollen masses, it is likely that the patient has nasal polyps. Patients with a history of asthma and nasal polyps may also have a sensitivity to aspirin that causes bronchospasm. The combination of asthma, nasal polyps, and aspirin sensitivity is known as the Samter triad. Due to this potential reaction, aspirin should be avoided in this individual.Acetaminophen, ibuprofen, and oxycodone are not contraindicated in patients with asthma and nasal polyps.

Prednisone is not contraindicated in patients with nasal polyps. In fact, a short course of nasal or oral steroids may actually treat nasal polyps. For those refractory to medical management, surgical removal of nasal polyps may be necessary.

A 37-year-old Caucasian woman swims regularly for exercise. She swims 100 laps 4 to 6 times per week. She starts to notice severe right ear pain. She also notes that her right ear is very itchy. She sees her family doctor and mentions her symptoms. When he goes to insert the otoscope, he gently pulls on her ear. This causes her quite a bit of pain. He notes an inflamed external ear canal, but the tympanic membrane is normal.

Question
What is the most likely pathogen?

Answer Choices
1 Pseudomonas aeruginosa
2 Streptococcus pneumoniae
3 Haemophilus influenzae
4 Branhamella catarrhalis
5 Corynebacterium diphtheriae

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

The image included here is a photomicrograph of Pseudomonas aeruginosa. The image is courtesy of the CDC.

A 25-year-old woman presents with watery eyes and a runny nose. The symptoms get worse after she has been outside, especially if she plays in the grass with her 2-year-old. Allergy testing reveals that she is highly allergic to several grass pollens. Allergy shots using grass pollens as the antigens might be helpful; what event must occur in order for the body to synthesize the complete antibody protein specific for her allergy?

Answer Choices
1 Different rRNA molecules must be spliced together
2 Site-specific recombination of DNA must occur
3 All antibody molecules not specific for these antigens must be degraded
4 Various protein precursors must be joined into 1 polypeptide chain
5 Specific DNA sequences must be amplified

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

A typical antibody molecule is composed of both heavy and light chains. The genes for both heavy and light peptide chains undergo somatic cell rearrangement, which yields approximately 3,000 different light chain combinations and approximately 5,000 heavy chain combinations. The gene sequences needed to form the mature antibody chains are brought together. A complete Ig chain can only be synthesized after this genetic recombination occurs.

A 30-year-old woman presents to the emergency room at 7 am with severe pain and swelling of her right eye. She was awakened early the previous evening due to the discomfort and swelling of the surrounding conjunctiva. She found it difficult to sleep due to the discomfort. She planned on going to work, but the swelling had closed her eye shut, and she developed excruciating pain in the eye that radiated internally.

The patient does not recollect any previous trauma or injury to the eye. She uses contact lenses, but they were not in use due to the condition of her eye. The contact lenses were stored in a small pillbox container with some fluid that she later described as tap water. She ran out of sterile cleaning and soaking solution for the contact lenses, so she has been using tap water as a substitute for approximately 5 days. She frequently sleeps with her contacts in.

The patient is afebrile. Pulse is 70/min, and blood pressure is 135/80 mm Hg. Lungs are clear, and there is no evidence of lymphadenopathy. The eye has a profound conjunctivitis that is acute and follicular. Purulent drainage is present. The acute nature of the conjunctivitis requires an ophthalmologist consult.

The ophthalmologist obtains ocular fluid for culture and Gram stain. CBC results are unremarkable. The Gram stain reveals the following results (see image). Prompt and aggressive therapy is initiated. What is the most likely organism causing this acute eye threatening infection?

Answer Choices
1 Chlamydia trachomatis
2 Pseudomonas aeruginosa
3 Haemophilus aegyptius
4 Bacillus cereus
5 Acanthamoeba spp
6 Staphylococcus aureus
7 Candida albicans

Pseudomonas
Explanation
Pseudomonas aeruginosa is a Gram-negative rod; it is a non-lactose fermenting, oxidase-positive motile bacteria. Growth on MacConkey agar is usually characterized by the production of a “grape-like” smell. A blue-green color, due to the production of the diffusible fluorescent pigments pyoverdin and pyocyanin, is characteristic of the colonies growing on MacConkey. Pseudomonas aeruginosa is a very common opportunistic source of human infections, especially in the hospital setting. Pathogenesis is due to its minimal nutritional requirements, relative resistance to antibiotics, and a host of other invasive and toxicogenic substances that it produces. It can cause a keratitis that is rapid in its development. The infection is usually the result of a previous injury to the eye, which causes an interruption in the epithelial surface and allows bacterial invasion of the underlying stroma. It can also be caused by contact lenses. Fever is usually absent, and leukocytosis is absent or minimal. The infection can lead to corneal ulceration, resulting in the rapid loss of ocular function; therefore, these infections need to be approached as a medical emergency. Scrapings from the floor of the ulcer exhibiting Gram-negative rods are strongly indicative of Pseudomonas aeruginosa and should necessitate treatment. Immediate initiation of combined topical and subconjunctival therapy with an aminoglycoside antibiotic such as gentamicin or tobramycin is advised. Topical steroids are sometimes used to reduce ocular inflammation.Chlamydia trachomatis is an obligate intracellular parasite with a unique biphasic life cycle. It does not Gram stain; laboratory procedures used for diagnosis include isolation in tissue culture, EIA detection of antigen, immunofluorescent staining, cytologic examination for intracytoplasmic inclusions, and by the demonstration of nucleic acid by direct hybridization or by amplification techniques. It can cause inclusion conjunctivitis and ocular trachoma (as well as urethritis, lymphogranuloma venereum, urogenital infections, infertility, salpingitis and endometritis, reactive arthritis, etc.). The inclusion conjunctivitis presents as an acute follicular conjunctivitis and is usually self-inoculated from an infected genitourinary site. The patient frequently notes a foreign body presence in the eye. These symptoms are usually unilateral, and in the first 2 weeks, there is a mucoid discharge that becomes purulent. Usually the inclusion conjunctivitis resolves without complications, but some untreated or improperly treated cases can result in a prolonged infection that can last for months, and it can produce conjunctival and corneal scarring that is similar to mild ocular trachoma. Antibiotics, such as the tetracyclines, macrolides, rifampin, and some of the fluoroquinolones, have activity against chlamydia.

Haemophilus aegyptius is a Gram-negative coccobacillus; it is non-motile, fastidious bacteria requiring the presence of special factors for its growth on agar media. These factors are hemin and nicotinamide adenine dinucleotide, which are present in chocolate agar. The organism is indigenous to humans. It is an important cause of a purulent conjunctivitis called pink eye, and it can occur in outbreaks because of its contagious nature. The diffuse pink color of the sclera and the presence of a serous or purulent discharge are virtually diagnostic of Haemophilus aegyptius infection. Leukocytosis is absent. The infection is not acute in presentation. The treatment of Haemophilus aegyptius is with topical antibiotics. Because of the infectious nature of the infection, instructions should be provided to the patient to help prevent the spread of the infection to others.

Bacillus cereus is a Gram-positive (or Gram-variable) rod that is aerobic and spore forming; it is ubiquitous in nature. Bacillus cereus is an important cause of food poisoning. It has also been recognized as an ocular pathogen. The ocular infection is acute in presentation and requires aggressive intervention to save the eye. It is many times associated with metal-on-metal projectile injuries, soil and dust contamination as seen in rural farm areas, and drug abuse. The presence of progressive corneal deterioration and ring abscess formation is a complication of panophthalmitis caused by Bacillus cereus. Except for infections with Pseudomonas aeruginosa, this finding is almost pathognomonic of Bacillus cereus. Because of the seriousness of the infection, early diagnosis is important. Patients presenting with ocular infections after trauma or in the setting of drug abuse should arouse suspicion. As with Pseudomonas aeruginosa, it is important for the prompt initiation of therapy before permanent structural changes occur, leading to loss of vision. Clindamycin and gentamicin in combination, administered intravitreally, is the course of therapy favored by ophthalmologists. The prognosis is poor and usually results in the loss of the eye unless an aggressive approach is undertaken; even then, there is assuredly some loss of vision. Topical steroids are sometimes used to reduce ocular inflammation.

Acanthamoeba is a free-living amebae that can cause granulomatous amebic encephalitis and keratitis. Detection is usually made by observing the free-living motile organisms in a wet prep preparation. Acanthamoeba keratitis is a corneal infection that occurs in healthy people and is usually associated with contact lens wearers. To prevent Acanthamoeba keratitis, it is recommended that contact lenses be cleaned and stored with Benzalkonium chloride-preserved saline and solutions containing thimerosal with edetate. Swimming in fresh water (where the organism is naturally found) with contact lenses can predispose the wearer to Acanthamoeba keratitis. The keratitis is slow in developing and is frequently mistaken for herpes, bacterial, or fungal keratitis. Frequently, the average delay to definitive treatment can range from days to months. Symptoms include blurred vision, conjunctivitis, tearing, severe pain to the eye, and photophobia. The keratitis achieves an advanced stage in several days to several months, and it can exhibit patchy stromal infiltrates and dendriform epithelial involvement without frank corneal ulceration in its early stages. A ring corneal infiltrate is characteristic of this keratitis in its late stages. Early diagnosis, aggressive surgical debridement, and medical management can prevent eye damage. High concentrations of topical antimicrobial drugs (1% miconazole, 0.1% propamidine isethionate, and Neosporin) for a minimum of 3 – 4 weeks is part of the antibiotic therapeutic regimen employed in the treatment of Acanthamoeba keratitis.

Staphylococcus aureus is a Gram-positive staining cocci that is catalase positive and coagulase positive. It is probably the 2nd most common bacterial isolate of human infections behind Escherichia coli and the most common cause of bacterial endophthalmitis. Staphylococcus aureus has a host of invasive and toxigenic characteristics that enhance the pathogenesis of the organism in the human host. The organism has been described as an etiologic agent of many infections including, but not limited to, conjunctivitis, endocarditis, septicemia, abscesses, and urinary tract infections. The conjunctivitis caused by Staphylococcus aureus is usually characterized as non-severe where there is little to no lid edema, scant purulent discharge, and normal cornea; however, in some cases the presentation can be severe. Topical agents are usually used to treat this infection such as cephalosporins or semisynthetic penicillins. In suspected cases of resistance, topical vancomycin should be considered.

Candida albicans is a yeast. Yeast appear on Gram stain as large Gram-positive organisms that are approximately 3 – 5 times larger than Gram-positive cocci. They are aerobic and generally grow well on most non-selective agar media. Endophthalmitis due to yeast is generally a common and serious complication of intravenous drug use. Candida albicans is the most common fungal cause. It is usually of hematogenous origin, where the patient has infective endocarditis or some other infective process occurring. The symptoms are blurred vision, decreased vision, white cotton appearing exudative lesions in the choroid and retina with vitreous haziness, and eye pain. A definitive diagnosis is made by obtaining vitreous fluid for Gram stain and culture. The treatment consists of parenteral amphotericin B together with flucytosine. Intraocular amphotericin B administration as therapy is controversial. The incidence of permanent intraocular damage is high.

A 12-year-old girl does not want to eat and appears to have a fever. She has an inflamed throat, and you decide to treat her with 7 days of penicillin, but her mother tells you that her daughter is allergic to penicillin. What antibiotic should you prescribe to this child?

Answer Choices
1 Cefaclor
2 Ampicillin
3 Amoxicillin
4 Cephalexin
5 Doxycycline

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

An 8-year-old boy in the 3rd grade is referred to you by his school doctor to be evaluated for poor speaking and reading ability, failure to follow directions in class, and classroom disruptiveness. Despite these problems, he appears to be alert and interactive with other children and there is no demonstration of aggressive behavior or rage. He does not appear to be preoccupied with internal stimuli, and IQ testing results are within normal range.

Question
What is the most likely cause of his symptoms?

Answer Choices
1 Autism
2 Childhood schizophrenia
3 Hearing impairment
4 Learning disability (reading disorder)
5 Seizure disorder (Epilepsy)

Hearing Impairment
Explanation
Hearing impairment is the most likely cause for this boy’s poor communication and reading ability and his classroom problems. Children with hearing impairment appear to learn more slowly because they miss many important cues and information. They often become frustrated and develop other behavioral disturbances such as classroom disruptiveness. Thus, sensory impairment is an important consideration in the differential diagnosis of any child with symptoms that might suggest MR/ID or learning and communication disabilities.The 4 most common causes of speech or language delay are developmental language disabilities (i.e., normal cognition (IQ), impaired intelligibility, and delayed emergence of phrases, sentences, and grammatical markers), mental retardation/intellectual disability (MR/ID), hearing impairment, and autistic spectrum disorders.

That being said, research has shown that approximately one third of hearing impaired children will also be found to have at least 1 other disability that affects development of speech and language (e.g., mental retardation, cerebral palsy, craniofacial anomalies).

Any child who shows developmental warning signs of a speech or language problem should have a hearing assessment by an audiologist and an examination by a geneticist as part of a comprehensive evaluation.

Autism is unlikely in this case because the boy is interactive with classmates and his environment.

Reading disorder (or “Developmental Dyslexia”) is the most common learning disability. The clinical picture is consistent with a learning disability in that the IQ score is higher than academic performance would suggest (poor speaking and reading ability, failure to follow directions). However, before this boy can be given a diagnosis of a learning disability, hearing impairment must be ruled out with audiometric studies.

Childhood schizophrenia is a rare condition that can cause learning disabilities and is characterized by inattention and disruptive behavior; however, it is unlikely in this case, as there appears to be no impairment in social skills, no preoccupations with internal stimuli, and no aggression or rage behavior.

Seizure disorders (epilepsy) can cause cognitive disturbances, but these should be detectable with IQ testing. The boy in this case has a normal IQ. Although a topic of much discussion and debate, it is well known that chronic epilepsy has an association with neuropsychological impairment.

A 67-year-old woman presents saying her husband says she doesn’t listen to anything he says. The patient states that occasionally she has to ask people to repeat themselves when sitting to her right. She denies any dizziness, headaches, or visual disturbances. Her current medication is furosemide. On physical examination, the Weber test reveals lateralization to the left ear. Air conduction lasted for 15 seconds and bone conduction lasted 10 seconds. What do you suspect as the cause of this hearing loss?
Answer Choices
1 Cerumen impaction
2 Otosclerosis
3 Ototoxicity
4 Meniere’s disease
5 Middle ear effusion
Ototoxicity
Explanation Ototoxicity secondary to furosemide is the correct answer. Loop diuretics can cause sensory hearing loss, as evidenced by this patient’s physical exam finding of lateralization to the good ear and air conduction slightly longer than bone conduction. The Rinne test should reveal an air:bone conduction ratio of 2:1.
Cerumen impaction will cause a conductive hearing loss with the lateralization to the affected ear and a negative Rinne test.Otosclerosis typically will result in conductive hearing loss.

Meniere’s Disease is incorrect because the patient does not exhibit any vertigo or tinnitus.

Middle ear effusion is incorrect because it would cause a conductive hearing loss.

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

Question
What is the most likely diagnosis?

Answer Choices
1 Acute rhinitis
2 Migraine
3 Acute pharyngitis
4 Acute sinusitis
5 Influenza

Acute Sinusitis
Explanation
Acute sinusitis is a common condition that is characterized by nasal congestion, purulent nasal discharge, headache, facial pain, cough, teeth pain, myalgias, and low-grade fever. Other symptoms include halitosis, anosmia, and metallic taste in the mouth. Out of these 11 features, presence of 4 or more is diagnostic for bacterial sinusitis. History regarding previous medications (rhinitis medicamentosa), occupational rhinitis, polyps in the nose, or vasomotor rhinitis needs to be taken. Maxillary sinuses are tender, as in this case, along with congested nasal mucosa. Diagnosis is usually clinical. Radiological confirmation may aid in definitive diagnosis and treatment. Transillumination of maxillary sinuses with a torchlight may reveal loss of normal illumination, but doing so is generally not recommended in practice. Plain radiographs in various sinus views may show opacification or air fluid level. The imaging of choice in recent times has been a limited CT scan of sinuses, which is fairly reasonable price wise and has proven to be quite helpful. It can show opacification, mucosal thickening, abscess formation, bone destruction, tumors, and blockage of the osteomeatal complex. Treatment includes a 2-week course of amoxicillin, amoxicillin-clavulanate, cefuroxime, or quinolones, along with an oral decongestant, nasal decongestant, and anti-inflammatory medications.Acute rhinitis is usually viral and characterized by serous nasal discharge, rather than purulent, fever, fatigue, sneezing, scratchy throat, and moderate cough. Examination is not very remarkable. It is self-limiting, and it resolves after 4 – 7 days. There is no response to antibiotics. Symptomatic treatment with decongestants and antitussives is indicated.

Migraine headaches are not associated with nasal congestion, fever, cough, or sore throat. Recurrent headaches are common, and patients may get an aura prior to an attack.

Acute pharyngitis is associated with severe sore throat, pain on swallowing, erythematous pharynx with or without exudates, and enlarged tonsils. There may be headache and body ache with fever, especially in streptococcal infections. Throat swab can be sent for culture. Office-based rapid streptococcus tests are also available. Sinus pain and tenderness are absent, and nasal congestion is absent or mild.

Influenza is a viral illness with high fever and chills, severe myalgias, headache, malaise, and fatigue. It can be debilitating and life threatening in the elderly. Dry hacking cough with sore throat may be present. Examination reveals few positive findings. Mild hyperemia of the pharynx and flushed face may be the only findings other than fever. Diagnosis is clinical. Treatment is supportive.

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

Answer Choices
1 Hordeolum
2 Bacterial conjunctivitis
3 Trachoma
4 Blepharitis
5 Viral conjunctivitis

Blepharitis
The symptoms described above are typical for blepharitis, an inflammation of the lid margins. There are 2 types of blepharitis:Ulcerative blepharitis: it is caused by bacterial infection (mostly staphylococci) of follicles and meibomian glands. Adherent crusts develop that result in bleeding if removed. Pustules form in the lash follicles and turn into small ulcers. Repeated episodes can lead to permanent loss of lashes, scarring of the lids, and sometimes even corneal ulceration. Treatment consists of application of antibiotic ointment for 7 to 10 days.
Seborrheic blepharitis: the cause is not known. Sometimes it is associated with seborrhea of scalp and face. The scales are easily removable. Treatment is usually to just keep the eyelids clean. If it does not clear, antibiotic ointment is needed.
Hordeolum is a localized infection of the Zeis, Moll, or meibomian glands; it is usually caused by staphylococci. It can be associated with blepharitis or follow it.

The internal hordeolum (affecting the meibomian glands) involve pain, redness, and localized edema with an elevated yellow area near the affected gland that turns into an abscess, which rarely ruptures spontaneously.
The external hordeolum (affecting the glands of Zeis or Moll) starts with pain, redness, and tenderness, which turns into an induration with a yellowish spot in the center. The abscess soon ruptures and emits pus.
Acute conjunctivitis is an inflammation of the conjunctiva that can be bacterial, viral, or allergic. The most common pathogens for bacterial infection in adults are Staphylococci, Streptococcus pneumoniae, and Haemophilus influenzae. In children, bacterial conjunctivitis is more common than viral conjunctivitis and is caused by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Symptoms are itching, irritation, foreign body sensation, tearing, and in bacterial infection, mucopurulent discharge. Small bumps with fibrovascular cores on the palpebral conjunctiva that look like a velvety surface are a typical papillary reaction. Bacterial conjunctivitis is usually self-limiting but can also cause corneal or systemic complications (like meningitis in primary meningococcal meningitis) and should therefore be treated with topical antibiotics (e.g., polymyxin-bacitracin, ciprofloxacin, or ofloxacin).

Viral conjunctivitis is more common than bacterial conjunctivitis in adults; it is caused by herpes virus or during the course of systemic or cutaneous infections, such as rubella, measles, cytomegaly, syphilis, or systemic adenovirus infections. Occasionally permanent vision loss can occur, as well as cataract, microphthalmos, retinal involvement, interstitial keratitis, and optic neuritis.

Trachoma is a chronic conjunctivitis caused by chlamydia trachomatis. It is transmitted via contact (hands, towels, etc.), and it is a major cause of blindness in developing countries due to poor hygiene and economic conditions. In the United States, only mild forms are typically seen, usually in immigrants from endemic areas. The disease presents as conjunctivitis with small lymphoid follicles. Cultures are often false negative; therefore, PCR to prove the presence of chlamydial DNA in ocular secretions should be performed. Treatment consists of topical or systemic tetracycline or erythromycin.

A 22-year-old woman presents with nosebleed. Her nosebleed occurred spontaneously with no known injury. Her past medical history is significant for seasonal allergies and migraine. Examination reveals bleeding from the nasal septum.

Question
What is the appropriate initial treatment for this patient?

Answer Choices
1 Have patient lean back to drain blood from nose
2 Apply direct pressure with patient leaning forward
3 Posterior nasal packing
4 Cauterization of the nasal cavity
5 Surgical ligation of the nasal artery supply

apply direct pressure with patient leaning forward
Explanation
Apply direct pressure with patient leaning forward is correct. The patient has epistaxis. The majority of cases of epistaxis originate from Kiesselbach’s plexus in the anterior nose. Patient should first have direct pressure applied to the nose while the patient is leaning forward. Pressure should be continued for a minimum of 5 minutes.Have patient lean back to drain blood from nose is incorrect. Leaning back will cause the blood to collect in the posterior pharynx. Blood in the posterior pharynx may cause nausea or airway obstruction.

Posterior nasal packing is incorrect. This patient has anterior epistaxis, so posterior packing should not be done.

Cauterization of the nasal cavity is incorrect. Cauterization may be required for severe bleeding, but it is not a first line treatment.

Surgical ligation of the nasal artery supply is incorrect. Surgery may be required for severe bleeding, but it is not a first line treatment.

What description of “red eye” is caused by acute glaucoma?

Answer Choices
1 Homogeneous bright red patch between conjunctiva and sclera, normal pupil size, and unaffected vision
2 Diffuse flush and dilatation of central vessels around the iris, pupils anisocoric, decreased vision
3 Inflamed eyelids, normal vessels, normal pupil size, and unaffected vision
4 Dilated conjunctival vessels, normal pupil size, and unaffected vision
5 Dilated central and conjunctival vessels, dilated pupil, and decreased vision

Dilated central and conjunctival vessels, dilated pupil, and decreased vision

Explanation
Acute glaucoma is the sudden increase in intraocular pressure secondary to blocked drainage from the anterior chamber. It manifests as dilatation of both the central and conjunctival vessels. Pupil size is often dilated, and vision is decreased. It is considered an ocular emergency.

Conjunctival injection is the dilatation of the conjunctival vessels. Pupil size and vision are unaffected. It is a result of superficial processes, such as infection, allergies, irritation, and vasodilators.

Ciliary injection is the dilatation of the branches of the anterior ciliary artery, and it manifests as a diffuse flush and dilatation of the central vessels around the iris. The pupil may be normal, but it is usually small and anisocoric. Vision is decreased. It is a result of disorders of the cornea or inner eye, and requires immediate attention.

A subconjunctival hemorrhage is a patch of blood that appears outside the vessels between he conjunctiva and sclera. Pupil size and vision are unaffected. It may be the result of trauma, bleeding disorders, or sudden increases in venous pressure, such as from coughing. It is usually not of clinical significance.

Blepharitis is inflammation of the eyelid margins. Vessels, pupil size, and vision are all normal. Seborrhea and staphylococcal infections are common causes.

An 8-year-old boy presents with his father on a Sunday afternoon with left ear pain. His father reports that he had 2 ear infections as a baby, but he cannot remember in which ear. The visit occurs during the summer months, and the patient’s father says that the boy has been swimming almost daily in a neighbor’s pool. Physical examination of the ears bilaterally reveals left ear canal erythema and edema, and pain with manipulation of the left pinna. No other physical examination findings are abnormal.

Question
What is the most likely treatment?

Answer Choices
1 Neomycin/polymyxin B/hydrocortisone topical solution
2 Clotrimazole 1% topical solution
3 Ciprofloxacin oral suspension
4 Triamcinolone 0.1% topical solution
5 Amoxicillin oral suspension

Neomycin/polymyxin B/hydrocortisone topical solution
Explanation
Neomycin/polymyxin B/hydrocortisone (Cortisporin) solution is the correct answer. In this case, the patient has the diagnosis of acute left bacterial otitis externa. Initially, removal of any desquamated epithelium and moist cerumen should be performed. Topical solutions are usually adequate to treat the infection and should be chosen based on the most likely causative organism. Bacterial cases of otitis externa are usually caused by Pseudomonas aeruginosa or Staphylococcal species. Cortisporin has broad spectrum coverage, including a steroid to reduce inflammation. It is usually given 3-4 times daily for 7-10 days. This is not the first choice, however, if the patient has a perforation of the tympanic membrane in the infected ear.Clotrimazole 1% solution is not the correct answer for treatment of bacterial otitis externa. However, it would be adequate for treatment of fungal otitis externa, as clotrimazole is an antifungal rather than an antibacterial medication.

Ciprofloxacin oral suspension is not the correct answer. Topical treatments are usually enough to resolve episodes of acute otitis externa. However, should it become recurrent or if signs of invasive infection (such as fever or cellulitis) are present, then oral antibiotics may be necessary. In those cases, fluoroquinolones are often chosen.

Triamcinolone 0.1% solution is not the correct answer. Some children suffer from eczematous otitis externa, and this should be treated differently from acute bacterial otitis externa. Topical therapy is still effective, but acetic acid 2%, aluminum acetate, or various steroid preparations (such as triamcinolone 0.1% solution) are used.

Amoxicillin oral solution is not the correct answer. Topical treatments are usually enough to resolve episodes of acute otitis externa. However, should it become recurrent or if signs of invasive infection (such as fever or cellulitis) are present, then oral antibiotics may be necessary. Amoxicillin would likely not be chosen over an oral fluoroquinolone and is more likely to be chosen as treatment for acute otitis media.

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

A 25-year-old man presents to you with an acute otitis media with serous otitis in the right ear. You perform the Weber and Rinne tests.

