Exam 2: Mouth/Throat/Nose [5]

Question 1

A patient reports persistent nasal blockage, nasal discharge, and facial pain lasting on the right side for the past 5 months. There is no history of sneezing or eye involvement. The patient has a history of seasonal allergies and takes a non-sedating antihistamine. What does the NP suspect is the cause for the symptoms?

A. Allergic rhinitis
B. Autoimmune vasculitis
C. Chronic rhinosinusitis
D. Rhinitis medicamentosa

Answer 1

A patient reports persistent nasal blockage, nasal discharge, and facial pain lasting on the right side for the past 5 months. There is no history of sneezing or eye involvement. The patient has a history of seasonal allergies and takes a non-sedating antihistamine. What does the NP suspect is the cause for the symptoms?

A. Allergic rhinitis
B. Autoimmune vasculitis
C. Chronic rhinosinusitis
D. Rhinitis medicamentosa

Answer is C: Chronic rhinosinusitis is present when symptoms occur longer than 12 weeks

Allergic rhinitis: sneezing and itchy watery eyes
Autoimmune vasculitis: affects upper and lower respiratory tracts as well as kidneys
Rhinitis medicamentosa: occurs with use of nasal decongestants and not oral antihistamines

Question 2

A patient is in the ED with unilateral epistaxis that continues to bleed after 15 minutes of pressure on the anterior septum and application of a topical nasal decongestant. The provider is unable to visualize the site of the bleeding. What is the next step for this patient?

A. Chemical cautery
B. Electrocautery
C. Nasal packing
D. Petrolatum ointment

Answer 2

A patient is in the ED with unilateral epistaxis that continues to bleed after 15 minutes of pressure on the anterior septum and application of a topical nasal decongestant. The provider is unable to visualize the site of the bleeding. What is the next step for this patient?

A. Chemical cautery
B. Electrocautery
C. Nasal packing
D. Petrolatum ointment

Answer: C - nasal packing is used if bleeding continues after initial measures (rhino rocket should be removed by ENT after you put it in)

Chemical cautery: used only if the site of bleeding is visualized
Electrocautery: used only if the site of bleeding is visualized
Petrolatum ointment: applied once the bleeding is stopped

Question 3

A patient has recurrent sneezing, alterations in taste and smell, watery, itchy eyes, and thin, clear nasal secretions. The NP notes puffiness around the eyes. The patient’s vital signs are normal. What is the most likely diagnosis for this patient?

NOTE: This if pre-covid

A. Acute sinusitis
B. Allergic rhinitis
C. Chronic sinusitis
D. Viral rhinitis

Answer 3

A patient has recurrent sneezing, alterations in taste and smell, watery, itchy eyes, and thin, clear nasal secretions. The NP notes puffiness around the eyes. The patient’s vital signs are normal. What is the most likely diagnosis for this patient?

NOTE: This if pre-covid

A. Acute sinusitis
B. Allergic rhinitis
C. Chronic sinusitis
D. Viral rhinitis

Answer: B

Sinusitis: causes facial pain, fever, and purulent discharge
Viral rhinitis: causes purulent discharge and other symptoms of URI

Question 4

A patient with allergic rhinitis develops acute sinusitis and begins treatment with an antibiotic. Which measure may help with symptomatic relief for patients with underlying allergic rhinitis?

A. Intranasal steroids
B. Oral mucolytic
C. Saline solution rinses
D. Topical decongestants

Answer 4

A patient with allergic rhinitis develops acute sinusitis and begins treatment with an antibiotic. Which measure may help with symptomatic relief for patients with underlying allergic rhinitis?

A. Intranasal steroids
B. Oral mucolytic
C. Saline solution rinses
D. Topical decongestants

Answer: (A) Intranasal steroids should be considered for symptomatic relief of sinusitis and especially allergic rhinitis

Oral mucolytics: have little support for efficacy
Saline: may provide some relief but there is no evidence to support their usefulness
Topical decongestants: decrease nasal congestion and edema but the potential harm of rebound congestion requires recommendation with caution

Question 5

A patient reports a sudden onset of sore throat, fever, malaise, and cough. The NP notes mild erythema of the pharynx and clear rhinorrhea without cervical lymphadenopathy. What is the most likely cause of these symptoms?

A. Allergic pharyngitis
B. Group A Strep
C. Infectious mononucleosis
D. Viral pharyngitis

Answer 5

A patient reports a sudden onset of sore throat, fever, malaise, and cough. The NP notes mild erythema of the pharynx and clear rhinorrhea without cervical lymphadenopathy. What is the most likely cause of these symptoms?

A. Allergic pharyngitis
B. Group A Strep
C. Infectious mononucleosis
D. Viral pharyngitis

Answer: (D) Viral pharyngitis will cause sore throat, fever, and malaise and is often accompanied by URI symptoms of cough and runny nose

Allergic pharyngitis: usually also causes dryness
Group A strep: causes high fever, cervical lymphadenopathy, and marked erythema with exudate
Infectious mono: will cause an exudate along with cervical adenopathy

Question 6

A patient has a sore throat, a temp of 38.5 C, tonsillar exudates, and cervical lymphadenopathy. What will the NP do next to manage this patient’s symptoms?

A. Order anti-streptolysin O (ASO) titer
B. Perform a rapid antigen detection test (RADT)
C. Prescribe empirical penicillin
D. Refer to otolaryngologist

Answer 6

A patient has a sore throat, a temp of 38.5 C, tonsillar exudates, and cervical lymphadenopathy. What will the NP do next to manage this patient’s symptoms?

