Eye
A 22-year-old woman presents with a 1-year history of flaking and scaling around her lashes, along with itching and a burning sensation. She has also noted her lid margins are red, and some of her lashes are missing.
Her history is significant for diabetes and for seborrheic dermatitis of the scalp, eyebrows, and external ears.
Dx?
Blepharitis
A 30-year-old Black male patient is admitted to the hospital to undergo stapedectomy for the treatment of otosclerosis. He has experienced increased hearing loss in the right ear for a few years. The patient's mother had had the same condition when she was in her 40s, and she underwent a successful operation. Assessment is performed using the Weber and Rinne tests.
Expected PE finding?
Bone conduction of the affected side is greater than air conduction.
A 41-year-old woman presents to the local emergency department with a 14-day history of nasal drainage, congestion, fever, and cheek pain. She was started on amoxicillin/clavulanate initially, but she was switched to levofloxacin 7 days ago due to no improvement in symptoms. After 7 days of levofloxacin therapy, she presents again, reporting that she is no better. The fever continues and she now has upper tooth pain. On exam, she is in mild distress, with thick purulent rhinorrhea and halitosis.
Next step?
Refer to ENT for sinus aspiration
Explanation
The patient has bacterial sinusitis that is amoxicillin/clavulanate and levofloxacin resistant. She has failed both first line and second line therapies. The sinuses need to be aspirated and cultured so that the correct antibiotic therapy can be instituted.
This moderately ill patient does not warrant admission and intravenous therapy or surgical intervention. Such treatments are reserved for those who are severely ill.
Since the second-line therapy of levofloxacin has had no effect after 7 days, the infection is likely resistant to this medication.
Clinical trials do not support the use of broad-spectrum antibiotics for routine cases of bacterial sinusitis.
A 36-year-old man presents with nasal congestion, headache, fatigue, facial pain, and chronic post-nasal drip. He has had similar episodes in the past, occurring 2-3 times a year for the last several years. He has been diagnosed with acute sinusitis and antibiotics have been prescribed, providing him with relief for a brief period. This time, however, his symptoms have bothered him on and off for the last 3 months. He was given a 14-day course of antibiotics, but he experienced only partial relief. He is tired of the recurrent episodes and wants a cure. On exam, he is afebrile, nasal mucosa is inflamed, and there is mucopurulent secretion in the nasal cavity. The right maxillary sinus is tender on palpation. Lungs are clear.
Next step?
Sinus CT
Explanation
This patient has chronic sinusitis. Repeated regimens of different antibiotics have not provided him relief, and now he fits the criteria for chronic sinusitis, including 12 weeks of symptoms. Chronic sinusitis is most commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. These three bacteria account for 70% of cases. A limited CT scan of the sinuses defines the location and extent of disease and helps in deciding further management. It is quick, low cost, and sensitive. CT scanning also helps in delineating anastomotic blockage of the osteomeatal complex, so there is a role for it in cases of endoscopic surgery.
A 3-week course of antibiotics may relieve symptoms briefly, but it is unlikely to cure him, especially since he already has had several courses. Amoxicillin-clavulanate or cefuroxime are traditionally used for 3 weeks. In intractable cases, a 6-week course may also be given. Clarithromycin and clindamycin are used for patients who are allergic to penicillin. Quinolones are only used if cultures show gram-negative bacteria.
Plain X-rays are no longer recommended; they are not sensitive enough in the visualization of the sinuses, and they often miss findings.
Nasal cultures can be contaminated with colonized organisms in the nose, such as Staphylococcus aureus, and do not correlate well with culture obtained from the sinuses. Endoscopically-guided cultures of secretions in the middle meatus or within a sinus are usually not done in clinical practice, even though occasionally it may provide the exact causative pathogen.
MRI of the sinuses tells us more about the soft tissue pathology, but bony structures cannot be studied in detail. MRI is done if malignancy is suspected or if there are signs and symptoms of possible intracranial extension.
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 denies recent swimming and 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 profound conjunctivitis that is acute and follicular. Purulent drainage is present. The acute nature of conjunctivitis requires an ophthalmologist consult.
Causative Agent?
Psuedomonas
A 44-year-old man presents for follow-up of poorly controlled type 1 diabetes mellitus that was diagnosed 32 years ago. What change on his funduscopic examination would indicate a need for urgent referral to an ophthalmologist?
Neovascularization
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 25-year-old male patient presents with an acute otitis media with serous otitis in the right ear. Weber and Rinne tests are performed.
Expected result?