Question
Which of the following results would you most likely expect to find?
Answer Choices
1 Weber – sound is heard louder in right ear, Rinne – bone conduction exceeds air conduction in right ear
2 Weber – sound is heard louder in left ear, Rinne – bone conduction exceeds air conduction in right ear
3 Weber – sound is heard louder in right ear, Rinne – air conduction exceeds bone conduction in right ear
4 Weber – sound is heard louder in left ear, Rinne – air conduction exceeds air conduction in right ear
5 Weber – sound is equal in both ears, Rinne – bone conduction greater than air conduction in right ear

Weber – sound is heard louder in right ear, Rinne – bone conduction exceeds air conduction in right ear

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

A 56-year-old man presents to his GP with a history of persistent and progressive unrelenting hoarseness for the last few months. He used to be a 50-pack-per-year smoker but quit 1 year ago. Physical examination demonstrated a 2 cm firm, non-tender right anterior cervical lymph node.

Question
Which of the following is the most likely diagnosis?
Answer Choices
1 Laryngitis
2 Thyroid cancer
3 Vocal cord nodule
4 Laryngeal cancer
5 Streptococcal tonsillitis

Laryngeal cancer
Explanation The correct answer is laryngeal cancer. Tobacco abuse is a common predisposing factor in laryngeal cancer and affects men more often than women. Persistent hoarseness in this population should cause suspicion of cancer. Many patients with laryngeal cancer present with palpable anterior cervical lymphadenopathy.Acute laryngitis lasts for about 1 week and typically follows a viral infection. Chronic laryngitis often due to irritants, vocal abuse, or gastroesophageal reflux does not typically have accompanying non-tender lymphadenopathy.

Thyroid cancer may present with anterior cervical lymphadenopathy but is rarely seen with progressive hoarseness.

Vocal cord nodules are typically found in patients who overuse their voices and are not related to tobacco abuse.

Streptococcal pharyngitis typically causes tender cervical lymphadenopathy unrelated to tobacco abuse and does not cause progressive laryngitis.

A 69-year-old woman presents with epistaxis. She has been applying pressure to her nose for the last hour, but she came to the emergency room when the bleeding did not subside. Past medical history is significant for type II diabetes, hypertension, and an acute myocardial infarction 2 years ago, which was treated with stent placement. On physical exam, the patient is afebrile, with pulse 92 beats per minute, respirations 23 per minute, and a blood pressure of 185/105. There is blood flowing through both nares, and blood is seen down the posterior oropharynx. Examination of the nasal cavity does not reveal a specific area of bleeding.

Question
What is the appropriate next step for this patient?

Answer Choices
1 Resume placing direct pressure
2 Cauterization of the nasal cavity
3 Anterior nasal packing
4 Posterior nasal packing
5 Surgical ligation of the nasal artery supply

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

Surgical ligation of the nasal artery supply can be used in the treatment of posterior epistaxis. However, it is reserved for patients who do not respond to posterior nasal packing.

A 25-year-old woman presents due to constant sneezing episodes that have progressively worsened over the last few months. Further questioning reveals she also suffers from severe bilateral eye irritation, excessive tearing, and pruritus. On physical examination, you note hypertrophic nasal mucosa that is boggy in appearance, with the turbinates appearing pale. The patient states that this is especially bothersome during spring months; however, it also occurs to some degree during the fall.

Question
Based on the history and physical examination findings, what is the most appropriate first-line clinical intervention at this time?

Answer Choices
1 Oral antihistamines
2 Oral decongestants
3 Intranasal decongestants
4 Intranasal corticosteroids
5 Oral steroids

Intranasal corticosteroids
Explanation
The scenario above is describing a common presentation of allergic rhinitis, most likely leaning more towards the seasonal rhinitis. Based on this diagnosis, the most appropriate first-line treatment is intranasal corticosteroids (ICS). The use of ICS for treatment of allergic rhinitis has essentially been a revolution; evidence-based reviews have found ICS to be much more effective and much less expensive than oral antihistamines. They are also less sedating. Key components of ICS therapy that must be addressed with all patients when prescribing them include appropriate training on usage as well as educating the patient that it will typically take 2 or more weeks to note any improvement.Oral antihistamines are a viable alternative for treatment of allergic rhinitis, but they should not be considered first line. If the patient is unable to tolerate ICS or proper usage cannot be executed, oral antihistamines could potentially be initiated.

Oral steroids and oral decongestants are not indicated for the treatment of allergic rhinitis.

Intranasal decongestants should not be prescribed to any patients who are diagnosed with allergic rhinitis, and they should be discouraged in general. These over the counter nasal sprays will lead to a condition known as rhinitis medicamentosa after around 5 – 7 days of treatment; a characteristic of this condition is severe rebound nasal congestion. Increased and longer use of intranasal decongestants will further worsen this condition, creating a viscous and endless cycle.

A 38-year-old man presents with a firm, painless bump on his left eyelid. On examination, you note a 5 mm mass within the tarsus of the left eye. The skin is freely movable over the mass. The remainder of the eye exam is unremarkable. What is most likely diagnosis?
Answer Choices
1 Pterygium
2 Ectropion
3 Internal hordeolum
4 Chalazion
5 External hordeolum
Chalazion
Explanation The clinical picture is an example of a chalazion. A chalazion is a painless chronic mass in the eyelid.
Chalazions differ from hordeolums in that they are usually painless apart from the tenderness caused when they swell up, and are generally larger in size than styes.Ectropion is when the eyelid sags outwardly and the lid does not close well.

Hordeolum are acute, red, and painful.

Pterygium involves the sclera.

A 7-year-old boy presents to his pediatricians office with a 3-week history of clear nasal discharge, itchy eyes, and excessive sneezing. The family recently took in a stray cat, which sleeps with the boy. On examination of the nasal passage, you note swelling of the turbinates with clear drainage from the nares bilateral. On examination of the oral cavity, you note slight pharyngeal erythema, post-nasal drip, and no tonsillar edema.

Question
Based on your suspected diagnosis, if you were to microscopically exam the nasal secretions, you would expect to see an excess amount of which of the following?

Answer Choices
1 Eosinophils
2 Neutrophils
3 Lymphocytes
4 Monocytes
5 Histiocytes

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

A 50-year-old man with a past medical history of hypertension, asthma, hyperthyroidism, tachyarrhythmia, and aspirin allergy presents with chronic “nasal congestion,” nasopharyngeal itching, sneezing, and diminished sense of smell. His physical examination reveals normal vital signs, no lymphadenopathy, and normal eye, mouth, throat, and pulmonary exams. His nasal exam was noteworthy for reduced patency, diminished sense of smell, and for the findings on internal speculum exam in the image below.

Question
What is the most effective pharmacological treatment of this patient’s condition?

Answer Choices
1 Ipratropium bromide (Atrovent) nasal spray
2 Beclomethasone (Beconase) nasal spray
3 Fexofenadine (Allegra) tablets
4 Clindamycin (Cleocin) tablets
5 Pseudoephedrine (Sudafed) tablets

Beclomethasone (Beconase) nasal spray
xplanation
This patient is demonstrating signs and symptoms consistent with a nasal polyp and contributory allergic rhinitis. They present as yellowish boggy masses of hypertrophic mucosa and are associated with long-standing allergic rhinitis.Intranasal corticosteroids are the mainstay of treatment of allergic rhinitis. Intranasal corticosteroid sprays have revolutionized the treatment of allergic rhinitis. Evidence-based literature reviews show that these are more effective (and frequently less expensive) than nonsedating antihistamines. Patients should be reminded that there may be a delay in onset of relief of 2 or more weeks. Corticosteroid sprays may also shrink hypertrophic nasal mucosa and nasal polyps, thereby providing an improved nasal airway and osteomeatal complex drainage. Because of this effect, intranasal corticosteroids are critical in treating allergy in patients prone to recurrent acute bacterial rhinosinusitis or chronic rhinosinusitis.

Intranasal anticholinergic agents, such as ipratropium bromide 0.03% or 0.06% sprays (42-84 mcg per nostril 3 times daily), may be helpful adjuncts when rhinorrhea is a major symptom. Ipratropium nasal sprays are not as effective as intranasal corticosteroids for treating allergic rhinitis but are useful for treating vasomotor rhinitis.

In general, first- and second-generation antihistamines have been shown to be effective at relieving the histamine-mediated symptoms associated with allergic rhinitis (e.g., sneezing, pruritus, rhinorrhea, ocular symptoms), but are less effective than intranasal corticosteroids at treating nasal congestion. Antihistamines offer temporary, but immediate, control of many of the most troubling symptoms of allergic rhinitis. Over-the-counter antihistamines include nonsedating loratadine (10 mg orally once daily), fexofenadine (60 mg twice daily or 120 mg once daily), and minimally sedating cetirizine (10 mg orally once daily).

Clindamycin is an antibiotic and not appropriate for non-infections conditions.

Oral and topical decongestants (such as Sudafed) improve the nasal congestion associated with allergic rhinitis by acting on adrenergic receptors, which causes vasoconstriction in the nasal mucosa, resulting in decreased inflammation. The abuse potential for pseudoephedrine should be weighed against its benefits. Common adverse effects that occur with the use of intranasal decongestants are sneezing and nasal dryness. Duration of use for more than 3 to 5 days is not usually recommended, because patients may develop rhinitis medicamentosa or have rebound or recurring congestion. Because oral decongestants may cause headache, elevated blood pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia, patients with underlying cardiovascular conditions, glaucoma, or hyperthyroidism should only use these medications with close monitoring.

A 10-day-old male infant presents with bilateral conjunctivitis with moderate white discharge. He is acting normally, has no fever, and is feeding well. He was born full term via vaginal delivery without any complications. His mother had prenatal care starting at 12 weeks. He has been gaining weight well. On exam, he is alert and active.

Question
What is the most likely cause of this infant’s conjunctivitis?

Answer Choices
1 Chlamydia trachomatis
2 Herpes simplex
3 Neisseria gonorrhoeae
4 Silver nitrate
5 Coxsackievirus

Chlamydia
Explanation
Ophthalmia neonatorum is a form of conjunctivitis occurring in infants younger than 4 weeks. The usual incubation period for C. trachomatis is 5 – 14 days and 2 – 5 days for N. gonorrhoeae.Conjunctivitis due to silver nitrate drops usually occurs within 6 – 12 hours after birth. Staphylococcus aureus can also cause ophthalmia neonatorum.

Since this infant’s mother had appropriate prenatal care, she most likely would have had a c-section if she had active herpes lesions.

Coxsackievirus is not a common cause of conjunctivitis in neonates.

A 17-year-old baseball player presents to the clinic after being struck in the eye with a baseball. On examination, you note bright red blood in the anterior chamber.

Question
What is your initial diagnosis?

Answer Choices
1 Corneal abrasion
2 Pinguecula
3 Retinal detachment
4 Hyphema
5 Hypopyon

Hyphema
Explanation
The clinical picture is suggestive of a hyphema. Hyphema is defined as hemorrhage into the anterior chamber.Patients with a corneal abrasion note severe pain and photophobia following a history of a traumatic event to the affected eye.

Pinguecula is a yellow, elevated conjunctival nodule; it is commonly located on the nasal side of the eye.

Most retinal detachments occur spontaneously, and blood in the anterior chamber is not found.

Hypopyon is described as pus (white and cloudy fluid) in the anterior chamber; it usually follows a fungal infection.

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

Loss of cochlear hair cells

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

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

Question
What is the most likely cause of this patient’s condition?

Answer Choices
1 Oral candidiasis
2 Herpetic gingivostomatitis
3 Herpangina
4 Nursing bottle caries
5 Foreign body impaction

Herpetic gingivostomatitis
Explanation
Herpetic gingivostomatitis, caused by herpes simplex virus type 1, is the most common cause of stomatitis in children 1 – 3 years of age. Symptoms may appear abruptly, with high fever, drooling, fetid breath, and refusal to eat, as noted in the above vignette. However, the fever may precede the oral lesions by 2 – 3 days and presage to a more insidious onset of the disease. The tongue, cheeks, and gingiva are most commonly affected, but the entire oral cavity may be involved. These areas can present with ulcers that are yellowish-gray in color, and the gingiva may be quite friable. Drooling may be present secondary to the pain associated with chewing and swallowing, and dehydration is a real concern in the management of the patient. Cervical and submaxillary adenitis is common. The acute phase may last up to 1 – 2 weeks. Treatment consists of measures to relieve the pain and facilitate the intake of fluids for adequate hydration.Oral candidiasis (thrush) typically presents in the infant period and is usually caused by the yeast Candida albicans. This common affliction presents with white curd-like plaques on the oropharyngeal mucosa and tongue. Scraping the plaques may reveal an erythematous base. Treatment is usually accomplished with oral nystatin. It may be seen in older infants and children on antibiotic treatment or with immunodeficiencies.

Herpangina is usually associated with a prodrome of fever, headache, and occasional emesis. Lesions are characteristically 1 – 3 mm in diameter, present as vesicles and ulcers, and are yellow-white in color. Each lesion is surrounded by an erythematous halo up to 10 mm in diameter. The lesions are most always found on the anterior tonsillar pillars, as well as the uvula, soft palate, and tonsils. The anterior mouth is rarely affected. The illness is caused by members of the Enterovirus family and the affected children do not appear as toxic as those that have herpes gingivostomatitis. Treatment is supportive and the acute phase lasts 3 – 6 days.

Nursing bottle caries is relatively common, and it is seen in patients that sleep with a bottle in their mouth. These children present with significant erosion of the enamel of the anterior dentition. Treatment typically consists of extraction of severely affected teeth to prevent pain and spread of infection of contiguous tissues.

Impaction of a foreign body would lead to pain, edema, and erythema of only a localized portion of the gingivae and not the widespread inflammation noted in the vignette. Difficult cases should be referred to a dentist for further treatment.

A 10-year-old boy presents to your office with chronic otitis media with accompanying purulent discharge occurring over the past 6 months. He is very irritable, and his mother has been increasingly frustrated that he has not completely responded to the treatments.

Question
Which of the following organisms is most likely associated with this patient’s condition?
Answer Choices
1 Haemophilus influenzae
2 Pseudomonas aeruginosa
3 Streptococcus pneumoniae
4 Mycoplasma pneumoniae
5 Enterococcus faecalis

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

A 69-year-old man presents to his physician with a 3-month history of white oral lesion. Exam findings are suspicious for oropharyngeal cancer.

Question
What is the most common type of oropharyngeal cancer?

Answer Choices
1 Adenocarcinoma
2 Basal cell carcinoma
3 Squamous cell carcinoma
4 Papillary carcinoma
5 Medullary carcinoma

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

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

Answer Choices
1 Blepharitis
2 Chalazion
3 Entropion
4 Hordeolum
5 Ectropion

Hordeolum
Explanation
The clinical picture is suggestive of hordeolum, which is an infection of the lid glands. The most common causative agent is staphylococcus aureus, which may either be acute or subacute. When the Meibomian glands are infected it is referred to as internal hordeolum, wherein the lesion tends to be large and extend to the skin or conjunctival surface. If it affects the glands of Zeis and Moll, it is referred to as an external hordeolum or stye. It is smaller, more superficial, and points to the lid margins. Treatment, like any abscess, is warm compresses and surgical drainage (if needed). Topical antibiotics are also used. If left untreated, it may progress to cellulitis of the lid or orbit, which requires systemic antibiotics. Recurrence is also frequent, and children with recurrent styes should be evaluated for an immunologic problem.Blepharitis is an inflammation of the lid margins, which is characterized by redness and a scaling or crusting lesion. It is initially manifested by itching, irritation and burning sensation. It is recurrent, chronic, and usually bilateral. In cases of the seborrheic type, the scales are greasy, erythema is less, and ulceration seldom occurs. In cases of the staphylococcal type, ulceration is common; lashes may fall out, and it is often accompanied by conjunctivitis and superficial keratitis. Most of the blepharitis is of mixed type. Application of antistaphylococcal agent or sulfonamides directly to the lids daily is the treatment of choice. Daily cleaning of the lid with moist cotton applicator to remove scales and crusts is very helpful.

Chalazion is an inflammation of the meibomian glands characterized by a firm nodule on the upper eyelid, which is non-tender. It differs from hordeolum because it does not have the presence of inflammatory signs. Excision is recommended if the nodule is large enough to cause astigmatism by exerting pressure on the globe. Some cases subside spontaneously.

Entropion is a condition in which the lid margin is directed inwards. It usually causes discomfort and corneal damage because the eyelashes are also turned inwards. It is most commonly caused by scarring due to inflammation seen in trachoma; it may also result from Steven-Johnson-syndrome. Surgery is effective.

Ectropion is the opposite of entropion, in which the lid margin is turned outwards or everted; it is associated with an overflow of tears, maceration of the lid skin, inflammation of exposed conjunctiva, and/or superficial exposure keratopathy. Scarring from inflammation, burns, trauma, or orbicularis muscle weakness from facial palsy are the common causes. Surgical correction is necessary to protect the cornea.

A previously healthy 13-year-old boy presents with a 2-day history of sore throat and fever. On examination, his temperature is 102.4°F. He demonstrates a ‘hot potato voice’, and he is drooling. Examination of the throat is initially difficult because of trismus, but reveals a fluctuant left tonsil that is displaced medially, with erythema and edema of the soft palate. The uvula is deviated to the right. Tender cervical adenopathy is noted on the left. What is the most appropriate treatment option?

Answer Choices
1 Oral penicillin
2 Throat culture and treat if positive for Group A streptococcus
3 Intravenous antibiotics and surgical consultation
4 Intravenous antibiotics alone
5 Intramuscular penicillin

Intravenous antibiotics and surgical consultation
Explanation
A peritonsillar abscess results from a complication of acute tonsillitis. Usual etiologic agents include group A streptococci, Staphylococcus aureus, Streptococcus pneumoniae, and oral anaerobes. The infections have a rapid onset, and they are accompanied by fever, severe sore throat, trismus, drooling, alterations in speech and dysphagia. The tonsil is unilaterally displaced medially with erythema and edema of the soft palate. Uvular deviation may be deviated to the opposite side. The infection is usually unilateral, but can be seen bilaterally in up to 10% of cases.Therapy consists of intravenous antibiotics and surgical drainage of the abscess. Some surgeons may opt for serial aspirations of the abscess. Occasionally the infection may be seen early in the course and intravenous antibiotics are all that is required. However, this patient has frank abscess formation and, therefore, would require surgery.

Oral or intramuscular antibiotics are not indicated initially. Throat culture may help guide therapy, but should never be a replacement for hospitalization and surgical consultation. Complications include upper airway obstruction, aspiration pneumonia due to rupture of the abscess, and spread to the retropharyngeal or mediastinal spaces. Tonsillectomy may be done in an elective basis 3 to 4 weeks after the inflammation resolves. Acute tonsillectomy may be performed for significant airway obstruction or other complications.

A 19-year-old woman presents for management of seasonal allergic rhinitis. Her symptoms begin in the spring peak in the late summer/early fall, and have worsened over the last 2 to 3 years. She has taken over-the-counter (OTC) diphenhydramine (Benadryl) 25 mg in the past, which controlled her symptoms well. However, her use of the medication was impaired by the drowsiness she experienced. Currently, she takes loratidine (Claritin) 10 mg daily, but she has not experienced any improvement in her symptoms.

Question
What medication is the best choice to initiate next in this patient?

Answer Choices
1 Cetirizine (Zyrtec) 10 mg once daily by mouth
2 Mometasone furoate (Nasonex) 100 mcg (2 sprays) once daily per nostril
3 Ipratropium bromide 84 mcg (2 sprays) per nostril 3 times daily as needed
4 Oxymetazoline 0.05% 2 sprays per nostril every 12 hours
5 Amoxicillin 875 mg 2 times daily for 10 days

Mometasone furoate (Nasonex) 100 mcg (2 sprays) once daily per nostril
Explanation
The treatment options for patients with allergic rhinitis are numerous, and choosing which medication to use in a particular patient is based on his/her clinical symptomatology as well as its timing, efficacy, cost, and side effects.Intranasal corticosteroid sprays (e.g., mometasone furoate, fluticasone propionate/Flonase, etc.) have revolutionized the treatment of allergic rhinitis, and evidence-based literature shows that these medications are more effective than non-sedating antihistamines. In some cases, they are also less expensive. Because intranasal corticosteroid sprays also can shrink hypertrophic nasal mucosa seen in allergic rhinitis, increasing airway patency and enhancing drainage, these medications are also crucial in treating allergy patients prone to recurrent sinusitis. Side effects are limited, with epistaxis being the most bothersome.

Numerous over-the-counter (OTC) and prescription antihistamines are available. First generation antihistamines (diphenhydramine, brompheniramine, and chlorpheniramine) offer immediate but temporary control of many of the most troubling symptoms of allergic rhinitis. While these medications are inexpensive, they are usually associated with higher rates of drowsiness. Second generation antihistamines (cetirizine, fexofenadine (Allegra), loratadine, and desloratadine (Clarinex)) boast less sedation, but still can cause some levels of drowsiness and are usually more expensive, even those that are now over the counter (loratadine and cetirizine). Other potential side effects of oral antihistamines include xerostomia (dry-mouth), dizziness, decreased urination, and blurred vision.

Intranasal anticholinergic agents (ipratropium bromide) can be helpful as adjunct therapy when rhinorrhea is a major symptom. However, these nasal sprays are not as effective as intranasal corticosteroids for treating allergic rhinitis and are more useful for treating vasomotor rhinitis.

Oxymetazoline is an intranasal alpha agonists that causes vasoconstriction. It may be used for relief of nasal congestion caused by allergic rhinitis. However, it is not recommended to be used long-term, owing to the risk of rebound vasodilation and development of dependence.

As stated above, allergy patients can be prone to both acute and recurrent/chronic bacterial rhinosinusitis as a result of allergy-induced hypertrophy of the nasal mucosa and impaired osteomeatal complex drainage. While antibiotics (e.g., amoxicillin) may be necessary in these patients to treat the associated infection, they are not indicated in the current care of this patient.

A patient presents with epistaxis. What in the history and physical is most important to obtain?

Answer Choices
1 Airway patency
2 History of easy bruising
3 Signs of facial trauma
4 The age of the patient
5 The color of the blood

airway patency
Explanation
Many aspects of the history and physical are important to evaluation of epistaxis (or nose bleeds). However, the most urgent and important factors initially are assuring airway patency and hemodynamic stability. In cases of severe trauma or posterior epistaxis, bleeding can be brisk and compromise the airway.History of easy bruising can help establish the possibility of a bleeding disorder as the pathology behind the patient’s epistaxis.

Signs of facial trauma (as well as history of trauma) help the clinician to assess the cause of the epistaxis and address other potential injuries or conditions.

The age of the patient is not particularly helpful in evaluation of epistaxis. In some cases, pediatric patients may be more likely to put foreign bodies in their noses, and elderly patients may be slightly higher risk for posterior epistaxis.

The color of the blood is not helpful in evaluation of epistaxis.

A 41-year-old man presents for evaluation of hearing loss. He states that he is having more difficulty in his right ear than his left. He began to notice this about 6 months ago, when while talking on his cell phone, he had to routinely switch to his left ear because of difficulty understanding the words while listening with his right ear. He states that he has had ear drainage for approximately 6 months. He also states that he was in the Navy for a few years and as a recreation activity took up scuba diving. He recalls multiple ear infections during his time in the Navy.

Question
During the otoscope examination, you note deep retraction pockets, a white mass behind the tympanic membrane, and focal granulation at the peripheral of the tympanic membrane. What is the most appropriate treatment for this patient?

Answer Choices
1 10 days of therapy with 2nd generation cephalosporin
2 14 days of therapy with an otic solution of antimicrobials and corticosteroids
3 Close observation and follow-up in 2 weeks
4 Close observation and referral to an otologist for custom made ear plugs
5 Referral to an otolaryngologist for surgical intervention

Referral to an otolaryngologist for surgical intervention

Explanation
The treatment for cholesteatoma is surgical removal or marsupialization of the sac. This should be performed by a specialist.

Antibiotics and/or steroids are not effective treatment for cholesteatomas.

Observation and follow-up or ear plugs are not recommended since the cholesteatoma may cause destruction of the middle ear ossicles and spread to the mastoid process, worsening the condition.

A 22-year-old woman presents to her primary care physician. Over the last few weeks, she has had nasal congestion, sneezing, and itchy watery eyes. She denies coughing, fever, rhinorrhea, and malaise. Examination reveals pale nasal turbinates.

Question
What is the most effective treatment in this patient?

Answer Choices
1 Oral diphenhydramine
2 Oral loratadine
3 Fluticasone spray
4 Afrin spray
5 Oral azithromycin

Fluticasone spray
Explanation
Fluticasone spray is correct. Based on the patient’s history and the presence of pale nasal turbinates on examination, the patient is suffering from allergic rhinitis. Fluticasone is a corticosteroid spray that decreases nasal mucosal inflammation. Corticosteroid sprays have proven to be more effective than oral antihistamines in the treatment of allergic rhinitis.Oral diphenhydramine and oral loratadine are both incorrect. These agents are anti-histamines. Diphenhydramine is a first generation antihistamine, whereas loratadine is a newer agent that causes less sedation than diphenhydramine. While antihistamines may alleviate symptoms of allergic rhinitis, corticosteroid sprays are more effective.

Afrin spray is incorrect. Afrin is a nasal decongestant. The use of nasal decongestants long-term can actually cause rebound congestion, thereby worsening symptoms in the long run.

Oral azithromycin is incorrect. The patient does not demonstrate signs of bacterial upper respiratory infection, so antibiotics should not be given.

A 22-year-old woman presents because she developed a 101 degree fever this morning. She has a 2-week history of rhinorrhea, congestion, and headache. She states that her rhinorrhea was initially clear and actually improved after 5 days, then returned and developed into a green color. Her headache is felt in the forehead and cheeks and worsens when she bends over.

Question
What is the likely causative pathogen of her illness?

Answer Choices
1 Rhinovirus
2 Adenovirus
3 Streptococcus pneumoniae
4 Pseudomonas aeruginosa
5 Staphylococcus aureus

Strep pneumoniae
Explanation
The correct answer is Streptococcus pneumoniae. Given her symptoms of rhinorrhea accompanied by sinus pressure, she is likely suffering from sinusitis. While viruses cause the majority of cases of sinusitis, the patient’s clinical picture is more suggestive of a bacterial etiology for the following reasons: first, her duration of symptoms is longer than 10 days; second, her clinical condition improved then worsened again, suggesting that she may initially had a virus which allowed for a secondary bacterial infection to develop; and third, fever and purulent nasal discharge are present, both of which are more likely with bacterial sinusitis. Of the above bacterial causes, Streptococcus pneumoniae is the most common causative agent. Other streptococci species, as well as Haemophilus influenzae, are also common causes of bacterial sinusitis.Rhinovirus and adenovirus are both incorrect. While most cases of sinusitis are viral in nature, the patient’s clinical picture is more suggestive of a bacterial cause.

