Exam Style Q's Flashcards
A 32 year old women presents to the GP with complaints of recurrent dizziness. It comes on sporadically, often after turning around too quickly. It lasts for about 2 minutes a time. There is no associated hearing loss, tinnitus, aural fullness, vomiting, headache or neurological symptoms. Which investigation would clarify the diagnosis?
1) MRI head and neck
2) Epley manoeuvre
3) Dix-Hallpike manœuvre
4) Otoscopy
5) CT head
This patient is presenting with classical symptoms of BPPV. The vertigo lasts about 2 minutes, there are no associated symptoms and it comes on from rapid turning of the head.
The investigation/special test used to diagnose BPPV is the Dix-Hallpike manoeuvre. This involves sitting a patient up with their legs off the end of the bed, turning their head to 45 degrees and lying them down so their head is off of the end. A positive Dix-Hallpike causes nystagmus. In BPPV the Dix-Hallpike will be positive.
The epley manoeuvre is used to treat BPPV. Otoscopy would show no signs of disease and MRI/CT head and neck would also not show anything.
A 32 year old women presents to the GP with complaints of recurrent dizziness. It comes on sporadically, often after turning around too quickly. It lasts for about 2 minutes a time. There is no associated hearing loss, tinnitus, aural fullness, vomiting, headache or neurological symptoms. What is the pathological cause of this women dizziness?
1) Likely viral cause following URTI
2) Dilatation of the membranous labrinth in the inner ear
3) Displacement of the otoconia from the utricle
4) Schwann cell neoplasm growing on vestibular portion of CN VIII
This patient is presenting with classical symptoms of BPPV. The vertigo lasts about 2 minutes, there are no associated symptoms and it comes on from rapid turning of the head.
The correct answer is (3). Option 1 describes vestibular neuronitis or labyrinthitis where the cause is thought to be viral. Option 2 is meniere’s disease, where you get dilatation of the membranous labrinth (unknown cause of this) causing sudden attacks of vertigo that last greater than 20 minutes (often 2-4 hours). Option 4 describes a vestibular schwannoma, a benign tumour of the Schwann cells causing vertigo and hearing loss.
A 32 year old women presents to the GP with complaints of recurrent dizziness. It comes on sporadically, often after turning around too quickly. It lasts for about 2 minutes a time. There is no associated hearing loss, tinnitus, aural fullness, vomiting, headache or neurological symptoms. What treatment would best suit this women?
1) Epley manoeuvre
2) Symptomatic relief and vestibular sedatives e.g. bucastem
3) Avoidance of caffeine, betahistines.
4) Steroid ear drops
This patient is presenting with classical symptoms of BPPV. The vertigo lasts about 2 minutes, there are no associated symptoms and it comes on from rapid turning of the head.
The correct answer is number 1. The epley manoeuvre aims to move the otoconia back into the utricle. Option 2 describes the treatment for labrinthitis and vestibular neuronitis. Option 3 is the treatment for Menieres disease. Option 4 is a red herring.
A child presents with hearing loss over the last 24 hours. They complain of right sided ear pain (otalgia), mild hearing loss, fever, fatigue and general malaise. There has been no discharge, redness or scaling of the external ear. Rinne’s and Webers test reveals mild conductive hearing loss on the affected side. On otoscope the TM looks bulging and red. What is the likely diagnosis?
1) Acute otitis media
2) Otitis Externa
3) Cholesteatoma
4) Otitis Media with Effusion (glue ear)
5) Chronic Otitis media
This child presents with symptoms consistent of a diagnosis of acute otitis media. The presentation of sudden ear pain with systemic symptoms (fever, malaise) indicates the diagnosis. A bulging TM on otoscope also supports this.
Otitis externa is a good differential however unlikely to cause the systemic symptoms and TM changes seen above. Also the time frame is very acute, whereas otitis externa isn’t.
Otitis media with effusion is another good differential however the hearing loss is mild in this case, whereas it would be more severe in OME. Additionally, you may be able to visualise fluid behind the TM in OME. Often this presents with speech and language delay.
Cholesteatoma wouldn’t cause fever, fatigue or malaise. Chronic otitis media would have a much longer presentation course.
A child presents with hearing loss over the last 24 hours. They complain of right sided ear pain (otalgia), mild hearing loss, fever, fatigue and general malaise. There has been no discharge, redness or scaling of the external ear. Rinne’s and Webers test reveals mild conductive hearing loss on the affected side. On otoscope the TM looks bulging and red.
What is the management?
This child presents with symptoms consistent of a diagnosis of acute otitis media. The presentation of sudden ear pain with systemic symptoms (fever, malaise) indicates the diagnosis. A bulging TM on otoscope also supports this.
AOM commonly resolves spontaneously in most cases within 24 hours. If the patient suffers from symptoms for greater than 5 days or are immunocompromised, prescribe amoxicillin (erythromycin if pen allergic).
A child presents to the GP with suspected speech and language delays. The parents report difficulty communicating and understanding speech/conversation. They’re concerned about LD. On further questioning, the parents have noticed the child doesn’t respond when asked questions sometimes as he appears to not hear them.
O/E of the TM- it looks dull and retracted. There is evidence of fluid behind the TM. What is the likely diagnosis?
1) Otitis externa
2) Otitis media with effusion
3) Acute otitis media
4) Global developmental delay
5) Congenitally acquired hearing impairment
The likely diagnosis for this child is otitis media with effusion (option 2). They are having trouble hearing (conductive hearing loss) due to a build up of fluid in the middle ear cavity. This means they will have trouble communicating and can lead to a delay in development. On examination there is fluid visible behind the ear drum and the TM looks dull and retracted.