Weber—sound is heard louder in right ear; Rinne—bone conduction exceeds air conduction in right ear
A 20-year-old woman presents with a 3-day history of fever, sore throat, and enlarged glands in her neck. She denies any cough or runny nose, but she has malaise, body aches, and headaches. She has no other medical problems and does not take any medications. She works in a daycare center; she takes care of children 3-4 years old. On examination, she has a temperature of 101.5°F; pulse is 102/min, and BP 110/70 mm Hg. Oral exam reveals swollen tonsils with plenty of exudates. There is no nasal congestion, and lungs are clear. Cervical lymph nodes are enlarged bilaterally and tender. Abdomen is unremarkable. Throat swab is obtained by the physician.
Causative organism found in culture?
Group A streptococcus
Explanation
Based solely on the clinical features, the patient is suffering from acute streptococcal pharyngitis, which is characterized by fever, sore throat, exudates, and cervical adenopathy without cough or rhinorrhea. Group A streptococcus is the most likely causative organism among the choices. It is especially seen in children or adults exposed to children in schools, daycare centers, etc. Treatment with penicillin is recommended if rapid antigen test in the office is positive, if the throat culture comes back positive, or if the patient has all four clinical criteria (fever, exudates, cervical lymphadenopathy, and absence of cough).
Corynebacterium diphtheriae causes diphtheria and is characterized by pharyngitis, low-grade fever, malaise, and a gray membrane over the pharyngeal area that bleeds on stripping. Throat swab has to be cultured on a specific medium since regular media will not grow this bacterium. Treatment is with penicillin or erythromycin.
The Epstein-Barr virus causes infectious mononucleosis that is characterized by fever, respiratory congestion, splenomegaly, hepatomegaly, severe fatigue, as well as anterior and posterior cervical adenopathy. Definitive diagnosis is by noting atypical lymphocytes in the peripheral smear and heterophile antibody test. Serology is needed only in a few cases. Treatment is supportive because antibiotics are useless.
Haemophilus influenzae and Moraxella catarrhalis rarely cause pharyngitis. They more commonly cause otitis media or lower respiratory tract infections.
A 4-year-old boy has had intermittent rhinorrhea, nasal congestion, and cough for about 3 weeks. His mother says he had felt warm at night when his symptoms started, and he sneezes occasionally. He goes to a large daycare 4 days a week. Otherwise, he has been healthy except for an occasional dry itchy rash that he has had on and off for "a long time." Mom has been treating this with OTC moisturizers. On exam, his temperature is 98.4°F, respirations 24, pulse 86 beats/min. He appears somewhat tired, with dark circles under his eyes. There is slightly cloudy nasal drainage, turbinates seem a little boggy, lungs are clear, ears and throat are normal and his neck is supple without any lymphadenopathy. His skin exam reveals a fine roughened slightly hyperpigmented maculopapular rash in elbow creases with a few healing excoriations.
Dx?
Allergic rhinitis
Explanation
Allergic rhinitis can frequently be mistaken for a viral or bacterial infection of the upper respiratory tract, especially in patients too young to communicate their symptoms well. Allergic rhinitis is a hypersensitivity reaction to specific allergens mediated by immunoglobulin (IgE) antibodies in sensitized patients resulting in inflammation. It can be mild or severe and may be seasonal or perennial. Allergic rhinitis also may be intermittent or persistent. Children who have one component of atopy such as asthma or eczema have a threefold greater risk of developing a second component. A variety of signs and symptoms may be present, such as mouth breathing, snoring, nasal-sounding voice, sneezing, nasal itching, snorting, nose blowing, nasal congestion and drainage, and coughing. Patients can also experience headaches, fatigue, impaired concentration, decreased sleep, and social functioning.
Classic findings include pale bluish nasal mucosa, boggy turbinates, clear nasal secretions, and pharyngeal cobblestoning. Characteristic signs include allergic shiners due to suborbital edema and allergic crease or a transverse skin line across the bridge of the nose due to constant rubbing upward.
Infectious rhinitis will typically present in the early years of childhood before allergic rhinitis occurs. Nasal secretions are commonly mucopurulent; there may be a posterior pharyngeal discharge and fever.
Chronic infectious rhinosinusitis also involves a mucopurulent nasal discharge, postnasal drip with cough, and an olfactory disturbance for at least 28 days.
Vasomotor rhinitis consists of profuse rhinorrhea and nasal obstruction occurring with a change in environmental conditions, such as going from a warm house to frigid outdoor temperatures.
Though a foreign body could be likely in this age group, especially with a history of daycare attendance, it usually will present with persistence of unilateral nasal obstruction and a purulent foul-smelling nasal discharge.
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 a gram-negative bacillus; it is oxidase positive and citrate positive. It does not ferment carbohydrates, and it produces a blue-green pigment.
Causative Agent?
Psuedomonas
A 42-year-old man presents with a firm painless bump on his left upper 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.