Pseudomonas aeruginosa is not a common cause of sinusitis.

Staphylococcus aureus may cause sinusitis, but Streptococcus pneumoniae is more common.

An 18-year-old female college student presents with a 2-day history of severe left ear pain. In the last 5 hours, the pain has become intolerable. Initially, the ear had an intense period of itchiness. Her history is significant for being a member of the college swim team. An examination of the ear canal is remarkable for the presence of edema and redness. A culture swab of the ear canal is performed. The patient is discharged with a course of treatment consisting of polymyxin with a steroid in an acid vehicle, and she is told to return if the symptoms do not subside within the next day. The next day, the microbiology laboratory isolates isolates a Gram-negative bacillus; it is oxidase positive and citrate positive. It does not ferment carbohydrates, and it produces a blue-green pigment. What is the cause of this patient’s external otitis?

Answer Choices
1 Moraxella catarrhalis
2 Pseudomonas aeruginosa
3 Streptococcus pneumoniae
4 Haemophilus influenzae
5 Bacteroides fragilis

Pseudomonas A
Explanation
Pseudomonas aeruginosa is a Gram-negative facultative bacilli that grows on MacConkey as a nonlactose fermenter (colonies are not pink). Colonies can appear to have a blue to purple hue due to the production of pigments, and they may also produce a grape-like odor. The organism is oxidase positive, citrate positive, and does not ferment carbohydrates. The organism is a major pathogen and a common cause of nosocomial infections. Because it is a common nosocomial pathogen, they tend to multiply resistant organisms when isolated in the hospital setting. The organism can cause infections in all areas of the body, and these infections can range from mild to life threatening in severity. Pseudomonas aeruginosa infections of the ear are associated with swimming (“swimmer’s ear”), an external otitis. Injury, wet humid conditions, inflammation, and maceration can predispose the external auditory canal to Pseudomonas aeruginosa infections. External otitis due to Pseudomonas aeruginosa is common in humid southern climates.Moraxella catarrhalisis a Gram-negative cocci that is relatively plump and occurs in pairs. The organism was until recently called Branhamella catarrhalis. Moraxella catarrhalis is oxidase positive, catalase positive, non-motile, oxidation and fermentation glucose negative, and nitrate negative. Growth is good on blood and chocolate agar but variable on MacConkey agar. Moraxella catarrhalis is generally resistant to penicillin due to the overwhelming incidence of B-lactamase production among various strains. The organism is a saprophytic organism of the upper respiratory tract and occasionally of the female genital tract. It is a commonly isolated pathogen in pediatric patients and immunocompromised or debilitated adults (especially in the hospital setting). Moraxella catarrhalis plays an important role in otitis media and sinusitis, as well as nosocomial pneumonia and various other infections.

Streptococcus pneumoniae is a Gram-positive cocci that occurs in pairs and is “lancet” shaped. The organism is catalase negative, alpha-hemolytic on blood agar, grows best at 35° C with a 5% CO2 atmosphere, is negative for bile esculin as well as failing to grow in 6.5% NaCL, and is bile soluble. Streptococcus pneumoniae is the number 1 cause of acute otitis media (the 2nd being Haemophilus influenzae, and the 3rd being Moraxella catarrhalis). In children, it is the cause of otitis media in 40 – 50% of the cases in which an etiological agent is isolated. In adults, it is found to also be the major cause of otitis media. Prior viral respiratory infections are thought to be contributory to the predisposition and development of Streptococcus pneumoniae otitis media due to the congestion of the opening to the eustachian tube. The organism can cause a variety of other infections including bacteremia and meningitis.

Haemophilus influenzae is a Gram-negative cocco-bacillus that is small and light staining. It will only grow on chocolate agar due to the organism requiring the presence of growth factors hemin and NAD for growth. In chocolate agar media, the growth factors (found in red blood cells) are released in the media, while in blood agar media, the growth factors are trapped within the red cells and thus are unavailable to Haemophilus influenzae. Haemophilus influenzae is the 2nd most common cause of otitis media. Otitis media due to Haemophilus influenzae most commonly occurs between the ages of 6 months to 5 years. The organism can cause a variety of other infections, most importantly meningitis in children as well as sinusitis.

Bacteroides fragilis is a Gram-negative anaerobic bacilli. Biochemical reactions of significance are growth at 20% bile, indole positive, and resistance to kanamycin/vancomycin/colistin. The organism will only grow under strict anaerobic conditions. It can be a cause of chronic otitis media infections and is frequently found concomitantly with other organisms such as streptococci, staphylococci, and Pseudomonas aeruginosa.

A 12-year-old girl, diagnosed using a quick antigen test as having a pharyngeal infection due to Streptococcus pyogenes, also presents with a rash that is on the upper part of the chest and trunk. This rash is caused by Streptococcus pyogenes producing what?

Answer Choices
1 Exfoliative toxin
2 Elastase
3 Enterotoxin
4 Erythrogenic toxin
5 Streptolysin

Erythrogenic toxin
Explanation
Erythrogenic toxin (streptococcal pyrogenic exotoxin) is produced by Streptococcus pyogenes. The toxin is responsible for the rash of “scarlet fever”. The toxin has been shown to exhibit pyrogenicity and cytotoxicity. It usually appears at the 2nd day of infection, on the upper part of the chest, spreading to the rest of the trunk out towards the rest of the body, with the palms, soles, and face being spared.Exfoliative toxin, produced by Staphylococcus aureus, is responsible for scalded skin syndrome (SSS), wherein the patient appears to have acquired a burn of the skin. There is extensive scalding and flaking desquamation of the epidermis. The syndrome is especially common in infants and small children.

Elastase is an extracellular protease that is produced by Pseudomonas aeruginosa. The protease is associated with the organism’s virulence due to tissue destruction and bacterial invasion. Elastase is necrotizing to the skin, cornea, and lung; it is capable of producing hemorrhage.

Enterotoxin is produced by various bacteria. In Clostridium perfringens, the production of this toxin causes the symptoms of food poisoning. Clostridium perfringens type A is most associated with this toxin production. Enterotoxin is thought to act as a superantigen, which causes a massive release of inflammatory mediators and induces a calcium ion-dependent breakdown of permeability.

Exotoxin (diphtheria toxin) is produced by Corynebacterium diphtheriae. The toxin inhibits protein synthesis in mammalian cells, but not bacteria. It affects all cells in the body; the heart, nerves, and kidney are impacted the most.

A 22-year-old man presents with a 3-month history of worsening diarrhea that comes and goes. While performing a comprehensive oral exam, you note 2 lesions on the buccal mucosa on the right side of the oral cavity. You document these lesions as 2 round lesions that measure approximately 2 mm in diameter and have a white-yellow center, which is surrounded by a red halo. Pertinent positives also include a reduced appetite, abdominal pain, and cramping.

Question
Based on these current history, physical exam findings, and possible disease pathologies, what diagnosis is very high on your differential?

Answer Choices
1 Ulcerative colitis
2 Cholecystitis
3 Crohn’s disease
4 GERD
5 Colon cancer

Chrons’ disease

Explanation
The patient above has an aphthous ulcer, also sometimes referred to as a canker sore or aphthous stomatitis. These painful, open sores are found in the oral cavity and are the most common form of mouth ulcer. Many times these lesions are described as having a white or yellow center and are surrounded by a bright red area. They are benign, noncancerous, noninfectious, and many times, the cause is unknown; however, aphthous lesions are common extra intestinal manifestations found in patients suffering from Crohn’s disease.

Patients who have the other form of inflammatory bowel disease, ulcerative colitis, will not typically develop such signs as aphthous ulcers. More common signs of cholecystitis include right-sided abdominal pain, vomiting, fever, a positive Murphy’s sign, or even palpable gallbladder.

GERD symptoms generally surround the complaint of heartburn, although it can cause issues such as asthma, chronic cough, chronic laryngitis, sore throat, or even non-cardiac chest pain.

Colon cancer can present with anemic qualities on serology tests, abdominal pain, changes in bowel habits, as well as hemoccult-positive stool.

A 5-year-old child with no known drug allergies is diagnosed in your clinic with bilateral acute otitis media. Which of the following is the drug of choice?

A levofloxacin
B nitrofurantoin
C amoxicillin
D doxycycline
E gentamicin

amoxicillin
First choice antibiotic treatment for acute otitis media includes a 10-day course of amoxicillin (80 to 90 mg/kg/day in two divided doses) or a combination of erythromycin (50 mg/kg/day) and a sulfonamide (150 mg/kg/day). Reasons for amoxicillin therapy include spectrum of activity including both susceptible and intermediate resistant S pneumoniae, safety, cost, and tolerability.

A 58-year-old female presents to the outpatient clinic complaining of 1 week of rhinorrhea, nonproductive cough, and hoarseness. On physical exam she is noted to have erythematous nasal mucosa and decreased phonation without significant nasal discharge, sinus tenderness, pharyngeal erythema, or lymphadenopathy. Which of the following is the most likely causative organism for this patient’s condition?

A Clostridium diphtheriae
B Group A streptococcus
C Moraxella catarrhalis
D Mycobacterium tuberculosis
E Rhinovirus

rhinovirus
The presence of acute hoarseness associated with an upper respiratory infection is consistent with laryngitis, which may be caused by all of the organisms above (A-E), but most likely has a viral (E) etiology.

A 78-year-old Caucasian female has a 3-year history of stiffness and achiness of bilateral shoulders and hips. She has been tested for rheumatoid arthritis in the past and has been found negative. Multiple radiographs of her hips and shoulders are unremarkable. She admits that she was placed on prednisone for an allergic reaction and noted a temporary resolution of her symptoms. For the past two weeks she complains of increasing symptoms now involving her neck and pain in her jaw with chewing. Today she noticed that her scalp is sore when she brushed her hair on the right side. What is the most feared complication of this condition that may be prevented with prompt diagnosis and treatment?

A blindness
B costovertebral angle (CVA)
C aneurysm
D arm claudication
E polymyalgia rheumatica (PMR)

Blindness
The correct answer is (A). This patient has long standing symptoms of PMR with current symptoms suggestive of giant cell (temporal) arteritis. Visual loss is the most feared complication of temporal arteritis, but it can be prevented by prompt initiation of high-dose prednisone. PMR often occurs with or prior to development of temporal arteritis and is not considered a complication. Large vessel involvement–which may result in choices (B), (C), and (D)–is less common than temporal artery involvement in GCA. The patient does not have symptoms of large vessel involvement.

The source of most cases of epistaxis comes from what anatomic location?

A Posterior nasal septum
B Frontal sinuses
C Anterior nasal septum
D Anterior palate
E Maxillary sinuses

Anterior nasal septum
95 percent of epistaxis come from Kesselbach’s plexus, which is a superficial, fragile group of arterioles and veins that are the most likely cause of nosebleeds. Five percent are posterior bleeds that originate along the sphenopalentine artery.

A 2-year-old child presents to the pediatric office for a well child visit. The presence of which of the following risk factors places this child at high-risk for dental caries?

A Child receives fluoride varnishes
B Maternal smoking
C Parents are of low socioeconomic status
D Single parent home
E Use of fluoridated water

Parents are of low socioeconomic status
Factors that place children at high-risk for dental caries include the presence of white spots, cavities, or fillings on exam; mother/primary care giver having cavities; mother/primary caregiver being of low socioeconomic status (C); frequent between-meal sugar-containing snacks/beverages; or being put to bed with a bottle that contains sugary beverage. Fluoride (A) and fluoridated water (E) are protective. Maternal smoking (B) and single parenting (D) are not validated risk factors for dental caries.

Which of the following is indicated for treatment of oral thrush?

A Prednisone
B Penicillin
C Nystatin
D Cephalexin
E Acyclovir

nystatin
Oral candidiasis, also referred to as oral thrush, is most commonly seen in infants and immunocompromised patients. It can also occur in asthma patients being treated with a metered dose steroid inhaler. The antifungal treatment of choices is nystatin suspension. Other agents that can be used are fluconazole and clotrimazole oral troches.

A 54-year-old male presents to you with a sudden onset of severe left eye pain and blurred vision. He states that he is nauseated and vomited twice. He denies any history of eye problems, other than having to wear glasses for reading. His only recent problem has been a mild upper respiratory infection, for which he is taking an over-the-counter decongestant. On physical exam, the vision in the affected eye is 20/200. His pupil is mid-sized and non-reactive to light, and the conjunctiva is markedly injected. What diagnosis must you consider first?

A Retinal detachment
B Central retinal artery occlusion
C Open angle glaucoma
D Angle closure glaucoma
E Optic neuritis

Angle closure glaucoma
Acute angle closure is characterized by sudden onset of severe eye pain, blurred vision, nausea, vomiting, visual halos, and headache. Physical exam findings can include conjunctival injection, a rock hard ocular globe on palpation, a cloudy cornea, and a mid-position fixed pupil. Normal intraocular pressure is below 21mm Hg. Acute angle closure glaucoma can develop pressures of 60 to 80mm Hg.

A 4-year-old boy presents to the outpatient clinic for a well child visit. Developmental assessment is normal. Upon visual acuity testing his vision is noted to be 20/30 right eye, 20/40 left eye, and 20/30 with both eyes. Which of the following is the most appropriate management of this child’s vision?

A Re-assess his vision in 3 months
B Re-assess his vision in one year
C Re-assess his vision prior to enrolling in kindergarten
D Refer to an optometrist
E Refer to a pediatric ophthalmologist

Re-assess his vision in one year
Pediatric ophthalmology referral criteria for 3- to 5-year-old children include visual acuity of less than 20/40 in either eye or greater than a two line difference between eyes, so referral to an optometrist (D) or pediatric ophthalmologist (E), which is preferred by the American Academy of Pediatrics, is not warranted and his vision can be re-assessed at his next well child visit in one year (B).

A 30-year-old female presents with a five day history of a sore throat. She denies cough or nasal congestion. She also denies vomiting or diarrhea. On physical exam, her temperature is 101˚F, the pharynx is red with tonsillar exudates, and she has tender anterior cervical lymphadenopathy. What is your next step?

A Perform culture and sensitivity
B Perform rapid strep
C Treat symptomatically with antipyretics
D Begin oral penicillin
E Begin oral ciprofloxacin

Begin oral penicillin
the centor criteria include fever, tonsillar exudates, tender anterior lymphadenopathy and lack of cough. These signs and symptoms highly suggest group A beta hemolytic strep. Treatment with penicillin would be the most appropriate step, especially if cost is a concern to the patient. Penicillin v potassium, 250 mg three times per day, or 500 mg twice daily for 10 days, is highly effective. Some studies show a five-day regime to be as effective.

A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following diagnostic studies should be performed as a result of this finding?

A Fasting blood glucose
B MRI of the eye and orbit
C Rapid plasma reagin (RPR)
D Serum cortisol level
E Serum thyroid stimulating hormone level

Rapid plasma reagin (RPR)

Congenital cataracts may result from transmission of maternal infections such as herpes simplex virus, cytomegalovirus, toxoplasmosis, or syphilis and require further evaluation for potential systemic infection. A quantitative RPR (C) should be performed to assess for congenital syphilis. Endocrine disorders such as diabetes (A), Cushing’s syndrome (D), or hypothyroidism (E) aren’t common causes of congenital cataracts.

A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following is the most appropriate management for this patient?

A Cataract surgery within the next 6 weeks
B Cataract surgery within the next year
C Observation every 3 months
D Observation every 6 months
E Observation every year

Cataract surgery within the next 6 weeks

Congenital cataracts that are large and affect visual acuity (e.g., central) must be surgically corrected within the first two months of life (A) to avoid the development of deprivation amblyopia. Observation (C, D, and E) or delayed surgery (B) may result in permanent deprivation amblyopia.

Jane, a 21-year-old female, was seen in the office 10 days ago and was diagnosed with perennial allergic rhinitis and sent home with instructions for increased fluids, decongestants, and nasal steroids. She returns today with worsened symptoms of malaise, low-grade fever, nasal discharge, cough that is worse at night, mouth breathing, early morning unilateral pain over sinuses, and congestion. Physical examination reveals thick purulent nasal discharge, postnasal discharge visible in the posterior pharynx, periorbital swelling, and tenderness of sinuses upon palpation. She is 36-weeks pregnant and allergic to penicillin. Of the following, what is the most appropriate antibiotic?

A amoxicillin
B trimethoprim-sulfamethoxazole
C clindamycin
D levofloxacin

clindamycin
Most patients with a diagnosis of acute rhinosinusitis based on clinical grounds improve without antibiotic therapy. The preferred initial approach in patients with mild to moderate symptoms of short duration is therapy aimed at facilitating sinus drainage, such as oral and topical decongestants, nasal saline lavage, and—in patients with a history of chronic sinusitis or allergies—nasal glucocorticoids. Adult patients who do not improve after seven days, children who do not improve after 10 to 14 days, and patients with more severe symptoms (regardless of duration) should be treated with antibiotics. Empirical therapy should consist of the narrowest-spectrum agent active against the most common bacterial pathogens, including S. pneumoniae and H. influenzae—e.g., amoxicillin. But amoxicillin is contraindicated in patients with urticarial reactions to penicillins, and quinolones are similarly contraindicated in pregnancy. trimethoprim-sulfamethoxazole is contraindicated in the third trimester of pregnancy. The best choice is clindamycin.

A 5-year-old boy presents to urgent care complaining of painful lesions in his mouth that have made eating difficult the past 2 days. The mother confirms he has been unable to eat for 48 hours, but has been able to sip water. On physical exam he has a temperature of 102.6º F; numerous small vesicles and ulcers on the buccal mucosa and tongue; inflamed gingiva; and tender anterior cervical adenopathy. Which of the following is the most likely causative organism?

A Coronavirus
B Coxsackie virus A16
C Group A beta-hemolytic strep
D Herpes simplex 1
E Rhinovirus

HSV 1
The classic presentation of initial infection with herpes simplex virus 1 (D) includes multiple small, painful vesicles or ulcers on the mucousa with gingival involvement, fever, and adenopathy. Coxsakie virus A16 (B) causes hand, foot, and mouth disease. Coronavirus (A) and rhinovirus (E) cause viral pharyngitis.

Which of the following diagnostic studies is indicated for a patient with amaurosis fugax?

A CT of the head
B Intraocular pressure
C Temporal artery biopsy
D Carotid ultrasound
E Ocular fluorescein angiogram

Carotid ultrasound
Amaurosis fugax is a monocular vision loss that appears like a curtain passing over the eye, and comes from carotid artery disease. A CT of the head is indicated for lateralizing stroke symptoms. Intraocular pressure is taken for evaluation of chronic or acute glaucoma. A temporal artery biopsy is taken if giant cell arteritis is suspected. An ocular fluorescein angiogram is done to evaluate retinal disorders.

A 45-year-old female presents with a sudden onset of vertigo, nausea, and vomiting. Upon physical exam, you note that she is holding on to the rails of the bed, and her pain gets worse when you attempt any movement of her head. Neurologic exam is grossly normal. Which combination of the following medications is indicated to treat the patient’s symptoms?

A Hydrochlorothiazide, lorezapam, and gentamycin
B Lorezapam, prochlorperazine, and diphenhydramine
C Scopolamine, aspirin, and cisplatin
D Metoclopromide, hydrochlorothiazide, and cyclobenzaprine
E Diazepam, hydrocodone, and hydrochlorothiazide

Lorezapam, prochlorperazine, and diphenhydramine

All other combinations include an ototoxic medication: furosemide, gentamycin, aspirin, and cisplatin. Treatment of acute vertigo is more effective using a combination of vestibular suppressants (benzodiazepines), anti-emetics (prochlorperazine), and anticholinergics (diphenhydramine or scopolamine).

A 66-year-old female has a chief complaint of vision loss in her left eye. She denies pain and states that this occurred over the past few hours. Her past medical history includes hypertension, high cholesterol, and peripheral vascular disease. Upon funduscopic exam, you note marked hemorrhages in all quadrants and disc edema. The contralateral eye shows only mild hypertensive vascular changes. What is your diagnosis?

A Macular degeneration
B Retinal detachment
C Central retinal artery occlusion
D Cerebrovascular accident
E Central retinal vein occlusion

Central retinal vein occlusion
A central retinal vein occlusion is characterized by a “blood and thunder” fundus, with marked hemorrhages, tortuous vessels, and optic disc edema.

A 43-year-old woman presents to the outpatient clinic complaining of right eye redness, photophobia, and pain. She notes some blurred vision and denies the presence of discharge. On physical exam her visual acuity is 20/20 left eye, and 20/60 right eye. Her right eye has circumcorneal injections and the pupil is 3 mm and responds poorly to light. Her left pupil is 5 mm and responds well. Which of the following is the most likely diagnosis?

A Acute conjunctivitis
B Acute anterior uveitis
C Acute closed-angle glaucoma
D Corneal abrasion
E Corneal ulcer

Acute anterior uveitis
The patient’s symptoms of right eye pain, blurred vision, and small, poorly reactive pupil with no discharge is most consistent with acute anterior uveitis (B). The symptoms are similar to corneal abrasion or ulcer (D and E), but the lack of a discharge and no history of trauma makes those diagnoses less likely.

A 42-year-old male with a past medical history of renal failure and diabetes type II presents with facial swelling and pain. He states that it has been getting worse since it started five days ago. He also states that the side of his cheek became acutely swollen and painful five days ago when he was eating. His physical exam reveals a markedly swollen left submandibular space, with a firm and tender 1.5 cm nodule, palpable near the mandible, on the left side. When pressed, pus is seen coming out of the submandibular salivary duct. What is the most likely diagnosis?

A Sialolithiasis
B Parotitis
C Ludwig’s angina
D Sialadenitis
E Dental abcess

Sialadenitis

The history and physical exam is consistent with suppurative sialadenitis. The preceding episode of pain and swelling while eating indicates that the patient may have a salivary duct stone, which predisposed the patient to the salivary gland infection. Ludwig’s angina is a bilateral submandibular and sublingual abcess, most often caused by infected mandibular molars. Parotitis is seen in mumps, a bilateral inflammation of the parotid glands caused by paramixovirus. Sialolithiasis are salivary duct stones without infection, are unilateral, and can affect the sublingual, submandibular, and parotid glands.

A 43-year-old woman presents to the outpatient clinic complaining of right eye redness, photophobia, and pain. She notes some blurred vision and denies the presence of discharge. On physical exam her visual acuity is 20/20 left eye, and 20/60 right eye. Her right eye has circumcorneal injections and the pupil is 3 mm and responds poorly to light. Her left pupil is 5 mm and responds well. Fluorescein staining of the eye is unremarkable and intraocular pressures are normal. Which of the following treatment regimens should be prescribed?

A Homatropine 5% solution four times daily
B Homatropine 5% solution four times daily and prednisolone 1% solution every 1 or 2 hours while awake
C Prednisolone 1% solution every 1 or 2 hours while awake
D Prednisolone 1% solution every 1 or 2 hours while awake and sulfacetamide 10% solution three times a day
E Prednisone 60 mg by mouth once daily

Homatropine 5% solution four times daily and prednisolone 1% solution every 1 or 2 hours while awake
The patient’s presentation of acute uveitis is best treated with topical corticosteroids and cycloplegics (B) once infectious causes (e.g., HSV) have been ruled out. The addition of a cycloplegic helps reduce pain. Antibiotic drops (D) aren’t indicated for acute uveitis.

A patient presents to your office with a sudden onset of headache, right eye pain, decreased visual acuity, nausea and vomiting. His intraocular pressure is 47. Which of the following classes of medications are indicated for treatment of this condition?

A Alpha agonists and antihistamines
B Alpha agonists and Beta blockers
C Mydriatics
D Cycloplegics
E Angiotensin converting enzyme inhibitors

Alpha agonists and Beta blockers

Ophthalmic alpha-agonists (brimonidine) and beta blockers (timolol) decrease aqueous humor production, and decrease intraocular pressure. They facilitate aqueous flow through outflow tract and the canal of Schlemm. Other acute treatments include prostaglandin analogs(latanoprost) and carbonic anhydrase inhibitors(acetazolamide). Mydriatics, cycloplegics(tropicamide) and antihistamines( diphenhydramine) can precipitate angle closure glaucoma in patients at risk. Angiotensin converting enzyme inhibitors are used for treating systemic hypertension.

A 45-year-old man presents to the clinic complaining of a lesion in the middle of his right lower eyelid margin that is obscuring his vision when he works on fly-tying or other detailed projects. On physical exam there is a 5 mm round lesion that lacks erythema or tenderness. The patient’s visual acuity is 20/20. Which of the following interventions is most appropriate for this patient?

A Apply warm compresses four times daily until resolution
B Apply bacitracin ophthalmic ointment 500 units/gram three times a day
C Aspirate the lesion
D Excise the lesion
E Take amoxicillin-clavulanate 875/125 mg by mouth two times a day for 10 days

Excise the lesion

The patient’s presentation is consistent with a chalazion that is best treated by surgical excision of the granulomatous tissue (D). Warm compresses (A), bacitracin ointment (B), and amoxicillin-clavulanate (E) are effective treatment options for hordeolum, or hordeoulum with associated preseptal cellulitis.

A 12-year-old male begins to sneeze, and develops itchy, watery eyes about 15 minutes after being exposed to a cat. There is no respiratory difficulty. What phase of allergic response is he in?

A Humoral
B Priming
C Cellular
D Seasonal
E Perennial

Humoral
The humoral or early phase occurs in the first 15 minutes of being exposed to an allergen. The symptoms are caused by release of histamine. The cellular phase is the late phase, and occurs after four to six hours of allergen exposure. Seasonal allergic rhinitis occurs in a regular pattern each year, corresponding to pollen exposure. Perennial rhinitis occurs year round, and may be more linked with indoor allergen exposures.

A 73-year-old female with type 2 diabetes, hypertension, and hyperlipidemia presents to the outpatient clinic complaining of left ear pain, and a yellowish-green, foul-smelling discharge that began about 3 weeks ago. On physical examination, the patient is afebrile and examination reveals a markedly edematous left ear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized. Which of the following is the most likely diagnosis?