A. Order anti-streptolysin O (ASO) titer
B. Perform a rapid antigen detection test (RADT)
C. Prescribe empirical penicillin
D. Refer to otolaryngologist

Answer: (B) check for strep infection (RADTs are 90% accurate)

ASO titer: not used during initial diagnostic screening
Penicillin: should not be given empirically
Refer: specialist not required for a GAS infection

Question 7

A school age child has an abrupt onset of sore throat, nausea, headache, and temperature of 102.3 F. An exam reveals petechiae on the soft palate, beefy-red tonsils with yellow exudate and a scarlatiniform rash. A rapid antigen detection test (RADT) is negative. What is the next step?

A. Consider sexual abuse diagnosis
B. Obtain an anti-streptococcal antibody titer
C. Perform a follow-up throat culture
D. Prescribe amoxicillin for 10 days

Answer 7

A school age child has an abrupt onset of sore throat, nausea, headache, and temperature of 102.3 F. An exam reveals petechiae on the soft palate, beefy-red tonsils with yellow exudate and a scarlatiniform rash. A rapid antigen detection test (RADT) is negative. What is the next step?

A. Consider sexual abuse diagnosis
B. Obtain an anti-streptococcal antibody titer
C. Perform a follow-up throat culture
D. Prescribe amoxicillin for 10 days

Answer: (C) The rapid test is pretty accurate but a culture should be performed to confirm the diagnosis. If the culture is negative for GABHS other causes such as gonococcal infection may be considered but is much less likely

** Note: if the patient comes for testing after just 3 hours of sore throat, the viral load won’t be high enough to test positive for strep **

Sexual abuse: RADT does not assess for sexual abuse
ASO titer: not helpful in the diagnosis of acute pharyngitis
Amoxicillin: not indicated unless infection is confirmed

Question 8

What are the diagnostic criteria for diagnosis of AOM?

Answer 8

Red, bulging TM

Recent onset of ear pain

Question 9

Which of the following conditions decreases risk of AOM in children ages 6 months - 24 months?

A. Pacifier use
B. Male gender
C. Breastfeeding
D. Daycare participation

Answer 9

Breastfeeding

Question 10

What is the most common bacteria isolated from otorrhea in children with chronic suppurative otitis media?

A. MRSA
B. Strep pneuomiae
C. H. influenzae
D. Moraxella catarrhalis

Answer 10

What is the most common bacteria isolated from otorrhea in children with chronic suppurative otitis media?

Answer: (A) MRSA

Question 11

What is the most common bacteria isolated in children with acute otitis media?

A. MRSA
B. H. influenzae
C. MSSA
D. Pseudomonas aeruginosa

Answer 11

What is the most common bacteria isolated in children with acute otitis media?

Answer: (B) H. influenzae

Question 12

The most common cause of pharyngitis in adults is:

A. Bacteria
B. Viral
C. Fungi
D. Parasites

Answer 12

The most common cause of pharyngitis in adults is:

Answer: (B) Viral

Question 13

Which of the following is a complication of infectious mono?

A. Ulcerative keratitis
B. Hepatitis
C. Lymphoma
D. ITP

Answer 13

Which of the following is a complication of infectious mono?

Answer: (B) Hepatitis; draw liver labs to be sure

Question 14

At what age does a child have a complete set of primary teeth (20 teeth)?

Answer 14

2.5 year-old

Question 15

At what age does a child typically start to lose their primary teeth and gain their central incisors and first molars?

Answer 15

6-years-old

Get permanent teeth between ages of 6-13

Question 16

At what age do the wisdom teeth come in?

Answer 16

17-21

Question 17

Guidelines that help determine higher risk for a bacterial throat infection

Answer 17

Centor criteria

Question 18

What symptoms does the modified Centor criteria assess?

Answer 18

Presence of tonsillar exudates +1
Tender anterior cervical adenopathy +1
Fever by history +1
Absence of cough +1
Age < 15 years +1
Age > 45 years -1

0-1: no further testing; no antibiotics
2-3: rapid antigen test; if (+) treat w/antibiotics; if (-) throat culture
4: treat w/antibiotic; no further testing needed

Question 19

When should a child see a dentist?

Answer 19

Within 6 months of first tooth or by age 1

Many dentists will not see patients younger than age 3

Question 20

When should a child receive fluoride supplementation, use fluoride toothpaste or mouthwash?

Answer 20

Avoid supplementation < 6 months old
Avoid fluoride toothpaste < 2 years old
Avoid fluoride mouthwash < 6 years old

Question 21

What consists of a dental emergency where a patient should be referred to a dentist immediately?

Answer 21

Bone or tooth fracture
Crown or root fracture with visible pulp
Partial avulsion > 2 mm mobility

If the entire tooth is out:
Primary tooth - do not replant
Permanent tooth - place in milk or saline and go to dentist immediately

Question 22

What should we do with a toothache with swelling and/or cellulitis?

Answer 22

Start antibiotics and then send to dentist

Question 23

Name this condition:

Fever, fatigue/malaise, pharyngitis, lymphadenopathy
Enlarged tonsils with cryptic exudate (white or darker color)
Possibly upper quadrant pain
Occasionally a generalized red maculopapular rash

Answer 23

Infectious Mononucleosis

Upper quadrant pain can be caused by splenomegaly

Question 24

What is the treatment for mono?

Answer 24

Acute stages:
Limit physical activity x4 weeks to reduce risk of splenic rupture
Rest (fatigue can last weeks to months)
Avoid sharing toothbrushes, utensils, or using the same glass
Avoid using amoxicillin if patient has “strep” throat
Avoid aspirin