Dx?
Chalazion
Explanation
The clinical picture is an example of a chalazion. A chalazion is a usually painless chronic mass in the eyelid.
Ectropion is when the eyelid sags outwardly and the lid does not close well.
Hordeolum is acute, red, and painful.
Pterygium involves the sclera.
Xanthelasma is a yellow plaque filled with cholesterol that usually appears on the eyelids.
A 67-year-old woman presents; according to her, her husband says she never listens 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. On the left ear, air conduction lasted for 15 seconds and bone conduction lasted 10 seconds. On the right ear, air conduction lasted for 22 seconds and bone conduction lasted 10 seconds.
Hearing loss etiology?
Ototoxicity
Explanation
Ototoxicity secondary to furosemide is the most likely cause. 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.
Ménière's disease would exhibit any vertigo or tinnitus.
Middle ear effusion would cause a conductive hearing loss.
A newborn presents for a 2-week physical exam. On exam, irregular, white plaques on the buccal mucosa and palate are noted. Upon trying to remove the plaques, there is an underlying erythematous base.
Thrush (candida)
A 4-year-old Caucasian boy is seen for a 2-week history of purulent nasal discharge. He has been afebrile and has had no respiratory symptoms. Past history is unremarkable except for his mother's assessment that "he gets into everything." Examination revealed only a right-sided purulent nasal discharge, which was greenish-brown in color and extraordinarily foul-smelling.
What is the most direct method of diagnosing and treating this child's likely condition?
Direct visualization of the right nasal vestibule
Explanation
The history of an extremely foul-smelling unilateral purulent nasal discharge without other symptoms in an active young child strongly suggests a retained nasal foreign body, most readily diagnosed via direct visualization. Most foreign bodies can be removed during direct visualization or with positive pressure techniques.
Culture and sensitivity and gram stain and KOH prep are not indicated, as the patient is afebrile and symptoms are not secondary to an infectious etiology. This will not treat the underlying cause of this patient's symptoms.
Sinus radiographs will not visualize or remove the nasal foreign body.
Soft tissue lateral radiographs may not be helpful, as many foreign bodies are radiolucent, such as vegetable foreign bodies. This will not treat the present condition.
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.
What nerve is damaged?
Abducens
A 35-year-old woman presents with a painful swelling of her left eyelid. On physical exam, there is tenderness to palpation and erythematous swelling present on the lid margin involving the eyelashes.
Dx?
Hordeolum
A 65-year-old Caucasian man presents with a 3-day history of severe dizziness. The symptoms are exacerbated by turning his head and relieved by lying still. He reports nausea and vomiting for the first 2 days of his illness but successfully eats breakfast on the day he is seen in the clinic. He denies hearing loss and tinnitus. His past medical and surgical histories are unremarkable. He has no previous exposure to ototoxic drugs and denies further neurologic symptoms.
The otologic examination is without abnormality. Weber testing with a 512 Hz tuning fork is to midline. Romberg and Fukuda testing indicate right-sided pathology. Other than a crisp left-beating nystagmus, cranial nerve examination is normal. Vertigo is experienced after the Dix-Hallpike maneuver. Nystagmus is observed after a few seconds of lying down during the maneuver.
Dx?
BPPV
A 56-year-old man presents with a history of persistent and progressive unrelenting hoarseness for the last few months. He is a 50 pack-year smoker but quit 1 year ago. Physical examination demonstrated a 2-cm firm non-tender right anterior cervical lymph node.
Dx?
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 is not related to tobacco abuse.
Strep pharyngitis typically causes tender cervical lymphadenopathy unrelated to tobacco abuse and does not cause progressive laryngitis.
A 23-year-old man presents with a 2-day history of watery nasal discharge, malaise, sneezing, and nasal congestion. On examination, you notice inflammation of the nasal mucosa; pulse is 80/min, BP is 130/84 mm Hg; temperature is 98.8°F. The rest of the examination is normal.
Treatment?
Nasal decongestants and non-pharmacologic remedies
Explanation
This patient most likely has acute rhinitis, which is treated with nasal decongestants and steam inhalation.
Ibuprofen can be added in cases of fever but is unnecessary in this case, as the patient is afebrile.
Azithromycin is a macrolide antibiotic; its use for treating acute rhinitis is incorrect.
Antibiotics have no role in the treatment of uncomplicated non-specific upper respiratory infections; their misuse facilitates the emergence of antibiotic resistance. Only symptomatic treatment with decongestants and steam inhalation is necessary for treating acute rhinitis.
Antiviral agents are used in cases of an immunocompromised host and are not essential for otherwise healthy patients.
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 took up scuba diving as a recreational activity. He recalls multiple ear infections during his time in the Navy.