A Auricular cellulitis
B Cerebrospinal fluid leakage
C Malignant otitis externa
D Otitis externa
E Serous otitis media with perforation

Malignant otitis externa
Malignant otitis externa (C) is a more serious form of otitis externa (D) that most commonly occurs in patients with diabetes and is most commonly caused by pseudomonas. The case scenario describes the location as the external auditory canal without significant involvement of the auricle (A). Serous otitis media with perforation (E) and CSF leak (B) would present with a clear drainage.

A 45-year-old male presents to your office complaining of severe unilateral eye pain with some photophobia for one day. He denies any history of trauma. On examination and with staining, you notice a dendritic lesion to the cornea, and an otherwise normal examination. Which of the following medications would be contraindicated in this patient?

A atropine ophthalmic drops
B azelastine ophthalmic drops
C levofloxacin ophthalmic drops
D prednisolone ophthalmic drops

This patient has herpes simplex keratitis is an important cause of ocular morbidity. The ability of the virus to colonize the trigeminal ganglion leads to recurrences precipitated by fever, excessive exposure to sunlight, or immunodeficiency. The dendritic (branching) ulcer is the most characteristic manifestation. More extensive (“geographic”) ulcers also occur, particularly if topical corticosteroids have been used. Ophthalmic corticosteroids in cases of suspected herpes simplex keratitis are contraindicated.

A 23-year-old male presents to the clinic complaining of left anterior neck pain that developed over the past week following recovery from an acute upper respiratory infection. On physical exam a tender mass is felt anterior to the left sternocleidomastoid muscle from the mandible inferiorly to the level of the cricoid cartilage. Which of the following is the most likely diagnosis?

A Branchial cleft cyst
B Dermoid cyst
C Peritonsillar abcess
D Salivary gland tumor
E Thryoglossal duct cyst

Branchial cleft cyst
The development of a neck mass in a young adult following URI is consistent with branchial cleft cyst (A) and thyroglossal duct cyst (E). The location of this mass away from the midline and anterior to the SCM is most consistent with branchial cleft cyst (A). The location of the mass and history are inconsistent with dermoid cysts (B), which are typically midline, peritonsillar abcesses (C), which would be located in the retropharyngeal space, and salivary gland tumors (D), which would be located in the parotid, submandibular, or submental salivary regions.

A 3-year-old girl presents to the otolaryngologist for evaluation of a persistent left ear infection and drainage that have failed to respond to multiple antibiotic regimens. Which of the following is the most likely causative organism for this patient’s condition?

A Aspergillus
B Chlamydia pneumoniae
C E. coli
D Streptococcus pneumoniae
E Staphylococcus aureus

Staphylococcus aureus

Chronic otitis media is typically caused by P. aeruginosa, H. influenzae, S. aureus (D), Proteus species, Klebsiella pneumoniae, or Moraxella catarrhalis. Aspergillus (A) and E. coli (C) are associated with otitis externa and streptococcus pneumoniae (D) is the most common bacterial cause of otitis media.

You are examining a 65-year-old male who complains of partial vision loss in his right eye. Besides obtaining visual acuity, what is the most important initial part of the physical exam to perform in order to evaluate his condition?

A Cover uncover test
B Consensual papillary response
C Extraocular movements
D Visual fields by confrontation
E Intraocular pressure

Visual fields by confrontation
When a patient complains of vision loss, all of the choices are important parts of the eye examination; the visual field by confrontation exam is a screen to detect visual field defects.

Which of the following is a risk factor for cholesteatoma formation?

A Acute otitis media
B Chronic tympanic membrane retraction
C Diabetes mellitus
D Hyperlipidemia
E Smoking

Chronic tympanic membrane retraction

Cholesteatomas result from negative pressure in the middle ear chronically retracting the pars flaccida (B). Acute otitis media (A) may lead to short-term TM retraction or perforation, but without perforation or the placement of PE tubes it is unlikely to lead to cholesteatoma formation. Diabetes (C), hyperlipidemia (D), and smoking (E) are not associated with this localized pathology.

The American Academy of Pediatrics (AAP) recommends which of the following treatments for a two-year-old child with an acute otitis media who has a fever of 103.7˚F, had an ear infection two months ago, and in whom you suspect penicillin-resistant strep bacteria?

A Amoxicillin 45 mg/kg, divided into BID-dosing and administered for 10 days.
B Amoxicillin 90 mg/kg, divided into BID-dosing and administered for 10 days.
C Amoxicillin-clavulanate 45 to 90 mg/kg, divided into BID dosing and administered for 10 days
D Cephalexin 20 mg/kg, divided into QID-dosing and administered for 10 days
E Ceftriaxone 50 mg/kg, IM daily for three days.

C Amoxicillin-clavulanate 45 to 90 mg/kg, divided into BID dosing and administered for 10 days
AAP recommends consideration of amoxicillin as a first-line anti-infective for antibiotic naïve patients, and those at low risk. For patients who have received antibiotics in the previous 90 days, or those who have been exposed in day care or a medical facility, escalating antibiotics to cover penicillin-resistant streptococcus bacteria—such as amoxicillin-clavulanate—and a higher dose should be a consideration.

A patient has a 2-day history of an itchy red left eye and marked tearing. There is no history of injury. On physical exam the conjunctiva appear markedly erythemic. What physical finding would help most in differentiating this as a viral conjunctivitis?

A Copious discharge
B Subconjunctival hemorrhage
C Pre-auricular lymph node
D Vesicular rash around the eye
E Punctate keratitis

Pre-auricular lymph nodes
A palpable pre-auricular lymph node is most often seen with viral conjunctivitis and rarely seen in bacterial conjunctivitis.

A 3-year-old boy presents complaining of left ear pain since early this morning. The mother states he has had cold symptoms for 3 days and awoke crying, with left ear pain, and a temperature of 102.6˚ F. Which of the following physical exam findings most accurately establishes the anticipated diagnosis?

A Fever greater than 101.5˚ F
B Immobile or hypo-mobile tympanic membrane
C Post-auricular adenopathy
D Tenderness with palpation of the external ear
E Tympanic membrane erythema

Immobile or hypo-mobile tympanic membrane

The diagnosis of acute otitis media is best established through the use of pneumatic otoscopy demonstrating decreased tympanic membrane mobility (B). Fever (A), pain with palpation of the auricle (D), and tympanic membrane erythema (E) are all non-specific findings.

A 45-year-old male presents with purulent discharge from his right ear for three weeks. He states that despite being treated by his family doctor for an ear infection one month ago, the problem continues to get worse. Upon exam, you note purulent discharge in the ear canal, an erythemic tympanic membrane, and a possible perforation. What are the pathogens most likely to culture positive?
A Strep pneumoniae
B Pseudomonas aeroginosa
C Escherichia coli
D Candida albicans
E Mycoplasma pheumoniae
Psuedomonas
The clinical vignette describes a chronic otitis media. Usually, this refers to a complication of acute otits media with perforation. Pathogens that culture from these infections are usually pseudomonas, proteus, or staphylococcus aureus. Strep pneumoniae is often seen in acute otitis media. E.coli is a urinary tract pathogen. Candida albicans is a cause of vaginitis, and mycoplasma is a respiratory pathogen.

A 30-year-old male presents to your office complaining of sinus and facial pain, congestion, and purulent nasal discharge for one month. He has been treated with two courses of different antibiotics by another provider, and does not feel any improvement in his symptoms. What diagnostic test is indicated?

A Plain sinus radiographs
B MRI
C Aspiration and culture of maxillary sinuses
D CT scan
E Ultrasound of sinuses

CT scan
A CT scan is the current preferred method for sinus imaging of chronic sinusitis. CT imaging has better visualization of mucosal thickening air-fluid levels and bone structures. Plain radiographs and CT scans are of limited use in acute sinusitis, because viral pathogens that cause sinus abnormalities are indistinguishable from bacterial causes.

A patient presents with a cerumen impaction. Which of the following is true when performing the Rinne- Weber test?

A Weber lateralizes to the affected ear
B Weber is equal in both ears
C Weber lateralizes to the unaffected ear
D Air conduction > Bone conduction in the affected ear
E Air conduction = Bone conduction in the affected ear

Weber lateralizes to the affected ear

For conductive hearing loss, the Weber will lateralize to the affected ear and bone conduction will be greater than air conduction. Conductive hear loss prevents sound from entering the inner ear due to obstruction in the external auditor canal and middle ear. Examples would be cerumen impaction and otitis media. Sensory neural hearing loss affects the inner ear and cranial nerve VIII. Weber will lateralize to the unaffected ear (normal ear) and Rinne will reveal Air conduction > Bone conduction.

An 18-year-old female presents with two weeks of severe sore throat and fatigue. Her exam shows an exudative tonsillitis. A mono-spot test is positive, and a rapid strep test is positive. Which of the following medications should be avoided?

A Erythromycin
B Clindamycin
C Cephalexin
D Ampicillin
E Prednisone

Ampicillin
Ampicillin should be avoided, because a high percentage of mononucleosis patients develop a fine, non-allergic maculopapular rash when given ampicillin class drugs. The remaining antibiotics are appropriate for treating group A strep. Prednisone is used to reduce the pain and inflammation associated with severe tonsillitis.

A 24-year-old intoxicated male presents to the emergency department after being in a fight. He was punched in the nose, and now has mild deformity of the nose and some epistaxis. An x-ray reveals a fractured nasal bone. During his physical exam, what must you look for in order to prevent permanent destruction of his nasal septum?

A Orbital fracture
B Posterior epistaxis
C Septal hematoma
D Facial fracture
E Deviated septum

Septal hematoma
A septal hematoma can cause ischemic necrosis of the nasal septal cartilage if not identified and drained. A deviated septum can be expected with a nasal bone fracture, and must be addressed by the otolaryngologist. Excessive epistaxis that does not resolve with direct pressure and anterior packing may indicate a posterior bleed.

What is the most common bacterial pathogen isolated in otitis externa?

A Group A streptococcus
B Strep pneumonae
C Pseudomonas aeruginosa
D Hemophilus influenza
E Aspergillus

Pseudomonas aeruginosa

A patient presents with epistaxis from the right nares, along with direct pressure to the nares and elevation of the head. Which of the following is an appropriate initial treatment?

A Phenylephrine spray and anterior packing
B Triamcinolone spray and anterior packing
C Azelastine spray and anterior packing
D Momentasone spray and anterior packing
E Cromolyn sodium spray and anterior packing

Phenylephrine spray and anterior packing
Phenylephrine is a topical decongestant, and acts as a vasoconstrictor to aid in stopping minor anterior septal epistaxis. Triamcinolone and momentasone are nasal steroids used for allergic rhinitis. Cromolyn sodium is a mast cell stabilizer, and azelastine is a topical H1 selective antihistamine, used for allergic rhinitis.

A 4-year-old girl is brought to urgent care complaining of left ear fullness and difficulty hearing. The parents express concern that she put an elbow macaroni noodle into her ear. This concern is confirmed on otoscopic evaluation of the ear. Which of the following steps is most appropriate for removing this foreign body?

A Administer general anesthesia
B Anesthetize the ear canal with lidocaine solution
C Irrigate the ear with warm water
D Irrigate the ear with a hydrogen peroxide solution
E Remove the noodle with a loop

Remove the noodle with a loop
A loop (E) or alternative instrument should be used to pull the noodle outward and away from the tympanic membrane. Organic material may swell when wet, and irrigation (C and D) or the insertion of anesthetic solution (B) is not recommended.

A 35-year-old homeless male presents with a painful red right eye and decreased visual acuity, which occured over the past 48 hours. He doesn’t recall any trauma, and prior to this his vision was good. His past history includes alcoholism and liver disease. On physical exam you notice a white opacity in the center of his right cornea. You are unable to do an ophthalmoscopic exam due to the opacity, and a fluorescein staining is strongly positive. What is the likely etiology of the white opacity?

A Hypopyon
B Hyphema
C Corneal Infiltrate
D Corneal Ulcer
E Corneal Abrasion

Corneal Ulcer
A rapidly progressing central corneal ulcer must be considered first and treated aggressively. An ulcer will show fluorescein staining, due to a break in the corneal epithelium. Pseudomonas, strep pneumonia, herpes, and fungus must be considered as possible causes. An emergent ophthalmology consult can be sight saving.

Taking vitamin C, E, zinc, and beta carotene, and stopping smoking, have a preventative effect on the progression of which of the following diseases?

A Macular degeneration
B Retinal detachment
C Central retinal artery occlusion
D Diabetic retinopathy
E Central retinal vein occlusion

Macular degeneration
Smoking cessation and taking supplements, including vitamin C, E, zinc, and beta carotene, have shown an eight percent decrease in progression of late stage macular degeneration. However, smokers or previous smokers should not take beta carotene, due to its link with lung cancer in smokers.

A 54-year-old male patient presents to your office complaining of pain to the left eye with nausea, vomiting, and a headache after being brushed in the eye with his grandchild’s stuffed animal. On examination the conjunctiva is not injected, and the cornea has a steamy appearance. You cannot visualize the retina. The pupil is fixed and 4 mm. When you stain the eye you are unable to see any lesions or scratches. You suspect:

A acute bacterial conjunctivitis
B acute narrow angle glaucoma
C allergic conjunctivitis
D herpes simplex ophthalmicus
E traumatic iritis

acute narrow angle glaucoma
patients with acute glaucoma usually seek treatment immediately because of extreme pain and blurred vision, though there are subacute cases. The blurred vision is associated with halos around lights. Nausea and abdominal pain may occur. The eye is red, the cornea steamy, and the pupil moderately dilated and nonreactive to light. Intraocular pressure is usually over 50 mm Hg, producing a hard eye on palpation.

A 50-year-old male states that his eye is bothering him since yesterday. He complains of pain and redness. He states that he mowed his lawn yesterday and that it was windy outside. He attempted to irrigate the eye but still has significant irritation. He notes that it hurts to blink his eyes. What is the correct sequence of steps to treat this condition?

A Anesthetic drops, irrigate the eye, and perform tonometry
B Prescribe antibiotic cream and pain medication
C Fluorescein stain, irrigate the eye, and prescribe antibiotic cream
D Fluorescein stain and lid eversion
E Anesthetic drops, fluorescein stain, and lid eversion

Anesthetic drops, fluorescein stain, and lid eversion
The history suggests a retained foreign body to the upper eyelid. A fluorescein stain will reveal significant superficial vertical scratches on the cornea. An upper eyelid eversion must be done, to inspect for and remove the foreign body. If the practitioner is successful in removing the foreign body, relief of the irritation will be immediate.

A 5-year-old girl presents to the office with her mother, who states the child is experiencing excessive tearing, itching, and redness of her eyes. On physical exam you note marked injection with chemosis without discharge. The patient lacks adenopathy. Which of the following is the most appropriate treatment?

A Azithromycin 1 gram by mouth
B Observation and reassurance
C Olopatadine 0.1% ophthalmic solution twice daily
D Sulfacetamide 10% ophthalmic solution three times a day for 5 days
E Valacyclovir 500 mg by mouth twice daily for 10 days

Olopatadine 0.1% ophthalmic solution twice daily

Allergic conjunctivitis is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis and is treated with antihistamines/mast cell stabilizers (C). Azithromycin (A) is indicated for the treatment of conjunctivitis caused by chlamydia and antibiotic drops (D) are indicated for bacterial conjunctivitis. Observation and reassurance (B) is indicated for viral conjunctivitis. The patient lacks symptoms of herpes infection (E).

Which of the following will cause conductive hearing loss?

A Mumps
B Syphilis
C Multiple sclerosis
D Otitis media
E Medications

Otitis media
Conductive hearing loss is the result of blockage of sound waves from the external canal to the inner ear. Causes include cerumen, middle ear effusion, otitis media, and occiscle disruption. Multiple sclerosis causes VIIIth cranial nerve disruption and neural hearing loss. Mumps and syphilis can cause sensoryneural hearing loss.

As a diver descends for a deep water dive, at about 10 feet of depth he begins to feel nausea, severe ear pain, and develops vertigo and vomiting. What is the most likely cause of his symptoms?

A Decompression sickness
B Decreasing pressure in the middle ear
C Benign paroxysmal positional vertigo
D Increasing pressure in the middle ear
E Equalization of pressure between the middle ear and eustachian tube

Decreasing pressure in the middle ear
Boyle’s law states that as a diver descends, the increasing external pressure causes an equal decrease in pressure in the middle ear, which must be equalized during the descent. If the middle ear pressure is not equalized, the tympanic membrane becomes severely retracted, due to the negative middle ear pressure. This can result in hemotympanum, hemorrhage, or tympanic membrane perforation. Ascent causes increased pressure in the middle ear as the external pressure is decreased. Equalization techniques must also be used to prevent a tympanic membrane perforation. Decompression sickness occurs on ascent, when nitrogen gas bubbles are forced into the middle ear, and vascular and lymphatic spaces.

Which of the following conditions is a cause for central vertigo?

A Meniere syndrome
B Labyrinthitis
C Vestibular neuronitis
D Acoutic neuroma
E Perilymphatic fistula

Acoustic neuroma
Meniere syndrome, labyrinthitis, vestibular neuronitis, and perilymphatic fistula are causes of peripheral vertigo. Acoustic neuroma, or eight cranial nerve schwannomas, are among the most common intracranial tumors, and a cause for central vertigo.

A 43-year-old male presents to the Emergency Department complaining of right eye pain after treating his yard with fertilizer and lime. He attempted to flush his eye at home without relief of pain. Which of the following is the most appropriate initial step in managing this patient’s symptoms?

A Double evert his eyelids to look for remaining foreign bodies
B Fluorescein stain his eye
C Instill proparacaine 0.5% ophthalmic solution
D Irrigate his eye until the pH is between 6.8 and 7.4
E Refer to ophthalomogist

Instill proparacaine 0.5% ophthalmic solution

The patient requires all of the above steps and should be given pain relief (C) prior to thoroughly flushing the eye (D), removing foreign bodies (A), assessing for corneal injuries (B), and referring to ophthalmology (E).

You are evaluating a patient who is complaining of facial drooping , and inability to close his eye. During the cranial nerve exam you notice he is unable to wrinkle his forehead. Based on this information what is the most likely diagnosis?

A Cerebrovascular accident
B Transient ischemic attack
C Bell’s palsy
D Horner’s syndrome
E Isolated oculomotor palsy

Bell’s palsy
Bell’s palsy affects cranial nerve VII, the facial paralysis conforms to the all branches of the peripheral nerve including the side of the face, eyelid and forehead muscles. An acute cerebrovascular accident would present only with a facial droop, the ability to close the eye and wrinkle the forehead would be preserved and there would likely be other focal weakness on physical exam. Horner’s syndrome is miosis, ptosis and facial flushing and anhydrosis caused by abnormalities of the supercervical ganglion along the internal carotid artery.

Which of the following is the third component of the atopic triad, besides allergic rhinitis and asthma?

A Psoriasis
B Dermatitis
C Arthritis
D Urticaria
E Pruritus

Dermatitis

Atopic dermatits, or eczema, is the third chronic finding, along with asthma and allergic rhinitis, in patients who are atopic. Urticaria are common in acute and chronic allergies.

A 54-year-old female presents complaining of decreased visual acuity to her right eye over the past few hours. She denies pain, and describes having wavy vision and seeing flashes of light. Her visual acuity in the affected eye is 20/200. What condition best describes the following physical finding?

A Retinal detachment
B Central retinal artery occlusion
C Open angle glaucoma
D Angle closure glaucoma
E Optic neuritis

Retinal detachment
The image demonstrates a detached retina. The superior aspect of the retina appears wavy and flowing. A central retinal artery occlusion is characterized by a pale retina, as well as a cherry red spot on the macula. Open angle glaucoma does not cause acute vision loss. Angle closure glaucoma causes painful acute vision loss. Optic neuritis is characterized by painful visual loss and a swollen optic disc.

A 45-year-old male presents with a complaint of itching and burning of his upper eyelid. This has been present for a week. Some dried discharge is seen clinging to his eyelashes. Which of the following is the most likely diagnosis?

A Blepharitis
B Chalazion
C Dacryocyctitis
D Hordeolum
E Conjunctivitis

Blepharitis
Anterior Blepharitis is common and can be bilateral. Causes include staphylococcus and seborrhea. Posterior blepharitis is caused by meibomian gland dysfunctions.

A 20-year-old male presents with cough, nasal congestion, and a low grade fever for one week. His cough seems to be getting worse, which is the reason for his visit. His past medical history includes asthma and nasal polyps. On physical exam, his temperature is 101˚F, his pharynx is erythemic, and there is grey nasal discharge with a few nasal polyps seen using a nasal speculum. His lungs have a few expiratory wheezes bilaterally. What medication is to be avoided in this patient?

A Penicillin
B Acetaminophen
C Erythomycin
D Aspirin
E Ciprofloxacin

Aspirin
Aspirin should be avoided in patients with asthma and nasal polyps. Aspirin can precipitate bronchospasm in these patients, due to immunologic salicylate sensitivity.

A 73-year-old female with type 2 diabetes, hypertension, and hyperlipidemia presents to the emergency department complaining of left ear pain, and a yellowish-green, foul-smelling discharge that began about 3 weeks ago. On physical examination, the patient is afebrile and examination reveals a markedly edematous left ear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized. Upon cranial nerve exam the patient has left-sided facial weakness. Which of the following diagnostic studies should be performed first in the initial evaluation of this patient?

A CT scan of the head
B Culture and sensitivity
C Hemoglobin A1C
D HSV-1 antibody testing
E MRI of the brain

CT scan of the head
The patient has malignant otitis externa that has most likely extended to osteomyelitis and impingement of the facial nerve. Emergent CT scan (A) is indicated over MRI (E) to assess the extent of disease and the presence of osteomyelitis. Malignant otitis externa is most commonly caused by pseudomonas and empirical antibiotic therapy can be initiated prior to culture and sensitivity (B). Assessment of the patient’s diabetes control (C) should occur, but isn’t the highest priority study to order first. HSV-1 antibody testing (D) is not indicated in this patient.

Patients diagnosed with an auricular hematoma are at increased risk of developing which condition?

A Cartilage necrosis
B Cholesteatoma
C Coagulopathy
D Exostosis
E Otomycosis

cartilage necrosis
Auricular hematomas occupy the subperichondral space, leading to decreased or absent diffusion from the perichondrium to the cartilage and resulting in increased risk of necrosis (A). Coagulopathy (C) may predispose a patient to experiencing a hematoma. Cholesteatoma (B) may result from TM trauma, but not blunt trauma to the outer ear.

You are asked to examine an 88-year-old female resident of a nursing home, who presents with a red eye. Her notes from the nursing home say that the patient has had this problem for six months, but now seems to be getting worse despite using daily artificial tears and occasional topical antibiotic drops. On physical exam you notice markedly injected conjunctiva to the right eye, with no discharge. The lower lid appears to be curled in toward the bulbar conjunctiva, with the eyelashes pointing inward. What is the name of this condition?

A Conjunctivitis
B Dacryoadenitis
C Entropion
D Ectropion
E Endophthalmos

entropion
Aging causes a relaxation in the lower lid retractors, resulting in an entropion. This causes chronic irritation to the bulbar conjunctiva and corneal abrasions. Treatments include taping the lower lid to the cheek, botulinum toxin injection, or surgery.

A 26-year-old female patient presents to the emergency department complaining of left eye discharge, without significant pain. She has no known drug allergies. Physical exam reveals the following:

A gram stain reveals gram-negative intracellular diplococci. Which of the following is the most appropriate clinical intervention?

A Ceftriaxone 1 gram IM and ophthalmologic follow-up in 48 hours
B Ceftriaxone 1 gram IM and emergent referral to ophthalmologist
C Ciprofloxacin 500 mg twice daily for 10 days and ophthalmogic follow-up in 48 hours
D Ciprofloxacin 500 mg twice daily for 10 days and emergent referral to ophthalmologist
E Emergent referral to ophthalmologist

Ceftriaxone 1 gram IM and emergent referral to ophthalmologist

The patient has gonococcal conjunctivitis that is an ophthalmologic emergency due to potential risk of corneal perforation (C). Aggressive antibiotic therapy for gonorrhea (i.e., ceftriaxone) with immediate ophthalmology evaluation is the best course of action.

Which of the following is a result of untreated or partially treated otitis media, which presents with fever, ear pain, otorrhea, tenderness behind the ear, fluid collection, and destruction of air cells seen on head CT?

A Suppurative otitis media
B Peritonsillar abcess
C Mastoiditis
D Meningitis
E Ethmoid sinusitis

mastoiditis
Untreated or partially otitis media can result in mastoiditis. Tenderness, redness, and fluctuance over the mastoid bone is characteristic. Peritonsillar abcess symptoms include severe sore throat, drooling, dysphonia, and outpouching of the tonsillar pillar on the affected side and trismus. Ethmoid sinusitis presents with nasal congestion, discharge, and headache. Suppurative otits media is contained in the middle ear, without spreading to adjacent structures.

A 16-year-old male was hit on the left side of his face by a line drive baseball. Marked swelling is noted externally to the left eye. There was no loss of consciousness. Upon physical exam, he complains of diplopia during extraocular motion testing. Enophthalmos is noted, as well as decreased sensation of the left cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary sinus, and a fracture of the orbit. Based on this information, what is the most likely diagnosis?

A Zygomatic arch fracture
B Orbital blowout fracture
C Le Fort I fracture
D Le Fort II fracture
E Le Fort III fracture

B Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve. A Le Fort I fracture describes a transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum. A Le Fort II fracture describes a pyramidal through the central maxilla and hard palate. Movement of the hard palate and nose occurs, but not the eyes. A Le Fort III fracture describes a craniofacial disjunction, wherein the entire face is separated from the skull due to fractures of the frontozygomatic suture line, across the orbit and through the base of the nose, and ethmoids. The entire face shifts, with the globes held in place only by the optic nerve.

A 48-year-old female complains of ear fullness, episodes of tinnitus, and vertigo. She also complains that her hearing is not as good as it used to be. She states that this has occurred sporadically over the past year. What is the most likely diagnosis?

A Benign paroxysmal positional vertigo (BPPV)
B Labyrinthitis
C Vestibular neuronitis
D Meniere’s syndrome
E Presbycusis

meniere’s
BPPV is characterized by sudden vertigo, made worse with head position change, and accompanied by nausea and vomiting. Meniere syndrome is characterized by episodic severe vertigo, fluctuating sensorineural hearing loss, tinnitus, and ear “fullness.” Pathologically, there is distention of the endolymphatic system throughout the inner ear, presumably due to dysfunction of the endolymphatic sac. Labyrinthitis is characterized by severe vertigo and hearing loss, and is likely a result of a viral inner ear infection. Vestibular neuronitis is also a result of a viral inner ear infection, with symptoms of severe vertigo, nausea, and vomiting, without hearing loss. Both labyrinthitis and vestibular neuronitis resolve in one to two weeks. Presbycusis is age related hearing loss.

A 5-year-old male presents with a first-time, one-week history of a cough, nasal congestion, and a temperature of 101˚ F orally. Upon physical exam, you note a distended, erythemic right tympanic membrane that has decreased mobility, with pneumatic otoscopy. There are no known drug allergies. What is the first line antibiotic indicated for this condition?

A Ciprofloxacin
B Moxifloxacin
C Amoxicillin
D Clindamycin
E Cefaclor

amoxicillin
In cases of non-resistant otitis media, amoxicillin, erythromycin, or a sulfonamide are first line antibiotics. Flouroquinolones, like ciprofloxacin or moxifloxacin, are contraindicated in children.

Use of which of the following medications can result in hearing loss?

A Cefalexin
B Erythomycin
C Gentamycin
D Ciprofloxacin
E Hydrochlorothiazide

Gentamycin is an aminoglycoside, and can cause ototoxicity. Peak and trough levels must be drawn to determine the lowest effective dose. The remaining medications do not interfere with vestibular function.

An 18 month old female is brought to the pediatricians office with a history of cough, fever of 102, and decreased fluid intake. Her immunizations are not up to date as the family just moved to the United States from out of the country. On physical exam she is drooling and sitting up in a “tripod position” with mild stridor. What is the most appropriate treatment indicated for this condition?

A Humidified air
B Albuterol nebulizer
C Budesonide nebulizer
D Recemic epinephrine nebulizer
E Ipratropium nebulizer

D The clinical presentation suggests epiglotitis. This is an emergent airway condition. The anesthesiologist , or the pediatric otolaryngologist must be called to stand by to intubate or insert a tracheostomy if the patients airway closes. Racemic epinephrine via nebulizer relieves much of the edema to the upper airway in a patient with epiglotitis. It is a stabilizing measure until definitive care can be arranged. Oxygen and antibiotics should administered emergently also. No x-rays are indicated when the presentation is classic. Albuterol is a beta-agonist used for treatment of asthma. Budesonide,a steroid and ipratropium, an anticholinergic agent are most often used in combination with albuterol for treatment emphysema and asthma.

A 58-year-old female presents to the outpatient clinic complaining of 1 week of rhinorrhea, nonproductive cough, and hoarseness. On physical exam she is noted to have erythematous nasal mucosa and decreased phonation without significant nasal discharge, sinus tenderness, pharyngeal erythema, or lymphadenopathy. Which of the following is the most likely diagnosis?

A Laryngitis
B Laryngeal cancer
C Vocal cord hemorrhage
D Vocal cord paralysis
E Vocal cord polyp

laryngitis
The presence of acute hoarseness associated with an upper respiratory infection is consistent with laryngitis (A).

You are conducting a physical exam on a female, who was referred to you from an optometrist. She sought a visual screening due to progressive loss of visual acuity. She has not been seen by a physician in 10 years due to lack of insurance. She admits to a 15 lb weight gain in the past three years, and also complains of parasthesias in her feet. During an ophthalmoscopic exam you notice deep retinal microvascular hemorrhages, and cotton wool spots. What is the most likely cause of her visual disorder?

A Macular degeneration
B Retinal detachment
C Central retinal artery occlusion
D Diabetic retinopathy
E Central retinal vein occlusion

Diabetic retinopathy
The patient’s symptoms suggest a likelihood of diabetes. Retinal findings can include microaneurysms, deep hemorrhages, a flame-shaped hemorrhage, exudates, and cotton wool spots.

A 37-year-old male presents to your office with a history of vision loss in his right eye. He denies any pain, and states that the vision loss occurred suddenly. He noted there was a wavy, “curtain-like” visual disturbance preceding the vision loss. Upon physical exam you notice a cherry red spot over the macula and retinal pallor. What is the most likely diagnosis?

A Macular degeneration
B Retinal detachment
C Central retinal artery occlusion
D Cerebrovascular accident
E Central retinal vein occlusion

Central retina artery occlusion
Central retinal artery occlusion is characterized by a sudden, painless vision loss. A cherry red spot is characteristic on the macula, along with pallor to the retina.

A 5-year-old girl presents to the office with her mother, who states the child is experiencing excessive tearing, itching, and redness of her eyes. On physical exam you note marked injection with chemosis without discharge. The patient lacks adenopathy. Which of the following is the most likely diagnosis?

A Allergic conjunctivitis
B Bacterial conjunctivitis
C Inclusion conjunctivitis
D Keratoconjunctivitis
E Viral conjunctivitis

Allergic conjunctivitis
Allergic conjunctivitis (A) is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis. The absence of other viral symptoms (E) and discharge (B) make other diagnoses less likely. Preauricular adneopathy typically occurs in viral (E) or chlamydial conjunctivitis (C).

A 45-year-old presents with a markedly tender nodule protruding from the edge of his upper eyelid. He states that this has been present for 12 hours. No discharge is seen. He denies visual problems. What is the most likely diagnosis?

A Blepharitis
B Chalazion
C Dacryocyctitis
D Hordeolum
E Conjunctivitis

A hordeolum (sty) is caused by an acute infection of the Zeis or Moll’s glands of the eyelid. Symptoms include pain and tenderness. An “internal hordeolum” points to the inner conjunctiva of the lid and an “external hordeolum” points to the skin surface of the eyelid.

A 45-year-old male presents with a non-tender nodule protruding from his lower eyelid. There is some surrounding erythema to the conjunctiva, but no discharge is seen. He states that it has been there for one month. He has no visual problems. What is your diagnosis?

A Blepharitis
B Chalazion
C Dacryocyctitis
D Hordeolum
E Conjunctivitis

A chalazion is a sterile, chronic, and non-painful granulomatous nodule, caused by a previous acute infection in a meibomian gland. It can develop over a period of a few weeks. Treatment is intralesional steroids or surgical curettage.

While you are doing a funduscopic exam on an 80-year-old female with progressive vision loss, you notice drusen formations on her retinas. What is the most likely diagnosis?

A Macular degeneration
B Retinal detachment
C Central retinal artery occlusion
D Diabetic retinopathy
E Central retinal vein occlusion

macular degeneration
Drusen are yellow colored collagen deposits in Bruch’s membrane of the retina. They can be diffuse, discrete, or confluent. Retinal pigment changes and atrophy are see in “dry” macular degeneration. “Wet” macular degeneration demonstrates choroidal neovascularization, or serous retinal pigment hemorrhages and retinal detachments.

A 24-year-old female comes into the clinic complaining of a severe sore throat. She was seen three days ago at an urgent care facility, and was given amoxicillin. She states that the pain is worse, she is unable to drink fluids, and is now having difficulty swallowing. She talks with a muffled voice. A physical exam reveals a markedly swollen and erythemic right tonsil and tonsillar pillar, with the uvula deviating to the left. The patient has extreme difficulty opening her mouth. What is the most likely diagnosis?

A Tonsillitis
B Uvulitis
C Peritonsillar abcess
D Tonsillar cellulitis
E Diphtheria

Peritonsillar abscess
The physical exam is highly suspicious for peritonsillar abcess, which must be considered first. Tonisllar cellulitis, or phlegmon, is swelling and enlargement of the tonsil and peritonsillar tissue, without the presence of fluctuant abcess. Uvulitis can exist with a peritonsillar abcess or tonsillitis, but isolated uvulitis usually includes symmetric swelling and erythema as a result of irritation (snoring), allergy (angioedema), or infection from upper respiratory pathogens. Diphtheria is a tonsillitis, with a characteristic gray pseudomembrane on the tonsils and upper airway, caused by corneybacterium diphtheriae.

A 73-year-old female with type 2 diabetes, hypertension, and hyperlipidemia presents to the outpatient clinic complaining of left ear pain, and a yellowish-green, foul-smelling discharge that began about 3 weeks ago. On physical examination, the patient is afebrile and examination reveals a markedly edematous left ear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized. Which of the following is the most likely causative agent for this patient’s diagnosis?

A Escherichia coli
B Moraxella catarrhalis
C Pseudomonas aeruginosa
D Staphylococcus aureus
E Streptococcus pneumoniae

Pseudomonas aeruginosa
Malignant otitis externa is most commonly caused by pseudomonas (C). E coli (A) and S aureus (D) are less common causes of otitis externa, while S pneumoniae (E) and M catarrhalis (B) are common etiologies of acute otitis media.

You suspect that a 5-year-old patient has allergic conjunctivitis. Which of the following symptoms or signs would best support this diagnosis?

A Itching
B Fever
C Preauricular adenopathy
D Profuse discharge
E Sore throat

itching
Allergic conjunctivitis is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis (A). Fever (B) and sore throat (E) are more likely to occur in viral or bacterial conjunctivitis. Preauricular adneopathy (C) typically occurs in viral or chlamydial conjunctivitis.

A 65-year-old male presents to you with a growth on the inner aspect of his left eye. He states that it has been getting slightly larger. On physical exam, you note a fleshy triangle shaped protrusion on the inner bulbar conjunctiva, abutting and slightly crossing the limbic border. Which of the following is the correct diagnosis?

A Charazion
B Hordeolum
C Pterygium
D Pinguecula
E Cataract

pterygium
Pterygium is a complication of exposure to ultraviolet light and wind. It consists of hyaline and elastin tissue. If it encroaches on the cornea, surgical removal is indicated.

A 3-year-old male is brought to your office with a red, tearing right eye. The mother stated that the child was playing in another room with his 4-year-old brother. All she heard was the child beginning to cry. Upon physical exam, the child is intermittently crying, and his right eye is red and tearing. The child is continually rubbing the eye. The anterior chamber is clear and the pupil is equal and reactive. What is your next step in evaluating this patient?

A Contact child protective services
B Order a head CT scan
C Perform a tonometry
D Obtain a visual acuity
E Perform a fluorescein stain

Perform a fluorescein stain

A corneal abrasion must be ruled out in a child with a red eye.

A 65-year-old female presents with a red irritation in her right eye. She states that this has been occurring intermittently for about two years. She also states that her eyelids are “droopy,” and that she needs plastic surgery. On physical exam you notice a diffusely injected conjunctiva and an outwardly tilted lower eyelid. What is the most likely diagnosis for the abnormal physical finding?

A Conjunctivitis
B Dacryoadenitis
C Entropion
D Ectropion
E Exophthalmos

Ectropion
Ageing causes a relaxation of the obicularis oris muscle, and will cause the lower eyelid to sag outwardly. This prevents the lower lid from protecting the eye, and frequently results in exposure conjunctivitis and keratitis. Treatment is surgical.

Which of the following diseases is associated with the development of nasal polyps?

A Amyloidosis
B Allergic rhinitis
C Chronic sinusitis
D Chronic obstructive pulmonary disease
E Wegener’s granulomatosis

Allergic rhinitis
Nasal polyps are most commonly idiopathic although they may develop secondary to allergic rhinitis (B), or cystic fibrosis. Chronic sinusitis (C) may result from obstruction of the sinus drainage secondary to a polyp. Amyloidosis (A) and Wegener’s granulomatosis (E) lead to the development of lesions with histology and appearance different than a benign nasal polyp.

A 52-year-old male bus driver presents to the clinic with a chief complaint of intense, shooting pains in his left cheek, each lasting for only a few seconds. He avoids touching certain parts of his face and has started to chew food only on the right side of his mouth because he is afraid he will set off an attack of pain. In between attacks, the patient feels well. What is the most likely diagnosis?

A cluster headache
B tension-type headache
C trigeminal neuralgia
D giant cell arteritis
E dental abscess

Trigeminal Neuralgia
C Trigeminal neuralgia is characterized by sharp, brief pain often described as “shooting, jabbing, electric shock, or stabbing.” The history given for cluster headache (typically ipsilateral ocular headaches with tearing, and lasting for 2 hours) and tension-type headache is not at all like this patient’s. The history for temporal arteritis is generally different, as it typically includes ocular symptoms, but it may be worth getting a sedimentation rate just to be sure. This location pain pattern is different than that of a focal dental problem.

A 45-year-old patient came in to see his health care provider today, to discuss the results of his last annual assessment. He was told that he had developed type 2 diabetes mellitus. One of the recommendations from the physician assistant included a visit to an ophthalmologist. The physician assistant was concerned after seeing new capillaries, macular edema, and fibrous tissue within the retina during his funduscopic exam. What type of ocular complication does this patient most likely have at this time?

A Background retinopathy
B Closed angle glaucoma
C Macular degeneration
D Diabetic cataracts
E Proliferative retinopathy

Proliferative Retinopathy
The correct choice is E, proliferative retinopathy. The distinguishing factor in the patient’s presentation, which signals this disorder, is the development of newly formed vessels. Proliferative retinopathy is the leading cause of blindness in the United States. Up to 20% of patients with type 2 diabetes have retinopathy at the time of diagnosis. Choice A, background retinopathy, or simple retinopathy includes retinal microaneurysms, hemorrhages, exudates, and edema, without new vessel formation. Choice B, closed angle glaucoma, is relatively uncommon in patients with diabetes, except after cataract extraction. Choice C, macular degeneration, is not associated with diabetes mellitus specifically. Choice D, diabetic cataracts, tends to occur in patients with diabetes earlier than the general population, and may correlate with the severity of the disease.

A 24-year-old female comes into the clinic complaining of a severe sore throat. She was seen three days ago at an urgent care facility, and was given amoxicillin. She states that the pain is worse, she is unable to drink fluids, and is now having difficulty swallowing. She talks with a muffled voice. A physical exam reveals a markedly swollen and erythemic right tonsil and tonsillar pillar, with the uvula deviating to the left. The patient has extreme difficulty opening her mouth. What is the most likely diagnosis?

A Tonsillitis
B Uvulitis
C Peritonsillar abcess
D Tonsillar cellulitis
E Diphtheria

Peritonsillar Abscess
C The physical exam is highly suspicious for peritonsillar abcess, which must be considered first. “Hot potato” Voice.Tonisllar cellulitis, or phlegmon, is swelling and enlargement of the tonsil and peritonsillar tissue, without the presence of fluctuant abcess.
Uvulitis can exist with a peritonsillar abcess or tonsillitis, but isolated uvulitis usually includes symmetric swelling and erythema as a result of irritation (snoring), allergy (angioedema), or infection from upper respiratory pathogens. Diphtheria is a tonsillitis, with a characteristic gray pseudomembrane on the tonsils and upper airway, caused by corneybacterium diphtheriae.

A 58-year-old female presents to the outpatient clinic complaining of 1 week of rhinorrhea, nonproductive cough, and hoarseness. On physical exam she is noted to have erythematous nasal mucosa and decreased phonation without significant nasal discharge, sinus tenderness, pharyngeal erythema, or lymphadenopathy. Which of the following is the most likely causative organism for this patient’s condition?

A Clostridium diphtheriae
B Group A streptococcus
C Moraxella catarrhalis
D Mycobacterium tuberculosis
E Rhinovirus

Rhinovirus
E The presence of acute hoarseness associated with an upper respiratory infection is consistent with laryngitis, which may be caused by all of the organisms above (A-E), but most likely has a viral (E) etiology.

A 73-year-old female with type 2 diabetes, hypertension, and hyperlipidemia presents to the outpatient clinic complaining of left ear pain, and a yellowish-green, foul-smelling discharge that began about 3 weeks ago. On physical examination, the patient is afebrile and examination reveals a markedly edematous left ear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized. Which of the following is the most likely causative agent for this patient’s diagnosis?

A Escherichia coli
B Moraxella catarrhalis
C Pseudomonas aeruginosa
D Staphylococcus aureus
E Streptococcus pneumoniae

Psuedomonas Aeurginosa
C Malignant otitis externa is most commonly caused by pseudomonas (C). E coli (A) and S aureus (D) are less common causes of otitis externa, while S pneumoniae (E) and M catarrhalis (B) are common etiologies of acute otitis media.

A 5-year-old boy presents to urgent care complaining of painful lesions in his mouth that have made eating difficult the past 2 days. The mother confirms he has been unable to eat for 48 hours, but has been able to sip water. On physical exam he has a temperature of 102.6 F; numerous small vesicles and ulcers on the buccal mucosa and tongue, inflamed gingiva; and tender anterior cervical adenopathy. Which of the following is the most likely diagnosis?

A Aphthous ulcers
B Hand, foot, and mouth disease
C Herpangina
D Herpes simplex gingivostomatitis
E Viral pharyngitis

Herpes simplex gingivostomatitis
The classic presentation of initial herpes simplex infection (D) includes multiple small, painful vesicles or ulcers on the mucousa with gingival involvement, fever, and adenopathy. (A), (B), and (C) all present with ulcers, but typically involve an isolated area (A), or the tonsils and posterior pharynx (B and C).

A 45-year-old man presents to the clinic complaining of a lesion in the middle of his right lower eyelid margin that is obscuring his vision when he works on fly-tying or other detailed projects. On physical exam there is a 5 mm round lesion that lacks erythema or tenderness. The patient’s visual acuity is 20/20. Which of the following interventions is most appropriate for this patient?

A Apply warm compresses four times daily until resolution
B Apply bacitracin ophthalmic ointment 500 units/gram three times a day
C Aspirate the lesion
D Excise the lesion
E Take amoxicillin-clavulanate 875/125 mg by mouth two times a day for 10 days

Excise the lesion
The patient’s presentation is consistent with a chalazion that is best treated by surgical excision of the granulomatous tissue (D). Warm compresses (A), bacitracin ointment (B), and amoxicillin-clavulanate (E) are effective treatment options for hordeolum, or hordeoulum with associated preseptal cellulitis.

A 43-year-old woman presents to the outpatient clinic complaining of right eye redness, photophobia, and pain. She notes some blurred vision and denies the presence of discharge. On physical exam her visual acuity is 20/20 left eye, and 20/60 right eye. Her right eye has circumcorneal injections and the pupil is 3 mm and responds poorly to light. Her left pupil is 5 mm and responds well. Fluorescein staining of the eye is unremarkable and intraocular pressures are normal. Which of the following treatment regimens should be prescribed?

A Homatropine 5% solution four times daily
B Homatropine 5% solution four times daily and prednisolone 1% solution every 1 or 2 hours while awake
C Prednisolone 1% solution every 1 or 2 hours while awake
D Prednisolone 1% solution every 1 or 2 hours while awake and sulfacetamide 10% solution three times a day
E Prednisone 60 mg by mouth once daily

Homatropine 5% solution four times daily and prednisolone 1% solution every 1 or 2 hours while awake
The patient’s presentation of acute uveitis is best treated with topical corticosteroids and cycloplegics (B) once infectious causes (e.g., HSV) have been ruled out. The addition of a cycloplegic helps reduce pain. Antibiotic drops (D) aren’t indicated for acute uveitis.

Which of the following is a risk factor for cholesteatoma formation?

A Acute otitis media
B Chronic tympanic membrane retraction
C Diabetes mellitus
D Hyperlipidemia
E Smoking

Chronic tympanic membrane retraction
Cholesteatomas result from negative pressure in the middle ear chronically retracting the pars flaccida (B). Acute otitis media (A) may lead to short-term TM retraction or perforation, but without perforation or the placement of PE tubes it is unlikely to lead to cholesteatoma formation. Diabetes (C), hyperlipidemia (D), and smoking (E) are not associated with this localized pathology.

A 63-year-old male presents with an asymptomatic lesion in his mouth that was discovered by his dentist at a check-up. It is ill marginated with pigment ranging from medium brown to black. Parts of the lesion are raised. What is the next appropriate step in management?

A Biopsy of the lesion
B Inject the lesion with triamcinolone
C Observe for changes over the next six months
D Prescribe keflex for 10 days

Biopsy the lesion
A Oropharyngeal melanoma is characterized by varying pigment occurring in an irregularly shaped lesion. Although this is a rarely occurring melanoma, a biopsy should be done and any pigmented oral lesion should be excised. Areas which are raised within the lesion usually indicate sites of invasion.

The academic achievement of a previously straight A high school student starts to fall. He also develops an unexplained tremor in his arms and dysarthria. His neurologic symptoms progress before he is finally seen by his family physician. A slit lamp examination reveals that his cornea has a distinctive yellow-brown ring. His laboratory results are as follows:

TEST RESULTS REFERENCE RANGE
Ceruloplasmin 16 mg/dL 20-45 mg/dL
What is this disease called?

Answer Choices
1 Hemochromatosis
2 Hemosiderosis
3 Wilson’s disease
4 Whipple’s disease
5 Wermer’s syndrome

wilson’s disease
This patient has Wilson’s disease. This disease is also called hepatolenticular degeneration. Wilson’s disease is a disease of copper metabolism that results in copper deposition in the tissues. When copper is deposited in the cornea, it causes a yellow-brown ring called Kayser-Fleischer rings. Most patients with Wilson’s disease will have a decreased ceruloplasmin.Hemochromatosis is a disease due to excess iron deposition in tissues. Plasma iron will be elevated. Many organs can be affected by this disease. Skin pigmentation can be seen with hemochromatosis. Bronze diabetes can be seen with hemochromatosis. The liver is commonly affected with hemochromatosis. Hemochromatosis is autosomal recessive.

Hemosiderosis is an increase of storage iron in the body. Hemosiderin is a golden brown protein that contains iron.

Whipple’s disease is an intestinal disease of malabsorption accompanied by systemic manifestations. Steatorrhea is seen. Fever, arthralgia, and lymphadenopathy are some of the systemic manifestations. Whipple’s disease is also called intestinal lipodystrophy or lipophagic intestinal granulomatosis. Foamy macrophages can be seen in the intestinal mucosa.

Wermer’s syndrome is multiple endocrine neoplasia Type I. Wermer’s syndrome consists of hyperparathyroidism, pancreatic islet cell tumors, and pituitary tumors.

A 74-year-old man presents with a 1 ½-hour history of severe pain and blurred vision in his left eye. Upon examination, his left eye is erythematous with a steamy cornea and a nonreactive, dilated pupil. An ophthalmologic consult is ordered, and tonometry is completed, revealing an elevated intraocular pressure and a confirmed diagnosis of acute angle-closure glaucoma.

Question
What will be the definitive treatment for this patient?
Answer Choices
1 Left laser peripheral iridotomy
2 Bilateral laser peripheral iridotomy
3 IV acetazolamide
4 Oral glycerol
5 Topical timolol 0.25%

Correct Answer: Bilateral laser peripheral iridotomy
This is a procedure during which a puncture-like opening is made near the base of the iris in order to decrease intraocular pressure in patients with angle-closure glaucoma. While there are various medications used to treat acute episodes, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. If this occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally.Left laser peripheral iridotomy is not the correct answer. While there are various medications used to treat acute episodes of angle-closure glaucoma, this procedure will correct the disorder definitively, whereas the medications are temporary treatment. Patients with narrow anterior chambers are at risk for angle-closure glaucoma. Narrow anterior chambers always occur bilaterally. If acute angle-closure glaucoma occurs unilaterally, they are even more at risk for acute episodes in the other eye. For this reason, the procedure is typically performed bilaterally as opposed to being done in JUST the affected eye.

IV acetazolamide is not the correct answer. This medication is given in episodes of acute angle-closure glaucoma in order to decrease the intraocular pressure. It is typically given in a single 500mg IV dose followed by 250mg orally 4 times daily. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient’s underlying issue is narrow anterior chambers.

Oral glycerol is not the correct answer. This medication is an osmotic diuretic that can be given 1-2 g/kg in order to decrease a patient’s intraocular pressure during an acute episode of angle-closure glaucoma. This is effective to control the acute episode, but will not treat the disorder definitively, as the patient’s underlying issue is narrow anterior chambers.

Topical timolol 0.25% is not the correct answer. This medication is a topical β-adrenergic blocking agent used twice daily chronically in patients who have chronic glaucoma. The disorder does not require the acute lowering of intraocular pressure such as angle-closure glaucoma. Topical timolol would not be effective in lowering intraocular pressure in patients with angle-closure glaucoma.

A 68-year-old woman presents with episodic, monocular blindness lasting typically less than 5 minutes described as a curtain moving vertically over her visual field. She denies pain or other related vision symptoms. Fundoscopic exam reveals no significant abnormality. What is the most likely cause of the condition described?
Answer Choices
1 Detached retina
2 Retinal artery emboli
3 Retinal vein occlusion
4 Papilledema
5 Macular degeneration
retinal artery emboli
he answer is retinal artery emboli, as the diagnosis for this patient is amaurosis fugax. Amaurosis fugax is characterized by brief episodes of monocular blindness caused by retinal artery emboli, often from ipsilateral carotid disease. Carotid stenosis is best evaluated using intra-arterial angiography. To reduce stroke risk in patients with carotid disease who experience transient vision loss, an anti-platelet drug such as aspirin should be used.
The other answers are not correct because a detached retina does not cause brief, episodic occurrences of blindness and retinal detachment would be noted on fundoscopic exam. Retinal vein occlusion and macular degeneration do not cause the symptoms noted above and fundoscopic exam would reveal significant abnormalities. Papilledema would typically cause bilateral episodic blindness and fundoscopic exam would demonstrate optic disc swelling.
A 55-year-old woman comes to your clinic presenting with episodic vertigo, tinnitus, hearing loss, and ear fullness. Her ear and eye physical examination are unremarkable. You perform a Dix-Hallpike maneuver which is negative. There are no carotid bruits noted on auscultation. Which of the following is the best initial treatment for this patient?
Answer Choices
1 Restrict water intake
2 Diazepam10 mg BID
3 Antibiotics
4 Fluticasone propionate
5 Low sodium diet
The clinical picture is suggestive of Meniere’s disease. The classic syndrome consists of episodic vertigo lasting 20 minutes to several hours associated with fluctuating low-frequency sensorineural hearing loss, tinnitus, and a sensation of aural pressure. The Dix-Hallpike maneuver is a diagnostic maneuver for benign paroxymal positional vertigo. Treatment involves a low sodium diet and diuretics.
Restricting water intake will lead to dehydration and an increase in sodium levels, worsening the symptoms of Meniere’s disease.Diazepam can be used for Meniere’s disease but is usually used for severe vertigo. The question is indicating initial treatment.