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 definitive treatment for this patient?
Surgical ENT referral
Explanation
The treatment for cholesteatoma is surgical removal or marsupialization of the sac. This should be performed by a specialist.
Antibiotics and/or steroids can be tried as nonsurgical measures, but the question asks for the definitive treatment.
Observation and follow-up or earplugs are not recommended since the cholesteatoma may cause destruction of the middle ear ossicles and spread to the mastoid process, worsening the condition.
A 48-year-old Caucasian man presents with acute onset of blurring of vision and severe pain in the left eye that began 30 minutes ago. He notes seeing halos with his left eye. He is also experiencing nausea and vomiting. These symptoms started at the same time as the pain. The patient reports that he was relaxing on his porch when the pain started. His temperature is 36.9°C, pulse 90/min, BP 130/90 mm Hg, and respirations 20/min. Physical examination reveals a shallow anterior chamber, a hazy cornea, a fixed, moderately dilated pupil, and ciliary injection.
Next step?
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 far-sighted people. 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. Treatment involves immediate lowering of the intraocular pressure via systemic acetazolamide to decrease the production of aqueous humor, which should be supplemented with topical hyperosmotic agents and topical beta blockers. Topical 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.
A 66-year-old man presents to the clinic with a complaint of not being able to hear the beeping of his microwave. 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 what alteration in the ear?
Loss of cochlear hair cells
Explanation
Auditory disorders may be related to either conductive disorders or sensorineural disorders. Conductive disorders result from the mechanical impedance of sound waves from reaching the auditory sensory receptors. Sensorineural disorders result from the loss of the ability to transduce or convey the mechanical signal into the neural signal.
Loss of the cochlear hair cells, particularly at the beginning of the basal turn of the cochlea, typically results in the loss of high-frequency sounds. The specific frequency is lost 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, can be associated with hearing disorders during the aging process. Loss of neurons from the spiral ganglion would be another example of a sensorineural disorder.
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. These would result in a clinical situation with the loss of sound at all frequencies rather than only a high frequency or selected frequency.
The loss of otoconia in the otolithic membrane would probably have little effect on auditory responses.
A 9-year-old girl presents with a sore throat. The parents state that she began a fever a few days ago, reporting that her throat hurt. On physical exam, you note a red throat, a red and beefy tongue, tonsillar exudates, and swollen anterior cervical lymph nodes. The parents report a history of a severe anaphylactic reaction to penicillin.
Treatment?
Erythromycin
Explanation
The clinical picture is suggestive of Group A streptococcal pharyngitis. Penicillins are the first-line antibiotics in the treatment of strep pharyngitis. Since the patient has a history of anaphylaxis with penicillin and there is no evidence of skin testing, the guidelines do not recommend the use of a cephalosporin. Instead, these patients should receive a macrolide such as erythromycin or azithromycin as an effective alternative.
Augmentin contains amoxicillin, a member of the penicillin family with allergic cross-reactivity; it is contraindicated in patients with a severe allergy to penicillin.
Cephalexin, a cephalosporin, can be used to treat strep throat, but approximately 2% of patients who are allergic to penicillin are also allergic to cephalosporins.
Ciprofloxacin is effective against Gram-negative organisms. Since streptococcal species are Gram-positive, it would not be an appropriate treatment.
Mupirocin is a topical antibiotic and is not indicated for the treatment of strep throat.
A 28-year-old woman presents with an itchy throat, prolonged sneezing episodes, red and watery eyes, and inflamed nasal membranes. Her temperature is normal and a throat culture is negative. She most likely has allergic rhinitis.
Side effect of treatment?
Sedation
A 10-day-old male newborn presents with bilateral conjunctivitis with moderate white discharge. He is acting normally, has no fever, and is feeding well. He was born full-term without any complications. His mother had minimal prenatal care. He has been gaining weight well. On exam, he is alert and active. Culture with immunofluorescence reveals inclusion bodies.
Causative Agent?
Chlamydia trachomatis
Explanation
Chlamydia and gonorrhea are the most common causes of conjunctivitis neonates. Given the timing and presentation, chlamydia is the most likely cause of this conjunctivitis. A characteristic finding of chlamydial infection is the presence of inclusion bodies in the epithelial cells of a conjunctival smear. The usual incubation period for C. trachomatis is 5-14 days and 2-5 days for N. gonorrhoeae. Gonococcal conjunctivitis tends to produce a more purulent discharge than C. trachomatis.
Herpes conjunctivitis is sometimes contracted when neonates are born to mothers with herpes lesions in the genital region.
Conjunctivitis due to silver nitrate drops usually occurs 6-12 hours after birth.
Coxsackievirus is not a common cause of conjunctivitis in neonates.