Diazepam is used in the treatment of vestibular neuronitis. In vestibular neuronitis, a paroxymal, usually single attack of vertigo occurs without accompanying impairment of auditory functions and will persist for several days to weeks before clearing. Examination reveals nystagmus. These symptoms are not present in this patient.

Antibiotics are not indicated for Meniere’s disease.

Fluticasone propionate is an anti-inflammatory nasal spray used to treat the nasal symptoms of indoor and outdoor nasal allergies and year-round nonallergic nasal symptoms. Fluticasone helps reduce the inflammation that leads to nasal symptoms that include congestion, sneezing, and itchy, runny nose which are not indicated in this patient.

A 42-year-old man presents with a 3-day history of “not being able to hear in my right ear.” The patient’s past medical history is negative and he is not taking any medications. There is not a history of trauma. On physical exam, the whisper test is decreased on his right; the Weber test lateralizes to the right ear and the Rinne test is as follows: right ear bone conduction is greater (lasts longer) than air conduction; left ear air conduction lasts longer than bone conduction.

Question
What is the most likely diagnosis?

Answer Choices
1
Right ear sensorineural hearing loss possibly due to Meniere’s disease
2 Left ear sensorineural hearing loss possibly due to Meniere’s disease
3 Left ear conductive hearing loss possibly due to middle ear disease
4 Right ear sensorineural hearing loss possibly due to acoustic neuroma
5 Right ear conductive hearing loss possibly due to cerumen impaction

Hearing loss can be recognized at the bedside as either sensorineural or conductive through the Rinne and Weber tests. In this case, the Rinne test bone conduction (BC) lasts longer than air conduction (AC) in the right ear ( affected ear) and the Weber test lateralizes to the right ear (affected ear). Normally AC lasts longer than BC because of the amplifying effects of the eardrum and middle ear. If BC is longer than AC, the patient is likely to have conductive deafness. Both tests in this patient indicate a conductive hearing loss in the right ear probably produced by cerumen impaction since there is no apparent evidence of middle-ear disease. In sensorineural hearing loss, both AC and BC are equally diminished.

Right ear sensorineural hearing loss due to Meniere’s disease is incorrect. The patients Rinne and Weber test results indicate conductive hearing loss confined to the right ear not sensorineural hearing loss. There is no evidence of Meniere’s disease.

Left ear sensorineural hearing loss due to Meniere’s disease is incorrect. This patient’s hearing tests indicate a conductive hearing loss in the right ear. In sensorineural hearing loss both AC and BC are equally diminished. Symptoms of Meniere’s disease are not present.

Left ear conductive hearing loss due to middle-ear disease is incorrect. The patient’s hearing tests indicate a conductive hearing loss in the right ear not the left.

Right ear sensorineural hearing loss due to acoustic neuroma is incorrect. There is no evidence of sensorineural hearing loss or acoustic neuroma in this patient.

A 32-year-old woman presents with a 3-day history of irritation, burning, itching, and redness of both eyelids. She denies fever, visual changes, and photophobia. On physical examination, you note the presence of scales clinging to the eyelids bilaterally.

Question
What is the proper management in this case?

Answer Choices
1 Daily cleaning with a damp cotton applicator and baby shampoo
2 Short-term oral antibiotic therapy for 7 days
3 Short-term oral corticosteroid therapy for 14 days
4 Topical corticosteroid eye drops for 10 days
5 Prompt ophthalmologist referral

Daily cleaning with a damp cotton and baby shampoo

The scenario presented above depicts a patient with anterior blepharitis, which is a common disorder seen in primary care; it typically consists of a recurrent bilateral inflammation of the lid margins that involves the eyelid skin, eyelashes, and associated glands. Commonly, the underlying cause is seborrhea, which usually originates in the scalp, eyebrows, or ears. Sometimes, anterior blepharitis can be ulcerative, and the origin in the presented case is staphylococci. Anterior blepharitis can typically be resolved and controlled by cleaning the affected areas daily using a damp cotton applicator, warm water, and a baby shampoo mixture. The object of the daily cleaning is to remove the visible scales as efficiently as possible. None of the other listed options are an appropriate treatment plan for anterior blepharitis.

Patients can also be diagnosed with what is known as posterior blepharitis, which is an inflammation of the meibomian glands of the eyes. It is usually staphylococcal in origin, and it typically presents with significantly worse signs and symptoms, such as hyperemic lids, the presence of telangiectasias, inflammation of the gland or their orifices, or even abnormal secretions; tears may be described as being frothy or greasy. More significant cases of posterior blepharitis can lead to conjunctivitis, hordeola, chalazions, eyelash trichiasis, or even corneal vascularization and thinning. Treatments for posterior blepharitis may consist of long-term oral antibiotic therapy, short-term topical steroids, or short-term topical antibiotics eye drops; if significant complications are evident, an ophthalmologist referral is indicated.

A 35-year-old patient presents with a 2-day history of low-grade fever, headache, nasal congestion, and green nasal discharge. Physical examination reveals tenderness to palpation over the right maxillary sinus. You explain to the patient that she is most likely suffering from a right maxillary sinusitis.

Question
What treatment is indicated in this setting?

Answer Choices
1 A 10-14 day course of amoxicillin
2 A 10-14 day course of amoxicillin/clavulanate
3 Decongestants, nasal saline lavage and nasal glucocorticoids
4 Wait 2 more days, then give oral antibiotics if symptoms do not resolve
5 A prednisone taper

3 Decongestants, nasal saline lavage and nasal glucocorticoids
Acute sinusitis is due to an inflammation of the lining of the sinus cavity lasting for less than 4 weeks. The majority of these infections are of viral etiology, yet it is difficult to differentiate bacterial from viral causes. Bacteria are responsible for 0.2-2% of all cases. Most viral cases tend to improve on their own within 7-10 days. Therefore, due to increasing antibiotic resistance, the guidelines now suggest physicians wait at least 7-10 days prior to prescribing antibiotics for acute sinusitis.Initial management is symptomatic and supportive and includes decongestants, nasal saline lavage and nasal glucocorticoids and acetaminophen for pain. Antibiotics such as amoxicillin, doxycycline and trimethoprim-sulfamethoxazole can be given to adults who do not see improvement in their condition after at least 7 days and in children after 10-14 days.
If the patient is unresponsive to amoxicillin, then other medications such as amoxicillin/clavulanate or a second generation cephalosporin can be used. Other indications for antibiotic use are if the patient presents initially with more severe symptoms or symptoms worsen rather then improve after the diagnosis is made.

During your newborn nursery rounds, a young new mother tells you that there is a family history of eye problems that run on her dad’s side. She’s not sure what problem it is exactly, but many relatives have had to wear glasses. You begin to do a careful eye exam.

Which of the following can be detected by the corneal light reflex test?

Answer Choices
1 Cataracts
2 Glaucomas
3 Retinoblastoma
4 Esotropia
5 Amblyopia

Estropia
The corneal light reflex test, also called the Hirschberg test can reliably differentiate pseudoesotropia from true esoptropia. The corneal light reflex or small white dot on the front of the eye should be in the same position in each pupil. It is normally just slightly nasal to the center of each pupil. If the position is different in each pupil, then some type of strabismus is present. A prism dipoter (PD) is the unit measuring the deflection of light passing through a prism equal to a deflection of 1 cm at a distance or 1 meter. Infantile esotropia characteristically presents as a constant, moderate-to-large angle measuring approximately 25 to 60 PD with alternate fixation. Infants presenting at 2 to 4 months of age with constant esotropia of 40 PD or greater are valid candidates for surgical repair.Pseudoesotropia, or a false appearance of esotropia, is caused because the normal wide bridge of the nose covers most of the conjunctiva on the inner aspect of the eyeball. More white conjunctiva is visible lateral than medial to the iris.

Many cataracts or lens opacity in children are actually acquired within the first several years of life. A normal and equal red reflex in each eye will exclude cataracts. This is best done with the room lights dimmed and an ophthalmoscope held about 2-3 feet away from the infant so both pupils can be seen simultaneously, making comparisons easier. Dark lens opacities signify possible cataracts that will eventually produce a gray or white pupillary reflex or leukocoria. It is then best evaluated by a slit-lamp after pupillary dilation.

Most glaucoma can also be excluded with a normal and equal red reflex. Glaucoma is a common, progressive disease characterized by elevated intraocular pressure causing progressive damage to the optic nerve resulting in atrophy and blindness. This is due to improper development of the eye’s aqueous outflow system. Diffuse corneal haze will obscure the pupil and iris markings; in addition, the symptomatic triad of epiphora or excessive tearing, photophobia, and blepharospasm is evident.

Retinoblastoma can also be detected with an abnormal red reflex test. The affected eye will appear with the cat’s eye, white reflex, or leukocoria. Although rare, retinoblastoma is the most common malignant tumor in children that can be familial or sporadic and can be unilateral or bilateral. Bilateral disease is almost always familial. A mutation of a tumor suppressor gene on chromosome 13 appears to be responsible for tumor development. It may also present with strabismus, hyphema, and periocular inflammation resembling orbital cellulitis.

Amblyopia, or poor or blurry vision, in an otherwise normal appearing eye is caused by either no or poor transmission of the visual image for a sustained period of dysfunction or disuse during early childhood. This can be due to strabismus, anisometriopia, or vision obstructing disorders that result in an opaque ocular media such as with cataracts or corneal scarring from forceps injury. Unless an obvious abnormality is present, amblyopia may have no obvious signs.

A 25-year-old woman presents due to constant sneezing episodes that have progressively worsened over the last few months. Further questioning reveals she also suffers from severe bilateral eye irritation, excessive tearing, and pruritus. On physical examination, you note hypertrophic nasal mucosa that is boggy in appearance, with the turbinates appearing pale. The patient states that this is especially bothersome during spring months; however, it also occurs to some degree during the fall.

Question
Based on the history and physical examination findings, what is the most appropriate first-line clinical intervention at this time?

Answer Choices
1 Oral antihistamines
2 Oral decongestants
3 Intranasal decongestants
4 Intranasal corticosteroids
5 Oral steroids

intranasal corticosteroids
flonase!
The scenario above is describing a common presentation of allergic rhinitis, most likely leaning more towards the seasonal rhinitis. Based on this diagnosis, the most appropriate first-line treatment is intranasal corticosteroids (ICS). The use of ICS for treatment of allergic rhinitis has essentially been a revolution; evidence-based reviews have found ICS to be much more effective and much less expensive than oral antihistamines. They are also less sedating. Key components of ICS therapy that must be addressed with all patients when prescribing them include appropriate training on usage as well as educating the patient that it will typically take 2 or more weeks to note any improvement.Oral antihistamines are a viable alternative for treatment of allergic rhinitis, but they should not be considered first line. If the patient is unable to tolerate ICS or proper usage cannot be executed, oral antihistamines could potentially be initiated.

Oral steroids and oral decongestants are not indicated for the treatment of allergic rhinitis.

Intranasal decongestants should not be prescribed to any patients who are diagnosed with allergic rhinitis, and they should be discouraged in general. These over the counter nasal sprays will lead to a condition known as rhinitis medicamentosa after around 5 – 7 days of treatment; a characteristic of this condition is severe rebound nasal congestion. Increased and longer use of intranasal decongestants will further worsen this condition, creating a viscous and endless cycle.

A 1-day-old infant being examined in the newborn nursery is noted to have a central, 4 mm cataract affecting his right eye. Which of the following is the most appropriate management for this patient?

A Cataract surgery within the next 6 weeks
B Cataract surgery within the next year
C Observation every 3 months
D Observation every 6 months
E Observation every year

A Congenital cataracts that are large and affect visual acuity (e.g., central) must be surgically corrected within the first two months of life (A) to avoid the development of deprivation amblyopia. Observation (C, D, and E) or delayed surgery (B) may result in permanent deprivation amblyopia.

A 54-year-old male patient presents to your office complaining of pain to the left eye with nausea, vomiting, and a headache after being brushed in the eye with his grandchild’s stuffed animal. On examination the conjunctiva is not injected, and the cornea has a steamy appearance. You cannot visualize the retina. The pupil is fixed and 4 mm. When you stain the eye you are unable to see any lesions or scratches. You suspect:

A acute bacterial conjunctivitis
B acute narrow angle glaucoma
C allergic conjunctivitis
D herpes simplex ophthalmicus
E traumatic iritis

Acute Narrow angle glaucoma
Patients with acute glaucoma usually seek treatment immediately because of extreme pain and blurred vision, though there are subacute cases. The blurred vision is associated with halos around lights. Nausea and abdominal pain may occur. The eye is red, the cornea steamy, and the pupil moderately dilated and nonreactive to light. Intraocular pressure is usually over 50 mm Hg, producing a hard eye on palpation.

A 28-year-old man presents with a complaint of new-onset headache. The pain awakens him early in the morning and is described as a sharp, lancinating pain around his right eye, which is 9 out of 10. When he looks in the mirror he notices tearing of his right eye as well as redness and a different sized pupil compared to the left. The pain lasts only for a few minutes but can recur later in the morning. This has happened for the past several days. The patient has a history of recurrent headaches that follow this pattern and usually last for 5 to 7 days. Prior to this occurrence it has been 4 years since his last episode. Which of the following is the most appropriate preventive treatment the patient should be offered at this time?

A sumatriptan (Imitrex)
B dihydroergotamine
C verapamil (Calan)
D oral corticosteroids
E oxygen

Oral corticosteroids started immediately will often force a cluster cycle into remission and prevent future headaches. The infrequent recurrence pattern of the cluster headaches does not support the chronic use of verapamil. Sumatriptan, dihydroergotamine, and oxygen are very useful abortive agents but do not work on stopping the cluster cycle. Both sumatriptan and dihydroergotamine have maximum daily doses and may not be used for all attacks during the day as some cluster patients may have multiple attacks throughout the day.

An 8-year-old girl presents with her mother to the pediatrician’s office with persistent clear nasal drainage and nighttime cough for the past month. Her physical examination reveals clear rhinorrhea, dark circles under her eyes, and a transverse nasal crease.

Question
What is the most likely diagnosis?

Answer Choices
1 Nasal foreign body
2 Sinusitis
3 Allergic rhinitis
4 Upper respiratory infection
5 Influenza

allergic rhinits

A 55-year-old man presents with intermittent vertigo, tinnitus, and progressive hearing loss over the last 4 years. What will an MRI of the head most likely show?

Answer Choices
1 No abnormalities
2 Acoustic neuroma
3 Aneurysm
4 Stroke
5 Hemorrhage

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

A 45-year-old male presents to your office complaining of severe unilateral eye pain with some photophobia for one day. He denies any history of trauma. On examination and with staining, you notice a dendritic lesion to the cornea, and an otherwise normal examination. Which of the following medications would be contraindicated in this patient?

A atropine ophthalmic drops
B azelastine ophthalmic drops
C levofloxacin ophthalmic drops
D prednisolone ophthalmic drops

Prednisolone
This patient has herpes simplex keratitis is an important cause of ocular morbidity. The ability of the virus to colonize the trigeminal ganglion leads to recurrences precipitated by fever, excessive exposure to sunlight, or immunodeficiency. The dendritic (branching) ulcer is the most characteristic manifestation. More extensive (“geographic”) ulcers also occur, particularly if topical corticosteroids have been used. Ophthalmic corticosteroids in cases of suspected herpes simplex keratitis are contraindicated.

A 12-year-old male begins to sneeze, and develops itchy, watery eyes about 15 minutes after being exposed to a cat. There is no respiratory difficulty. What phase of allergic response is he in?

A Humoral
B Priming
C Cellular
D Seasonal
E Perennial

Humoral
The humoral or early phase occurs in the first 15 minutes of being exposed to an allergen. The symptoms are caused by release of histamine. The cellular phase is the late phase, and occurs after four to six hours of allergen exposure. Seasonal allergic rhinitis occurs in a regular pattern each year, corresponding to pollen exposure. Perennial rhinitis occurs year round, and may be more linked with indoor allergen exposures.

A 45-year-old male presents with purulent discharge from his right ear for three weeks. He states that despite being treated by his family doctor for an ear infection one month ago, the problem continues to get worse. Upon exam, you note purulent discharge in the ear canal, an erythemic tympanic membrane, and a possible perforation. What are the pathogens most likely to culture positive?

A Strep pneumoniae
B Pseudomonas aeroginosa
C Escherichia coli
D Candida albicans
E Mycoplasma pheumoniae

Pseudomonas Aeruginosa
The clinical vignette describes a chronic otitis media. Usually, this refers to a complication of acute otits media with perforation. Pathogens that culture from these infections are usually pseudomonas, proteus, or staphylococcus aureus. Strep pneumoniae is often seen in acute otitis media. E.coli is a urinary tract pathogen. Candida albicans is a cause of vaginitis, and mycoplasma is a respiratory pathogen.

A 30-year-old male presents to your office complaining of sinus and facial pain, congestion, and purulent nasal discharge for one month. He has been treated with two courses of different antibiotics by another provider, and does not feel any improvement in his symptoms. What diagnostic test is indicated?

A Plain sinus radiographs
B MRI
C Aspiration and culture of maxillary sinuses
D CT scan
E Ultrasound of sinuses

Ct scan
A CT scan is the current preferred method for sinus imaging of chronic sinusitis. CT imaging has better visualization of mucosal thickening air-fluid levels and bone structures. Plain radiographs and CT scans are of limited use in acute sinusitis, because viral pathogens that cause sinus abnormalities are indistinguishable from bacterial causes.

A 37-year-old male presents to your office with a history of vision loss in his right eye. He denies any pain, and states that the vision loss occurred suddenly. He noted there was a wavy, “curtain-like” visual disturbance preceding the vision loss. Upon physical exam you notice a cherry red spot over the macula and retinal pallor. What is the most likely diagnosis?

A Macular degeneration
B Retinal detachment
C Central retinal artery occlusion
D Cerebrovascular accident
E Central retinal vein occlusion

Central retinal artery occlusion
Central retinal artery occlusion is characterized by a sudden, painless vision loss. A cherry red spot is characteristic on the macula, along with pallor to the retina.

A 33 year-old man with cystic fibrosis is admitted to the hospital with pneumonia. You order a sputum culture and sensitivity. What is the most likely organism causing this patient’s pneumonia?

A Klebsiella pneumoniae
B Legionella
C Mycoplasma pneumoniae
DPseudomonas aeruginosa
E Streptococcus pneumoniae

Psuedomonas

Which of the following conditions is a cause for central vertigo?

A Meniere syndrome
B Labyrinthitis
C Vestibular neuronitis
D Acoutic neuroma
E Perilymphatic fistula

acoustic neuroma
Meniere syndrome, labyrinthitis, vestibular neuronitis, and perilymphatic fistula are causes of peripheral vertigo. Acoustic neuroma, or eight cranial nerve schwannomas, are among the most common intracranial tumors, and a cause for central vertigo.

A 67-year-old man presents with pain and stiffness in his shoulders and hips lasting for several weeks with no history of trauma. He also has complaints of headache, throat pain, and jaw claudication. It is imperative to diagnose this patient promptly in order to prevent which of the following complications?

A anemia
B cerebral aneurysms
C mononeuritis multiplex
D ischemic optic neuropathy
E respiratory tract complications

ischemia optic neuropathy
the most urgent need for diagnosis of a patient with symptoms of polymyalgia rheumatica (PMR) and giant cell arteritis is to prevent blindness caused by ischemic optic neuropathy as a result of occlusive arteritis of the ophthalmic artery. Early diagnosis is imperative as the neurological damage to the optic nerve is not reversible. Most patients with this diagnosis will have a normochromic-normocytic anemia, but this does not create urgency in treatment. Cerebral aneurysms are not common findings with PMR; large vessels such as the subclavian and aorta may be involved in giant cell arthritis in 15% of patients. Mononeuritis multiplex commonly presents with painful paralysis of a shoulder, and respiratory tract complications are more nonclassic findings with the presentation of PMR

A 54-year-old female presents complaining of decreased visual acuity to her right eye over the past few hours. She denies pain, and describes having wavy vision and seeing flashes of light. Her visual acuity in the affected eye is 20/200. What condition best describes the following physical finding?

A Retinal detachment
B Central retinal artery occlusion
C Open angle glaucoma
D Angle closure glaucoma
E Optic neuritis

retinal detachment
The image demonstrates a detached retina. The superior aspect of the retina appears wavy and flowing. A central retinal artery occlusion is characterized by a pale retina, as well as a cherry red spot on the macula. Open angle glaucoma does not cause acute vision loss. Angle closure glaucoma causes painful acute vision loss. Optic neuritis is characterized by painful visual loss and a swollen optic disc.

A 23-year-old man presents 2 hours after being involved in a road traffic accident in which he sustained right-sided periorbital injuries. He is seeing double; he denies headache, vomiting, and loss of consciousness. On examination, he is alert and oriented in time, space, situation, and person. His right eye is deviated downwards and temporally.

Question
What finding would you also expect to find in this patient?

Answer Choices
1 Loss of the corneal reflex
2 Ptosis
3 Pupillary constriction
4 Corneal anesthesia
5 Eye adduction

Ptosis
The clinical picture is suggestive of injury to the oculomotor nerve, which is the 3rd cranial nerve. It innervates the following striated muscles:Superior rectus
Inferior rectus
Medial rectus
Inferior oblique
Their denervation results in infraduction and abduction of the eye.

The oculomotor nerve also innervates the levator palpebrae superioris and the pupillo-constrictor. Their denervation results in ptosis and mydriasis respectively.

Causes of 3rd cranial nerve palsy include:

Intracranial and intraorbital lesions (e.g., neoplasms)
Head and orbital trauma
Ocular myopathies
Cerebral aneurysms
Transtentorial herniation
Patients usually present with diplopia, which is also known double vision. They may also mention the inability to see with 1 eye if the ptosis is severe enough to cover the pupil. They may also mention blurred vision and a glare in bright lights due to the mydriasis.

Corneal anesthesia with loss of corneal reflex is a result of interruption of the trigeminal nerve supply to the cornea and conjunctiva.

A 44-year-old man presents for follow-up of poorly controlled type I diabetes mellitus, which was diagnosed 32 years ago. What change on his funduscopic examination would indicate a need for urgent referral to an ophthalmologist?

Answer Choices
1 Blot hemorrhages
2 Cotton wool spots
3 Microaneurysms
4 Neovascularization
5 Flame-shaped hemorrhages

Neurovascularization
Neovascularization is the hallmark of proliferative diabetic retinopathy. New vessels can appear at the optic nerve and the macula as a result of retinal hypoxia. They are susceptible to rupture, resulting in vitreous hemorrhage, retinal detachment, and blindness. Proliferative retinopathy requires urgent referral to an ophthalmologist and is usually treated with pan retinal laser photocoagulation.The risk of developing diabetic retinopathy is related to the extent of glycemic control and the duration of diabetes. It is classified as nonproliferative and proliferative.

Blot hemorrhages, cotton wool spots, and microaneurysms are indicative of nonproliferative diabetic retinopathy, which is usually seen 10 to 20 years after the onset of diabetes. Nonproliferative retinopathy does not always progress to proliferative retinopathy, but if it becomes extensive, it can result in retinal ischemia, which increases the likelihood of proliferative disease.

Flame-shaped hemorrhages are indicative of hypertensive retinopathy.

A 52-year-old man presents for a follow-up visit. He saw you about 2 weeks ago with the chief complaint of losing his voice. The diagnosis of acute laryngitis was made at that time, and supportive treatment was described in detail to the patient. The patient returns a little worried today because he has had no improvement in getting his voice back since his last visit. The patient is a professor at a local university and desperately needs his voice to return in order to lecture properly. Social history reveals that he has been a 1 pack per day smoker for the past 32 years. Further questioning of the patient during your review of systems reveals a 5-pound unintentional weight loss since his last visit.

Question
What would be the next course of action based on the history and physical examination?

Answer Choices
1 Observation for another 2 weeks
2 Reassurance and supportive treatment
3 Urgent referral to a pulmonologist
4 Urgent referral to an otolaryngologist

Urgent referral to an otolaryngolist
Acute laryngitis, as in the patient scenario above, is most common cause of hoarseness in patients of all ages. More commonly acute laryngitis symptoms will last a week or more even after the resolution of an upper respiratory infection. Typical treatment at that point in time includes avoidance of vigorous use of his/her voice (such as singing or shouting) until it returns to normal. Often the source of acute laryngitis is viral in origin, but there has been incidence of M. catarrhalis and H. influenzae isolated from the nasopharynx of these patients. For this reason, antibiotics are occasionally prescribed to lessen the severity of hoarseness and cough.Certain age groups are risk factors and should lead a provider to a more aggressive search for the diagnosis of acute laryngitis. New or longer than 2-weeks duration of hoarseness in a patient who is known to be a heavy smoker (and especially in a patient who is male) is one of those red flags. This should sway one to contemplate squamous cell carcinoma of the larynx until it can be proven otherwise. Squamous cell is the most common malignancy of the larynx and appears exclusively in patients with a history of significant tobacco use, especially men aged 50-70 years. Our patient above substantially fits into this category. Another disturbing component is his unintentional weight loss that is revealed during the review of system questioning; this is of course a constitutional symptom/sign that cannot be missed.

For the reasons listed above, the correct answer is an urgent referral to an otolaryngologist for initiation of evaluation to confirm the suspected diagnosis. Further observation has an extremely low probability of bringing resolution, as is also the case with reassurance and observation. A pulmonology referral is not indicated at this time, and although the patient has the potential of having laryngopharyngeal reflux, the pertinent positives at this point more towards a type of malignancy.

A 44-year-old Caucasian man presents with chronic rhinitis, as well as nasal congestion, and a decreased sense of smell. He has had these symptoms for several years, but this is the first time he has sought care for them. The patient thought he may have seasonal allergies and has intermittently tried numerous over-the-counter allergy treatments, some of which diminish symptoms temporarily. On physical exam, the patient’s vitals are normal. His HEENT exam is positive for yellowish, boggy nasal mucosal masses protruding bilaterally in the nares. Surrounding tissue is relatively pale, without erythema. Some clear nasal discharge is noted. Posterior oropharynx is mildly inflamed without exudate. Ear exam is normal. Nodes within the neck, auricular and occipital region are not enlarged. Heart, lung, and abdominal exams are normal, with the exception of a dry, nonproductive cough noted a few times.

Question
Based on this patient’s history and physical, which of the following is the most likely diagnosis?

Answer Choices
1 Deviated septum
2 Nasal foreign body
3 Nasal polyps
4 Nasopharyngeal carcinoma
5 Rhinitis medicamentosa

nasal polyps
This patient most likely has nasal polyps, a consequence of long-term rhinosinusitis. Nasal polyps are benign mucosal masses that protrude into the nasal canal and may be unilateral or bilateral. They are associated with chronic allergies and diminished sense of smell.A deviated nasal septum can produce decreased nasal airflow and present with some congestion-like symptoms. However, the physical exam reveals the septum lying off midline, without the mucosal masses characteristic of polyps.

A nasal foreign body could present with a similar history of nasal congestion and rhinorrhea, but is more frequent in young children at risk for putting objects into their noses. The physical exam would readily identify and distinguish a foreign body from nasal polyps.

Neoplasms, such as nasopharyngeal carcinoma, are rare in comparison to the prevalence of nasal polyps and are typically asymptomatic until late in the disease process. A nasopharyngeal carcinoma is most common in patients of southern Chinese ethnicity. Symptoms might include rhinitis or nasal obstruction, similar to the presentation of this patient. However, a neoplasm may be more likely to include pain, nasal hemorrhage/bleeding, and unilateral symptoms if symptoms were present.

Rhinitis medicamentosa is a condition resulting in severe rebound nasal congestion after prolonged and/or frequent use of nasal decongestants, such as phenylephrine. There are typically no distinguishing physical exam findings from this condition.

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

Staph Aureus
Staphylococcus aureus is a gram-positive staining cocci that is catalase positive, coagulase positive, and frequently beta hemolytic on blood agar. It is probably the 2nd most common bacterial isolate of human infections behind Escherichia coli and the most common cause of bacterial endophthalmitis. The organism has been described as an etiologic agent of many infections, including but not limited to, conjunctivitis, endocarditis, septicemia, abscesses, and urinary tract infections. The conjunctivitis caused by Staphylococcus aureusis usually characterized as non-severe where there is little to no lid edema, scant purulent discharge, and normal cornea; however, in some cases the presentation can be severe.
Chlamydia trachomatis is an obligate intracellular parasite with a unique biphasic life cycle. It does not gram stain, and laboratory procedures used for diagnosis include isolation in tissue culture, EIA detection of antigen, immunofluorescent staining, cytologic examination for intracytoplasmic inclusions, and by the demonstration of nucleic acid by direct hybridization or by amplification techniques. It can cause inclusion conjunctivitis and ocular trachoma. The inclusion conjunctivitis presents as an acute follicular conjunctivitis and is usually self-inoculated from an infected genitourinary site. The patient frequently complains of a foreign body presence in the eye. These symptoms are usually unilateral, and in the first 2 weeks, there is a mucoid discharge that becomes purulent.Pseudomonas aeruginosa is a gram-negative rod, non-lactose fermenting, oxidase-positive motile bacteria. Pathogenesis is due to its minimal nutritional requirements, relative resistance to antibiotics, and a host of other invasive and toxinogenic substances that it produces. It can cause a keratitis that is rapid in its development. The infection is usually the result of a previous injury to the eye, which causes an interruption in the epithelial surface and allows bacterial invasion of the underlying stroma. Scrapings from the floor of the ulcer exhibiting gram-negative rods are strongly indicative of Pseudomonas aeruginosa and should necessitate treatment.

Haemophilus aegyptius is a gram-negative coccobacillus, non-motile, fastidious bacteria requiring the presence of special factors for its growth on agar media. These factors are hemin and nicotinamide adenine dinucleotide, which are present in chocolate agar but not on other isolation media. The organism is indigenous to humans. It is an important cause of a purulent conjunctivitis called “Pink Eye” and can occur in outbreaks because of its contagious nature. The diffuse pink color of the sclera and the presence of a serous or purulent discharge are virtually diagnostic of Haemophilus aegyptius infection. Leukocytosis is absent. The infection is not acute in presentation.

Bacillus cereus is a gram-positive (or gram-variable) rod that is aerobic, spore-forming, and is ubiquitous in nature. Bacillus cereus is an important cause of food poisoning. It has also been recognized as an ocular pathogen. The ocular infection is acute in presentation and requires aggressive intervention to save the eye. The presence of progressive corneal deterioration and ring abscess formation is a complication of panophthalmitis caused by Bacillus cereus. Except for infections with Pseudomonas aeruginosa, this finding is almost pathognomonic of Bacillus cereus. Because of the seriousness of the infection, early diagnosis is important. Patients presenting with ocular infections after trauma or in the setting of drug abuse should arouse suspicion.

Acanthamoeba is a free-living amebae that can cause granulomatous amebic encephalitis and keratitis. It can not be cultured by routine culture methods. Detection is usually made by observing the free living motile organisms in a wet prep preparation. Acanthamoeba keratitis is a slow-developing corneal infection that occurs in healthy people and is usually associated with contact lens wearers. Symptoms include blurred vision, conjunctivitis, tearing, severe pain to the eye, and photophobia. The keratitis achieves an advanced stage in several days to several months and can exhibit patchy stromal infiltrates and dendriform epithelial involvement without frank corneal ulceration in its early stages.

Candida albicans is a yeast. Yeasts appear on gram stain as large gram-positive organisms, approximately 3-5 times larger than gram-positive cocci, and are nonhemolytic on blood agar. They are aerobic and generally grow well on most non-selective agar media. Endophthalmitis due to yeast is generally a common and serious complication of intravenous drug use. Candida albicans is the most common fungal cause. It is usually of hematogenous origin where the patient has infective endocarditis or some other infective process occurring. The symptoms are blurred vision, decreased vision, white cotton appearing exudative lesions in the choroid and retina with vitreous haziness, and eye pain. A definitive diagnosis is made by obtaining vitreous fluid for gram stain and culture.

A 78-year-old Caucasian man presents with unilateral painless loss of vision in the right eye of 3 hours duration. Examination reveals an elderly gentleman who is anxious but in no acute distress. Visual acuity is light perception only in the right eye and 20/30 in the left eye. Pupillary examination is significant for an afferent pupillary defect on the right side. Penlight examination of the eyes is otherwise unremarkable. Retinal examination of the right eye reveals a cherry-red spot. Retinal examination of the left eye is unremarkable.

Question
What disease process most likely accounts for the patient’s presentation?

Answer Choices
1 Adult-onset Tay-Sach’s disease
2 Open angle glaucoma
3 Central retinal artery occlusion
4 Trauma
5 Cataract

Central retinal artery occlusion
This case represents the classic presentation of a central retinal artery occlusion, namely acute, unilateral, painless, loss of vision as well as a cherry-red spot on fundus examination.Tay-Sach’s disease is a lysosomal storage disease found predominantly in Ashkenazi Jews. Infants with this fatal neurodegenerative disease do have a cherry red spot on retinal examination. An adult-onset form of Tay-Sach’s disease is rare but does exist. Onset of symptoms is in the 3rd or 4th decade of life; however, it is characterized by neurologic deterioration and cherry-red spots would be bilateral. Although this patient does have a cherry-red spot, there is nothing in the presentation to suggest Tay-Sach’s disease.

Open angle glaucoma is a chronic, slowly progressive condition that would not be expected to cause acute visual loss. The patient gives no history of trauma and no evidence of trauma is seen on examination. A cataract, or opacification of the lens, would not be expected to cause acute visual loss.

A 49-year-old woman presents with a neck mass. On examination, a firm nontender, 3-cm thyroid nodule is felt. TSH, T3, and T4 levels are all normal.

Question
What is the most appropriate next step?

Answer Choices
1 Levothyroxine treatment
2 Potassium iodine treatment
3 Total thyroidectomy
4 Fine needle aspiration
5 Observation

Fine needle aspiration
Fine needle aspiration is the correct response. The patient presents with a thyroid nodule. TSH, T3, and T4 are all normal, which raises the suspicion of thyroid malignancy. Of the above options, fine needle aspiration is the most appropriate next step; it will determine if there are malignant cells present.Levothyroxine treatment is an incorrect response. The patient has normal TSH levels and does not require thyroid replacement.

Potassium iodine treatment is an incorrect response. The patient has normal thyroid function studies.

Total thyroidectomy is an incorrect response. If the patient’s fine needle aspiration yields malignant cells, the patient may require a partial or total thyroidectomy as treatment. At this point, it is unknown if the thyroid nodule contains malignant cells, so a total thyroidectomy would be inappropriate.

Observation is an incorrect response. Due to the size of the nodule and the presence of normal thyroid function studies, malignancy must be ruled out.

A 1.5-year-old boy presents with a squint in the left eye. His mother informed you that the child’s eyes were quite normal until about 2 months ago, when she noticed asymmetric movements of her son’s eyes. She also felt that the child could not see properly with his left eye. There is no history of trauma to the eye. Child was born at full term and his growth and development were within normal limits. Eye examination showed both eyeballs were equal in size. There was loss of vision in the left eye and a convergent squint in the same eye. Fundus examination showed absence of red reflex in the left eye, and instead a white pupillary reflex (leukocoria) was seen. X-ray of the skull showed calcification within the globe.

Question
What is the most likely diagnosis?

Answer Choices
1 Retinal detachment
2 Congenital cataract
3 Retinoblastoma
4 Congenital glaucoma
5 Persistent hyperplastic primary vitreous

retinoblastoma
The most likely diagnosis is retinoblastoma, as it is the most common primary ocular tumor in children below 5 years of age. 90% of cases are diagnosed below 3 – 4 years of age. The index case is a 1.5-year-old boy who has presented with a recent appearance of squint and absence of normal red reflex in the left eye, replaced instead by a white pupillary reflex (leukocoria). This is due to reflection of light from the white-colored tumor and loss of vision in that eye. The diagnosis is further supported by calcification seen in the globe in the X-ray of the skull. Fundoscopy may show the tumor as a white mass, which may be small and flat or may be large and protuberant. Orbital inflammation, hyphema, and irregular pupil are seen in advanced stages of the disease. Retinoblastoma gene is a recessive gene located on the chromosome13 at the 13q 14 regions, and the tumor may arise from any of the nucleated layers of the retina.Besides direct observation, ultrasonography or CT scan may help to confirm the diagnosis and demonstrate calcification within the mass. As biopsy can lead to the spread of the tumor, histopathological confirmation of the tumor can be made only after removal of the affected eye

Retinal detachment in infants and children more commonly occurs due to trauma, secondary to other abnormalities like myopia, or after cataract surgery. It can also occur in diabetes, sickle cell disease, and retinopathy of prematurity. Presenting signs can be loss of vision, secondary strabismus (squint), nystagmus, and leukocoria (white pupillary reflex). Calcification seen on an X-ray of the skull in retinoblastoma is absent in retinal detachment. Also ultrasonography and neuroimaging may be required to establish the cause of detachment.

Congenital glaucoma (elevated intraocular pressure) usually manifests during the first 3 years of life. The classical triad of symptoms of congenital glaucoma are epiphora (excessive lachrymation), photophobia (sensitivity to light), and blepharospasm (squeezing of the eyelids). These symptoms are due to corneal irritation. As the cornea and sclera are more elastic during early childhood, the elevated intraocular pressure therefore leads to expansion of the eyeball, including the cornea, and development of buphthalmos (ox eye), which means a large eye. This leads to corneal edema and conjunctival congestion. The cornea may become cloudy. There is no white pupillary reflex or calcification in the globe seen on an X-ray of the skull.

A cataract is an opacity in the lens and may cause significant impairment of vision. It may be an isolated defect or may be a part of a generalized disorder. Common causes are intra uterine infections like rubella, cytomegalovirus infection, toxoplasmosis, metabolic disorders like galactosemia, and chromosomal disorders like trisomy 13, 18, and 21. Trauma to the eyeball is a major cause of cataract in children. The red reflex may be absent or may be irregular or there may be a white pupillary reflex. The retina and the blood vessels may not be visualized due to the lenticular opacities. Nystagmus may be present. Poor visual fixation, squint, and poor social smile may be seen later on. Calcification in the globe is not present in cataract.

Persistent hyperplastic primary vitreous (PHPV) is caused by persistence of portions of the fetal hyloid vascular system and the associated fibromuscular tissue. The condition is usually unilateral, and the affected eye is smaller than normal. The anterior chamber is shallow, and the lens is also smaller than normal. Other presenting signs are white pupillary reflex (leukocoria) strabismus and nystagmus. The course is progressive and outcome is poor.

The major complication is spontaneous intraocular hemorrhage, swelling of lens caused by rupture of posterior capsule, and glaucoma. Sometimes the distinction between PHPV and retinoblastoma can be difficult. Ultrasonography and CT scan can be useful diagnostic aids that may show calcification within the mass in the case of retinoblastoma.

A 77-year-old male farmer has been your patient for many years. He presents with a sore that will not heal. When you see this patient, he describes an area on his right cheek that has been present for the last 6 months. At first, it was just a bump, and it had a pearly color to it. There is now is an open sore on the area, which has been present for the last 2 weeks and has not healed; it is what brings the patient in to see you today.

Question
Based on the history and physical examination findings of this patient, what is the most likely diagnosis is this case?

Answer Choices
1 Basal cell carcinoma
2 Squamous cell carcinoma
3 Actinic lentingines
4 Actinic keratosis
5 Malignant melanoma

Basal cell carcinoma
The lesion being described in the above patient scenario is most likely to be basal cell carcinoma. Key characteristics of lesions of basal cell include having a pearly, papular, erythematous patch that is usually larger than 6 mm or possibly appearing as a non-healing ulcer. The areas in question will commonly be found on sun-exposed areas of the body, specifically the face, trunk, or lower legs.Squamous cell carcinoma appears as a non-healing ulcer or a wart-like nodule. This also is due to long time sun exposure and is especially common in patients who are fair-skinned or those that are organ transplant recipients.

Malignant melanoma is another type of skin cancer that patients may present with but the characteristics are distinctly different from the 2 previous skin cancers described. Malignant melanoma lesions may be flat or raised, and they have irregular borders; initially, they are usually a pigmented area on the skin that has recently noticeably changed in appearance. Clinicians and patients will use the mnemonic “ABCD” rule when evaluating pigmented areas: asymmetry, border irregularity, color variegation, and diameter ? 6 mm.

Actinic keratosis is skin lesions that are not a form of cancer. These are small (0.2 – 0.6 cm) macules or papules that typically flesh-colored, pink, or even slightly hyper-pigmented. They possess a sandpaper consistency and may be tender when palpated. These also occur in sun-exposed area of the skin in fair skinned patients.

Actinic lentigines are also known as liver spots. They commonly present in older patients on areas that have significant exposure to the elements of weather, in such areas as the dorsum of the hand, wrist, and forearm. Lesions of actinic lentigines are also a benign condition.

A 52-year-old man presents with concerns over hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only 1 side (his left). Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks that he is experiencing normal age-related hearing loss. His review of systems is negative for other neurological symptoms.

The patient’s past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use.

On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed, and it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells.

Question
What structure is likely involved in this patient’s condition?

Answer Choices
1 Foramen ovale
2 Internal carotid artery
3 Semicircular canals
4 Tensor tympani
5 Vestibulocochlear nerve

vestibulocochlear nerve
this patient is presenting with a vestibular schwannoma (or acoustic neuroma), affecting his vestibulocochlear nerve (cranial nerve VIII). This is one of the more common benign head and neck neoplasms. A common presentation is unilateral hearing loss and tinnitus. An understanding of basic head anatomy can help the clinician appreciate the affected structures.The foramen ovale is an oval-shaped opening in the sphenoid bone, through which the mandibular nerve (the 3rd division of the trigeminal nerve) passes.

The internal carotid artery is one of the major blood supplies to the head. Part of its path lies near the ear structures, but an intracranial mass affecting the internal carotid artery would not produce the characteristic sensorineural hearing loss.

The 3 semicircular canals are openings that are set in right angles to each other; they are found in the bony structure of the ear, which communicate with the vestibule and are partly responsible for balance. The patient’s history, exam and tests do not suggest the tumor is affecting the semicircular canals.

The tensor tympani are short (about 2 cm long) muscles in each ear, which pull on the malleus and tighten the tympanic membrane. Their role is to prevent hearing damage when exposed to loud sounds. They are innervated by the mandibular nerve, which is a branch of the trigeminal nerve.

A 16-year-old boy presents with ringing in his ears. His mother states that, over the past year, he has had the volume on the television and radio turned up very high. He prefers to listen to music with headphones on, and he plays the drums in both the school band and a rock band. His mother has observed that he is uncomfortable in crowded rooms with a lot of people talking. His grades in school have also been deteriorating. He has no prior history of ear infections. Examination of the ears demonstrates normally formed auricles. Ear canals are clear. Tympanic membranes appear normal, and they move well with insufflation. A Weber test localizes sound to the middle of the forehead. Rinne test demonstrates air conduction > bone conduction bilaterally. Neurological examination demonstrates no focal findings. A screening audiogram demonstrates a 30 db hearing threshold at 4000 Hz. He was referred for formal audiology testing which demonstrated a symmetric hearing loss most pronounced at 4000 Hz. The history, physical examination, and audiogram are consistent with what condition?

Answer Choices
1 Congenital Stapes Fixation
2 Meniere’s Disease
3 Noise induced hearing loss
4 Otosclerosis
5 Tympanosclerosis

noise induced hearing loss
It is estimated that 12% of American youth between 12 and 19 years of age have noise-induced hearing loss (NIHL). The louder the sound, the shorter the time it takes to cause hearing loss. Continuous exposure to sound >85 dB can cause damage. There may be a genetic predisposition to NIHL. Damage can be caused by a single sound, such as a gunshot or explosion, or continuous exposure to loud noises. Sometimes, a single loud noise can cause a temporary loss called a threshold shift, which produces ringing in the ears after the event. An early symptom of noise induced hearing loss is trouble understanding speech when there is increased background noise. Symptoms may include distorted or muffled speech, ringing in the ears, or difficulty in hearing in the classroom. Loud noises damage hair cells in the inner ear that send noise impulses to the brain.Otoscopic examination is generally normal, and rarely reveals tympanic membrane disruption or damage to the ossicles. The Weber test, done by holding a tuning fork on the middle of the patient’s head, is only useful with asymmetric hearing loss. The sound localizes to the side with a conductive hearing loss or away from the side with a sensorineural hearing loss. When the sound is heard in the middle of the forehead, it indicates either that hearing is normal or there is a symmetric hearing loss. The Rinne test, done by placing a tuning fork over the mastoid and then moving it to the external auditory canal when sound can no longer be heard, demonstrates air conduction > bone conduction with normal or sensorineural hearing loss and bone conduction > or equal to air conduction with conductive hearing loss.

Chronic NIHL usually requires 10 – 15 years of chronic exposure with constant noise, which is more damaging than intermittent noise. It is always sensorineural, equal bilaterally, rarely produces a profound loss, no longer progresses when the noise is removed, and higher frequencies are more commonly affected. The loss is permanent. It is seen in a wide variety of occupations including factory workers, miners, armed forces, aviation workers, railroad workers, and construction workers.

Meniere’s Disease presents with attacks that may include vertigo, tinnitus, and hearing loss. Affected individuals tend to be sensitive to loud noises. Attacks may last from 20 minutes to 24 hours. Hearing loss is usually unilateral and usually progresses to a permanent sensorineural hearing loss. Typical age of onset is 40 – 60 years. It is rare in children. Both the cochlear and vestibular systems are affected.

Otosclerosis may appear as early as 7 – 8 years of age, but it most commonly presents between 15 and 35 years. Hearing loss and tinnitus are the presenting symptoms but vary in severity and rate of progression. Dizziness occurs in some. Causes may include a prior history of frequent otitis media leading to ossicular discontinuity, necrosis of the incus, and replacement of the union between the incus and stapes with a fibrous band. Most commonly, otosclerosis produces a conductive hearing loss due to fixation of the footplate of the stapes in the niche of the oval window. However, it may cause sensorineural hearing loss if it involves other areas of the cochlea. Surgical treatment generally consists of stapedectomy in both children and adults or cochlear implant in advanced cases. Flourides have been used and may slow or halt the progression of the disease. Sodium fluoride, an enzyme inhibitor, reduces osteoclastic bone resorption and may rebuild pseudohaversian bone.

Congenital stapes fixation is detected in the initial 10 years of life and presents with a non-progressive hearing loss. Acquired stapes immobility resulting from typmanosclerosis that fills the oval window with tympanosclerotic plaques. It often results from chronic otitis media and is more common than otosclerosis. Paget’s Disease and osteogenesis imperfecta result in stapes fixation and present clinically like otosclerosis. Audiometric evaluation shows conductive hearing loss with absent stapedius reflex.

A 17-year-old boy was in your clinic 4 days ago for evaluation of a 101.8° F fever and was diagnosed with acute pharyngitis. You prescribed penicillin VK 250 mg TID for 10 days. The patient returns today because his sore throat is now worse. He has not been able to drink fluids, and he has excruciatingly severe pain with swallowing. You recognize the muffled “hot potato” voice. On re-examination, you identify a right medial deviation of the soft palate with a 4+ right tonsillar swelling.

Question
What is the most likely diagnosis?

Answer Choices
1 Oral candidiasis
2 Peritonsillar abscess
3 Laryngitis
4 Mononucleosis
5 Dental abscess

Peritonsilar abscess
This patient is clearly suffering from a peritonsillar abscess. This occurs when an active infection penetrates the tonsillar capsule and then involves the surrounding tissue. These patients will have a severe sore throat, odynophagia, trismus, deviation of the soft palate, and an abnormally muffled voice (i.e., a ‘hot potato voice’).Oral candidiasis (or thrush) does not present with the symptoms described in the scenario. Typically, oral candidiasis is painful and appears as creamy-white, curd-like patches; overlying erythematous mucosa can be found virtually anywhere in the oral cavity. The white patches can easily be wiped off when attempted.

Laryngitis is lower on the differential diagnosis list because it usually presents with the primary symptom of hoarseness. Laryngitis frequently occurs approximately 1 week after the occurrence of an upper respiratory viral infection that has since resolved.

A dental abscess would cause severe, persistent, throbbing toothache, sensitivity to hot and cold temperatures, sensitivity to biting or chewing, fever, possibly noticeable swelling in the face or cheek, or even lymphadenopathy relating back to the site of the abscess. The symptoms of a dental abscess do not match the clinical scenario presented.

Mononucleosis also presents somewhat differently than the scenario above, making it a less likely diagnosis. Malaise, fever, sore throat (sometimes exudative), lymphadenopathy, palatal petechiae, and even splenomegaly are found in patients with mononucleosis.

A 30-year-old man presents with recurrent vertigo. He gives a history of attacks when rising from bed in the morning and rolling over in bed. He does not have headache, earache, hearing loss, nausea, or vomiting. On examination, external auditory canals are normal. Hearing tests are within normal limits. Pulse is 72/min, and blood pressure is 120/78 mm Hg. Central nervous system examination, including higher functions and mental status, is within normal limits.

Question
What is most likely to be useful in treating the patient’s condition?

Answer Choices
1 Diuretics
2 Methylprednisolone
3 Selective serotonin reuptake inhibitors (SSRIs)
4 Repositioning maneuvers
5 Scopolamine patch

repositioning maneuvers
The correct answer is repositioning maneuvers. The patient gives a classic history of benign paroxysmal positional vertigo, which most often responds to treatment with repositioning maneuvers that utilize gravity to remove the otoconia (calcium carbonate crystals) from the semicircular canals that are thought to be responsible for causing the condition1.Diuretics are used in cases of vertigo in Meniere’s disease caused by increased endolymphatic pressure1. This patient does not have symptoms of Meniere’s disease, which usually include hearing loss, nausea, and vomiting.

Methylprednisolone is used to treat vertigo caused by vestibular neuritis which is associated with nausea, vomiting, and upper respiratory infections1.

Selective serotonin reuptake inhibitors (SSRIs) are used to treat vertigo in psychosomatic disorders like major depression, anxiety, and panic disorders1. This patient does not have symptoms associated with any of these disorders.

Scopolamine is an anticholinergic medication used to treat vertigo caused by motion sickness1. It causes symptomatic relief, but is not a treatment for vertigo.

A 22-year-old female college student presents due to mild year round symptoms of nasal blockage, sneezing, rhinorrhea, and excessive tearing. She reports a family history of allergies to various substances. A nasal smear reveals many eosinophils. Immediate skins tests show positive reactions to house dust, grass, and ragweed pollens. What is the most appropriate therapeutic intervention?

Answer Choices
1 Antigen avoidance measures
2 Environmental measures such as air conditioners
3 Intranasal corticosteroids
4 Antihistamine-adrenergic agonist preparations
5 Allergen immunotherapy

This patient has signs and symptoms of perennial allergic rhinitis.

Perennial rhinitis is a type 1 hypersensitivity reaction. Patients are symptomatic throughout the year and usually present with chronic nasal obstruction, rhinorrhea and excessive lacrimation. Sinusitis, nasal polyps, or aspirin sensitivity may complicate it. On examination, the nasal mucosa may be edematous, and is usually pale or bluish in color with thin nasal secretions. Nasal polyps maybe visualized. Conjunctival findings include injection and swelling with occasional chemosis.

The diagnosis is made by a positive history of atopic disease, the characteristic bluish red nasal mucosa and numerous eosinophils in a nasal smear stained with Wright stain.

Positive skin tests help to identify the particular allergen. Perennial allergens include:

1. House dust mites

2. Epidermal antigens produced by pets such as cats and dogs

3. Indoor molds such as spores of aspergillus and penicillium

4. Occupational allergens such as platinum salts and wood dust

5. Cockroach skin casts

Treatment should be based on the patient’s age and severity of symptoms. Patients should be advised to avoid known allergens and be educated about their condition. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for mild to moderate disease. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies (e.g., nasal irrigation). With the exception of cetirizine, second-generation antihistamines are less likely to cause sedation and impair performance. Immunotherapy should be considered in patients with a less than adequate response to usual treatments.

Antigen avoidance is most effective when a single agent is responsible for the symptoms. When complete avoidance is impossible (as with house dust), exposure may be reduced by such measures as wet mopping and dusting frequently.

Environmental measures such as air conditioners only reduce indoor mold and pollen counts but would not be the most effective measure for this patient who is allergic to house dust, grass and ragweed pollen.

Immunotherapy maybe indicated if a patient continues to experience clinically significant symptoms after appropriate environmental measures, antigen avoidance, and pharmacologic measures have been taken. This is done by injecting an extract of the allergen subcutaneously in gradually increasing doses.

A 22-year-old woman presents because she developed a 101 degree fever this morning. She has a 2-week history of rhinorrhea, congestion, and headache. She states that her rhinorrhea was initially clear and actually improved after 5 days, then returned and developed into a green color. Her headache is felt in the forehead and cheeks and worsens when she bends over.

Question
What is the likely causative pathogen of her illness?

Answer Choices
1 Rhinovirus
2 Adenovirus
3 Streptococcus pneumoniae
4 Pseudomonas aeruginosa
5 Staphylococcus aureus

strep pneumoniae
The correct answer is Streptococcus pneumoniae. Given her symptoms of rhinorrhea accompanied by sinus pressure, she is likely suffering from sinusitis. While viruses cause the majority of cases of sinusitis, the patient’s clinical picture is more suggestive of a bacterial etiology for the following reasons: first, her duration of symptoms is longer than 10 days; second, her clinical condition improved then worsened again, suggesting that she may initially had a virus which allowed for a secondary bacterial infection to develop; and third, fever and purulent nasal discharge are present, both of which are more likely with bacterial sinusitis. Of the above bacterial causes, Streptococcus pneumoniae is the most common causative agent. Other streptococci species, as well as Haemophilus influenzae, are also common causes of bacterial sinusitis.Rhinovirus and adenovirus are both incorrect. While most cases of sinusitis are viral in nature, the patient’s clinical picture is more suggestive of a bacterial cause.

Pseudomonas aeruginosa is not a common cause of sinusitis.

Staphylococcus aureus may cause sinusitis, but Streptococcus pneumoniae is more common.

A 2-year-old girl is brought to an otolaryngologist by her mother for chronic ear infections. The patient is otherwise healthy, with the exception of recurrent episodes of otitis media (OM). Examination and history show that the child has had average growth and development; she has not had invasive infections, skin disorders, or hospitalization. The child’s mother is concerned about the risk of hearing loss and its effects on development. What statement about hearing loss and OM is most accurate?

Answer Choices
1 Hearing loss does not result from OM, except in rare cases
2 Sensorineural, but not conductive hearing loss, is associated with OM
3 Hearing loss during OM may adversely affect cognition and language
4 Van der Hoeve syndrome, a sequela of OM, can cause hearing loss
5 Hearing loss associated with OM is always conductive and temporary

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

A 34-year-old woman presents to your office to establish care. Her past medical history is significant for gastritis. She has no other medical problems. As part of your new patient assessment, you perform a neurological examination. On confrontation with visual field testing, you note bilateral temporal field defects, specifically a bitemporal non-homonymous hemianopsia. The remainder of your neurological evaluation is unremarkable. What would be your next step in the management of this patient?

Answer Choices
1 Refer the patient to the emergency room for evaluation of a possible stroke
2 Order an outpatient MRI of the brain
3 Check thyroid function tests
4 Check an EKG in your office
5 Consult with ophthalmologist for possible glaucoma

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

While glaucoma can cause visual field defects, a bitemporal hemianopsia suggests a chiasmal lesion. Glaucoma would be unlikely in this setting and with a patient of this age.

A 7-year-old male is brought to the emergency room due to a 2-hour history of persistent bleeding from the nose. He has a history of several nosebleeds, which usually respond to pinching of the nose, but this episode has continued despite pinching the nose. His father reports that he is known to pick his nose and was noted to have some cold symptoms more recently. He did not experience excessive bleeding at circumcision, and there is no family history of bleeding disorders. On physical exam, he is alert and responsive to questions. His heart rate is 120 bpm; respiratory rate is 20/min; blood pressure is 105/64 mmHg; and oxygen saturation is 97% on room air. There is continuous active bleeding from his left nostril. On examination of the nose, no obvious bleeding site can be discerned in the anterior part of the nasal cavity. He receives phenylephrine and nasal packing after the initial evaluation, and his bleeding finally stops.

Question
What is the most appropriate next step in his assessment?

Answer Choices
1 MRA of sinuses
2 CT of sinuses
3 Nasopharyngoscopy
4 Chest X-ray
5 No further evaluation

nasopharyngoscopy
Nosebleeds are fairly common in children; they are usually associated with trauma (nose-picking), mucosal friability due to upper respiratory tract infection, and mucosal drying related to environmental conditions. Most episodes are self-limited and require simple measures, such as stopping the bleeding with pressure application (pinching) and comfort care. Recurrent nosebleeds are rarely noted to be due to an underlying anatomic or hematologic abnormality. Patients who require further evaluation are those who:have very frequent nosebleeds
have bleeding that is difficult to control or localize
have a positive family history of bleeding disorder
have other signs suggestive of a bleeding disorder
In most cases, initial evaluation of patient history and physical examination identifies the source and likely cause of the bleeding. About 90% of nosebleeds occur due to injury to the anterior vascular plexus of Kiesselbach in the anterior nasal septum; this site is usually visible on nasal exam. In this case, the inability to localize the source of the bleeding to the anterior vestibule suggests a more posterior source (bleeding from anterior or posterior ethmoidal or sphenopalatine arteries), which is more difficult to control. Nasopharyngoscopy helps identify the site and direct treatment. If a mass lesion or vascular anomaly is suspected, then CT or MRA may be considered as the next step in evaluation. In this case, chest X-ray would not provide any meaningful information that would help guide management.

For a suspected bleeding disorder, the initial evaluation should include complete blood count with platelet counts, peripheral smear evaluation, prothrombin, time, partial thromboplastin time, and type and cross match sample to be kept if transfusion is anticipated. Based on the initial results, further testing can then be directed towards evaluation for platelet function abnormalities, factor assays, or von Willebrand factor/ristocetin cofactor assay as required.

A previously healthy 5-year-old boy presents with complaints of bilateral eye pain and redness. The child’s mother reports that several children in his daycare facility have had similar symptoms. Results of physical exam indicate bilateral nonsuppurative conjunctival inflammation, photophobia, and preauricular lymphadenopathy. What is the most likely organism responsible for this outbreak of conjunctivitis?

Answer Choices
1 Haemophilus ducreyi
2 Adenovirus
3 Neisseria gonorrhoeae
4 Chlamydia trachomatis
5 Human herpesvirus 6

Adenovirus
A common source outbreak of epidemic keratoconjunctivitis, ‘pink eye’, is usually a result of contact with other infected individuals or improperly cleaned optical instruments. In this case, the acute onset, bilateral presentation, and epidemic nature point to adenovirus (types 8, 19, and 37) as the most likely pathogen. Ophthalmic infection with this highly communicable virus, for which humans are the only known reservoir, is about the only time the preauricular lymph node is evident.Haemophilus ducreyi is the causative agent of chancroid, a sexually transmitted disease causing a hard, localized chancre in the genital area.

Neisseria gonorrhoeae may cause conjunctivitis in adults and can be transmitted to neonates.

Chlamydia trachomatis is the leading cause of blindness worldwide. Infection with this obligate, intracellular pathogen results in trachoma (a chronic keratoconjunctivitis) in endemic areas such as Africa, Asia, and the Mediterranean. Chlamydia trachomatis also causes inclusion conjunctivitis, the most commonly seen infection in sexually active young adults. Infection occurs from inoculation of the eye with infected genital secretions.

Human herpesvirus 6 (HHV-6) is a common herpesvirus about which little is known. HHV-6 causes a maculopapular rash in infants known as roseola infantum, and may also be a common cause of high fevers in children.

A 52-year-old man presents with a concern of hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only 1 side (his left). Furthermore, he hears a ringing sound all the time. He is a business manager, and he denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms.

The patient’s past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and drug use.

On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI is performed; it shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells.

Question
What choice represents the best intervention for this patient’s current condition?

Answer Choices
1 Referral for chemotherapy
2 Referral for electroencephalography
3 Referral for surgery
4 Referral for unilateral hearing aid
5 Referral for ventricular shunt

referral for sx
This patient is presenting with a vestibular schwannoma (or acoustic neuroma), which is affecting his vestibulocochlear nerve (cranial nerve VIII). This is one of the more common benign head and neck neoplasms. A common presentation is unilateral hearing loss and tinnitus. Treatment is typically surgical removal; another possibility is radiation therapy. Of the choices listed, referral for surgery is the best option; if he turns out to be a poor surgical candidate, radiotherapy should be discussed.This patient should not be referred for chemotherapy. Schwannomas are not typically responsive to chemotherapy, so doing so could delay appropriate treatment.

If the patient was describing seizures, the provider should refer for electroencephalography (EEG), especially as some brain tumors are associated with seizures. However, this patient denied other neurological symptoms and has been clearly shown to have an intracranial mass. Referral for EEG would also delay definitive treatment.

A referral for unilateral hearing aid would not fix this man’s hearing loss; the treatment of his brain tumor would be delayed.

A referral for ventricular shunt should be done for patients with hydrocephalus. Shunts have no role in schwannoma treatment.

A 35-year-old woman presents with slowly progressive right-sided hearing loss, tinnitus, and continuous vertigo. Patient’s Weber test reveals lateralization to the left ear.

Question
What is the most likely cause of this patient’s symptoms?

Answer Choices
1 Vestibular neuronitis
2 Meniere’s disease
3 Acoustic neuroma
4 Labyrinthitis
5 Benign paroxysmal positional vertigo

acoustic neuroma
Acoustic neuroma is a benign tumor of the VIII cranial nerve. While these tumors are benign, their growth can lead to sensorineural hearing loss, vertigo, and tinnitus. Because the tumor is slow growing, symptoms typically have a gradual onset. Diagnosis is made by MRI.In vestibular neuronitis, patients present with paroxysmal episodes of vertigo without hearing loss. The patient may also have nystagmus.

Meniere’s disease also presents with vertigo, sensorineural hearing loss, and tinnitus; however, these symptoms are typically episodic in nature, whereas the symptoms of acoustic neuroma are continuous.

Labyrinthitis presents with an acute onset of continuous vertigo, hearing loss, and tinnitus. Symptoms gradually improve over several weeks, though hearing may remain impaired following recovery. Acoustic neuroma has a gradual onset, and symptoms will not improve until the tumor is treated.

Patients with benign paroxysmal positional vertigo have recurrent episodes of brief vertigo without hearing loss; the vertigo is related to changes in head position. There is no associated hearing loss.

A 64-year-old Asian man presents with a 1-hour history of severe right eye pain that started while he was watching a movie at the theater. He notes right eye “blurred vision and seeing halos around lights”. He denies loss of vision, trauma, discharge, and any symptoms in left eye. Last eye exam was 6 months ago, which resulted in new glasses. Past medical history is negative, and the patient denies any allergies. On physical exam, visual acuity is OS 20/25, OD is 20/70, and OU is 20/40. Pupil on right eye is 7 mm, and left eye is 3 mm. Right pupil is non-reactive to light; left pupil is reactive to light. Right cornea is steamy in appearance, and left cornea is clear.

Question
What is the most likely diagnosis?

Answer Choices
1 Acute angle-closure glaucoma
2 Chronic glaucoma
3 Cataract
4 Acute uveitis
5 Acute conjunctivitis

AACG
Acute angle-closure glaucoma is frequent among the older age group and in Asians. Essential for diagnosis is rapid onset of severe pain and profound vision loss/blurring with halos around lights. On physical exam, a fixed and dilated pupil as well as red eye with a steamy cornea is the hallmark.Chronic glaucoma is usually an insidious onset of bilateral loss of peripheral vision.

Cataracts usually present as gradually progressive and non-painful; there are clear corneas, normal pupil size, and normal light reaction.

Acute uveitis presents with blurred vision; the cornea is clear, and the affected pupil is small with poor papillary light response.

Acute conjunctivitis presents with copious discharge; it does not impact vision. There is a clear cornea, normal pupil size, and normal papillary light reaction.

A 25-year-old female college student presents with 2 lesions on the buccal mucosa on the right side of the oral cavity. You document these lesions with the following description: 2 round lesions, each measuring approximately 2 mm in diameter, with the presence of a white-yellow center that is surrounded by a red halo.

Question
What intervention would you recommend in order to help aid in healing?

Answer Choices
1 Oral antivirals
2 Oral antibiotics
3 Oral chlorhexidine
4 Oral aspirin
5 Oral acetaminophen

oral chlorhexidine
The patient above has an aphthous ulcer; they are also sometimes referred to as canker sores or aphthous stomatitis. These painful, open sores are found in the oral cavity, and they are the most common form of mouth ulcer. They are benign, noncancerous, and noninfectious; in most cases, the cause is unknown. The lesions are often described as having a white or yellow center that is surrounded by a bright red area.The majority of the time, aphthous ulcers will resolve without treatment. If they are causing the patient symptoms, a chlorhexidine-containing mouthwash may be prescribed. The mouthwash has been found to have an immediate bactericidal action and a prolonged bacteriostatic action, thereby relieving the pain of aphthous ulcers and aiding in healing. In fact, the clinical efficacy of chlorhexidine is well documented in review articles in post-op care following any dental pathologies or trauma.

Neither oral antibiotics nor antivirals are indicated at this time; there is no direct evidence of a virus or bacteria being the etiology of aphthous ulcers.

Acetaminophen and aspirin do not have any significant effects in terms of helping heal aphthous ulcers. These agents may aid in relieving some of the pain associated with them, but they will not aid in healing.

A 5-year-old girl was brought to the emergency room in acute respiratory distress. The patient had complained of a sore throat the previous day; it was accompanied by fever and dyspnea. Physically, the patient was irritable and appeared to have great difficulty trying to breath. She was sitting with her neck extended and chin protruding as if she had something blocking her throat. She was uncontrollably drooling saliva from the mouth. Her body temperature was 38.7°C; respiration rate was 130/min. An examination of her throat revealed a bright red epiglottis that was extremely swollen and obstructing the pharynx. A diagnosis was made based on the clinical presentation. The eventual isolation of a Gram-negative coccobacillus from the throat confirmed the diagnosis. What did this patient have an infection with?

Answer Choices
1 Bordetella pertussis
2 Haemophilus influenzae
3 Streptococcus pyogenes
4 Candida albicans
5 Corynebacterium diphtheriae

H influenzae
aemophilus influenzae can cause an acute respiratory obstruction of the upper airways by producing a cellulitis of the supraglottic tissues. Swelling of the epiglottis and aryepiglottic folds with complete obliteration of the vallecular and pyriform sinuses is typical. Children 2 – 7 years of age are prone to this epiglottitis. They will develop acute symptoms quickly, with the initial symptoms being a sore throat, fever, and dyspnea progressing rapidly to dysphagia, pooling of oral secretions, and drooling of saliva from the mouth. The child will many times present as restless and anxious while adopting a sitting position where the neck is extended and chin is protruding to reduce airway obstruction. Characteristically, the epiglottis is red and swollen, and it bears a striking resemblance to a bright red cherry obstructing the pharynx at the base of the tongue. Care should be taken when examining the larynx so as not to induce fatal respiratory obstruction.Candida albicans (a yeast) is the causative agent of thrush, an infection of the throat and tongue. Thrush is characterized by creamy white curd-like patches on the tongue and on other oral mucosal surfaces. These patches are actually a pseudomembrane consisting of Candida, necrotic tissue, keratin, bacteria, leukocytes, epithelial cells, and food debris. A diagnosis can be made by simply scraping the surface of the lesion and examining for the presence of masses of hyphae, pseudohyphae, and yeast forms. Thrush has become a more common occurrence in children due to the use of inhaled steroids for the treatment of asthma.

Bordetella pertussis (a Gram-negative bacillus) produces an infection that is symptomatic after an incubation period of less than 1 week to more than 3 weeks. This initial symptomatic period is called the catarrhal phase; clinically, patients will exhibit mild conjunctival infection, malaise, lacrimation, rhinorrhea, and a low-grade fever. These symptoms are similar to many upper respiratory or systemic diseases. Within a few days to a week, this phase eventually leads to a dry, nonproductive cough. This cough evolves into a paroxysm that consists of a series of short expiration bursts followed by an inspiratory gasp, which can result in the typical “whoop” of Whooping Cough. The disease will typically produce a leuko/lymphocytosis with a total white blood cells count that can exceed 50,000 cells/mm3. Pulmonary consolidation can be seen on more than 20% in chest radiographs. Coughs, though still paroxysmal, do not always produce the characteristic “whoop” in all patients.

Streptococcus pyogenes is the causative agent of Group A streptococcal pharyngitis, one of the most common bacterial infections of childhood. Streptococcal sore throat primarily occurs in children 5 – 15 years of age, and peak incidence occurs in the first few years of school. Incubation periods are between 2 – 4 days followed by a sudden onset of sore throat, malaise, headache, and fever. Some patients may complain of nausea, abdominal pain, and vomiting. There is redness, lymphoid hyperplasia, and edema of the posterior portion of the pharynx. Tonsils may be enlarged and have grayish white exudate patches on the surface. Tender lymph nodes can be noted at the angles of the mandibles. Temperatures of 101°F or greater are seen and white blood cells counts can exceed 12,000/mm3 with a pronounced left shift. Rheumatic fever can be a complication.

Corynebacterium diphtheriae (a Gram-positive bacillus) is the causative agent of diphtheria, a painful tonsillitis and/or pharyngitis with an associated pseudomembrane production. A presumptive diagnosis can be made by the clinical presentation of a patient with tonsillitis and/or pharyngitis with associated membrane, adenopathy and cervical swelling (especially if associated with membranous pharyngitis and signs of systemic toxicity), hoarseness and stridor, palatal paralysis, serosanguineous nasal discharge with associated mucosal membrane, and a temperature elevation rarely in excess of 103°F. Because of immunization, the disease is not commonly encountered.

A 48-year-old Caucasian man presents with acute onset of blurring of vision and severe pain in the left eye that began 1/2 hour ago. He notes seeing halos with his left eye; he is also experiencing nausea and vomiting; those symptoms started at the same time as the pain. The patient reports that he was relaxing on his porch when the pain started. His vital signs are: temp. 36.9 C, pulse 90/min, BP 130/90 mm Hg, and resp. 20/min. Physical examination reveals a shallow anterior chamber, a hazy cornea, a fixed, moderately dilated pupil, and ciliary injection. What would be the next step in the management of this patient?

Answer Choices
1 Lumbar puncture
2 X-ray to rule out a foreign body
3 Topical atropine to the eye to facilitate ophthalmoscopy
4 Tonometry
5 Discharge with topical antibiotic drops for the eye

tonometry
The history and physical examination of this patient are suggestive of acute angle-closure glaucoma, which can be easily confirmed by measuring the intraocular pressure using a tonometer (e.g., the Schiötz tonometer). Acute angle-closure glaucoma develops in individuals with pre-existing anatomic narrowing of the anterior chamber, which is seen mainly in hypermetropes. The condition usually develops in the twilight hours, which is when the pupil is dilated in response to the low level of illumination. It may also occur with pupillary dilation for ophthalmoscopy, so topical atropine would be contraindicated.Acute angle-closure glaucoma is an ophthalmologic emergency, and treatment involves immediate lowering of the intraocular pressure using acetazolamide to decrease the production of aqueous humor, which should be supplemented with hyperosmotic agents and topical beta-blockers. Pilocarpine is then used to cause miosis. Once the intraocular pressure is under control, a peripheral iridectomy can be done to prevent against future recurrences.

None of the other choices would be initial steps in management.

A 6-year-old girl presents with a 2-day history of a small, tender, superficial abscess on her left upper eyelid at the lid margin. She denies discharge, fever, or trauma. There is mild pain on palpation, and she has a normal ophthalmic exam. What treatment should be given?

Answer Choices
1 Warm compresses
2 Immediate surgical incision and drainage
3 Systemic antibiotics
4 Topical antiviral
5 Diphenhydramine and hydrocortisone ointment

Warm compress
This description is of a hordeolum, which is also called a stye. The usual causative agent is Staphylococcus aureus. Treatment involves warm compresses and frequently a topical ophthalmic antibiotic. Occasionally, surgical incision and drainage are required. There is no need for a systemic antibiotic for a minor infection, and the causative agent does not appear to be allergic or viral.A stye can be confused with a chalazion, which is a granulomatous inflammation of a meibomian gland characterized by a nontender nodule. The lesion tends to be chronic, and it shows no sign of acute inflammation.

A 19-month-old boy presents with a 3-day history of fever, irritability, and poor feeding. His mother noticed white patches on his tongue yesterday. He also began to drool and she can hardly get him to eat anything. His past history is significant for recurrent ear infections. He had tympanostomy tubes placed about 1 month ago. On examination, he is febrile with a temperature of 39.8C (103.6F). He appears unwell and is uncooperative and irritable when touched. He is noted to be drooling and has several shallow ulcers on his tongue and palate. The ulcers have a yellowish base with surrounding erythema. There are no lesions on any other areas of his body.

Question
What would be the most appropriate treatment for this child?

Answer Choices
1 Oral amoxicillin
2 Topical penciclovir
3 Oral acyclovir
4 Oral prednisone
5 Oral nystatin

oral acyclovir
This child has herpetic gingivostomatitis. Oral acyclovir is recommended for treatment of herpetic gingivostomatitis and leads to faster resolution of symptoms. Symptomatic treatment with oral analgesics and cold soothing foods, such as ice pops, is also helpful.Amoxicillin would not be used to treat a viral infection. Antibiotics may be indicated if there is evidence of secondary bacterial infection.

Topical penciclovir is indicated for treatment of herpes labialis on the lips and face. The safety and efficacy on mucus membranes is unknown.

Systemic steroids would likely worsen a viral infection.

Nystatin is an antifungal and would be indicated for the treatment of fungal infections like oral thrush.

A 37-year-old Caucasian woman swims regularly for exercise. She swims 100 laps 4 to 6 times per week. She starts to notice severe right ear pain. She also notes that her right ear is very itchy. She sees her family doctor and mentions her symptoms. When he goes to insert the otoscope, he gently pulls on her ear. This causes her quite a bit of pain. He notes an inflamed external ear canal, but the tympanic membrane is normal.

Question
What is the most likely diagnosis?

Answer Choices
1 Otitis externa
2 Otitis media
3 Malignant otitis
4 Otosclerosis
5 Otorrhagia

Otitis Externa
Pseudomonas aeruginosa is a Gram-negative aerobic rod. Other pathogens that can cause otitis externa include Peptostreptococcus, Staphylococcus aureus, Bacteroides, Proteus, and fungi.Otitis media is an infection of the middle ear. In contrast to the scenario here, the external auditory canal would not be involved, and the tympanic membrane would more than likely be involved.

Malignant otitis is an invasive otitis externa.

Otosclerosis is calcification that occurs in the ear.

Otorrhagia is bleeding that occurs from the ear.

The included image is a photomicrograph of Pseudomonas aeruginosa. The image is courtesy of the CDC.

A 34-year-old man presents due to something being “wrong” with his left ear. He reports his hearing has been gradually declining, but he recently noticed some discomfort and malodorous discharge draining from this ear. He denies any trauma to the ear and any symptoms in his right ear. Upon further questioning, he admits to some tinnitus and mild vertigo. He otherwise feels well. He denies nasal symptoms, headache, sore throat, and fevers.

His past medical history is unremarkable; he has no known medical conditions or history of surgery; he takes no medications and has no allergies. He lives with his wife and 2 children; he works as an office manager, and he denies the use of alcohol, tobacco, and drugs.

On physical exam, his vitals are normal. Examination of the left ear reveals mucopurulent drainage within the external auditory canal. The tympanic membrane is disrupted by a retraction pocket within the upper portion, with some thick yellow debris and a polyp protruding from the pocket. Hearing tests are not performed. The right ear reveals mild tympanosclerosis on the tympanic membrane, but it is otherwise normal. The remainder of the patient’s exam is normal.

Question
What is the most likely diagnosis?

Answer Choices
1 Cholesteatoma
2 Contact dermatitis of the ear canal
3 Labyrinthitis
4 Otitis externa
5 Psoriasis

cholesteatoma
This patient is presenting with a cholesteatoma, which a benign neoplasm of the tympanic membrane. It is considered a complication of chronic otitis media, so this patient could be expected to report a history of frequent otitis media. (The tympanosclerosis on the right is another clue.) The cholesteatoma is an epidermal inclusion cyst. Complications can include infection, and more significantly, erosion into bone and nerve damage.Contact dermatitis of the ear canal can produce local irritation with pain and/or pruritus, and if the inflammation is severe enough, discharge. The hearing loss and the physical exam findings of the pocket and polyp are not associated with contact dermatitis.

Labyrinthitis is a condition that can cause hearing loss, tinnitus, and nausea. The cause is not well understood, but it involves the inner ear, not the tympanic membrane. Ear discharge is not associated with labyrinthitis.

Otitis externa is an inflammatory condition of the ear canal, and can be most commonly caused by fungal or bacterial organisms. It can lead to ear pain and discharge. Typically, it should not causing hearing loss and tinnitus; furthermore, it would not cause the findings on this patient’s tympanic membrane.

Psoriasis is a dermatologic condition that affects skin all over the body. It is typically described as silvery scale over bright red plaques. It can affect the ear canals, causing pain and pruritus, but it does not typically the affect the tympanic membrane.

A 30-year-old female presents with a five day history of a sore throat. She denies cough or nasal congestion. She also denies vomiting or diarrhea. On physical exam, her temperature is 101˚F, the pharynx is red with tonsillar exudates, and …

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone [21%] 2. Client admitted 2 days ago with congestive …

With regard to pharyngitis caused by group C streptococci, the NP considers that: A. potential complications include glomerulonephritis B. appropriate antimicrobial therapy helps to facilitate more rapid resolution of symptoms C. infection with these organisms carries a significant risk of …

A 56-year-old man enters your hospital urgent care center complaining of moderately severe chest pain. His pain is substernal and left anterolateral, with some exacerbation on inspiration, and has been increasing in severity over the last 36 hours. He works …

David from ajethno:

Hi there, would you like to get such a paper? How about receiving a customized one? Check it out https://goo.gl/chNgQy