Otitis externa would have cutaneous symptoms of scaliness, erythema, maybe foul smelling discharge or complete blockage. This would be obvious on examination and also wouldn’t cause such prolonged communication issues. Acute otitis media often presents with ear pain and hearing loss in a much more acute onset. Global developmental delay would also cause gross motor and fine motor issues therefore is an unlikely diagnosis. Finally, congenitally acquired hearing impairment would not show any signs on otoscope.
What is the likely pathogen causing otitis externa?
1) viral cause
2) moraxella cattarhalis
3) pseudomonas
4) H influenza
5) Streptococcus
The likely causative organism is pseudomonas. However staph aureus is another likely cause. Viral causes and H influenza are more likely to cause AOM as they spread from the nose/throat. Streptococcus again is likely to cause a throat infection, not an ear infection.
A 21 year old male presents to the GP with recurrent bouts of nasal discharge, loss of smell, itchy eyes, sneezing and priuritis. The symptoms come on in the summer seasons and affect the individual for less than 4 days a week. It does not affect the individuals sleep. What is the likely diagnosis?
1) Intermittent allergic rhinitis
2) Rhinosinusitis
3) Perrineal (persistent) allergic rhinitis
4) Vasomotor rhinitis
5) Nasal polyps
This patient is presenting with signs and symptoms of allergic rhinitis. The symptoms of itchy eyes, nasal discharge, loss of smell and itching all indicate a type of rhinitis or polyps. The symptoms are only present for certain times of the year (summer) so this indicates that its more likely to be allergic than vasomotor or polyps. You also wouldn’t get the itchy eyes with these two options.
Rhinosinusitis would present with frontal facial pain, fever, discoloured purulent nasal discharge, headache maybe worse on bending forward. This patient does not fit these symptoms.
Distinguishing between intermittent allergic rhinitis and perineal allergic rhinitis depends on the duration of symptoms. If symptoms occur for less than 4 days at a time for periods of less than 4 weeks, it is intermittent. If more than this it is perennial (persistnet).
A 21 year old male presents to the GP with recurrent bouts of nasal discharge, loss of smell, itchy eyes, sneezing and priuritis. The symptoms come on in the summer seasons and affect the individual for less than 4 days a week. It does not affect the individuals sleep. What is the likely diagnosis?
1) Intermittent allergic rhinitis
2) Rhinosinusitis
3) Perrineal (persistent) allergic rhinitis
4) Vasomotor rhinitis
5) Nasal polyps
This patient is presenting with signs and symptoms of allergic rhinitis. The symptoms of itchy eyes, nasal discharge, loss of smell and itching all indicate a type of rhinitis or polyps. The symptoms are only present for certain times of the year (summer) so this indicates that its more likely to be allergic than vasomotor or polyps. You also wouldn’t get the itchy eyes with these two options.
Rhinosinusitis would present with frontal facial pain, fever, discoloured purulent nasal discharge, headache maybe worse on bending forward. This patient does not fit these symptoms.
Distinguishing between intermittent allergic rhinitis and perineal allergic rhinitis depends on the duration of symptoms. If symptoms occur for less than 4 days at a time for periods of less than 4 weeks, it is intermittent. If more than this it is perennial (persistnet).
A 21 year old male presents to the GP with recurrent bouts of nasal discharge, loss of smell, itchy eyes, sneezing and priuritis. The symptoms come on in the summer seasons and affect the individual for less than 4 days a week. What immunoglobulin mediates this type of reaction?
1) IgG
2) IgM
3) IgA
4) IgE
5) IgD
This patient is presenting with signs and symptoms of allergic rhinitis. The symptoms of itchy eyes, nasal discharge, loss of smell and itching all occurring in the summer months indicate intermittent allergic rhinitis.
Intermittent allergic rhinitis is a type 1 hypersensitivity reaction and is therefore IgE mediated.
IgM is the antibody produced first on antigen presentation before B cells undergo class switching. it is the immediate response.
IgA is expressed in mucosal tissues and secreted in mucous, saliva, breast milk etc so plays no role in allergic reaction.
IgG is the most common antibody in the blood, secreted by plasma cells. Can also cross the placenta. Has no role in allergic reaction.
IgD is on developing B cells but plays little role in mature B cells.
A 21 year old male presents to the GP with recurrent bouts of nasal discharge, loss of smell, itchy eyes, sneezing and priuritis. The symptoms come on in the summer seasons and affect the individual for less than 4 days a week. It does not affect the individuals sleep. What is the recommended treatment?
1) Antihistamines and intranasal steroids
2) polypectomy
3) Mild analgesia and nasal decongestants
4) Antibiotics
This patient is presenting with signs and symptoms of allergic rhinitis. The symptoms of itchy eyes, nasal discharge, loss of smell and itching all occurring in the summer months indicate intermittent allergic rhinitis.
The treatment for allergic rhinitis is antihistamines for the itchiness and intranasal steroids for the blockage. If these don’t work it can be escalated to add a leukotriene receptor antagonist such as monteleukast.
Polypectomy is used for the treatment of intranasal polyps. Mild analgesia and nasal decongestants are used for sinusitis. Antibiotics are not recommended.
A 61 year old lady presents to the GP with nasal discharge. It is not purulent and does not change depending on the time of year. On further questioning she has suffered from recurrent epistaxis which resolves spontaneously. She describes being short of breath and experiencing some mild chest pain.
O/E of the lungs, there are bibasal crackles and reduced air entry bilaterally. Nasal mucosa reveals no signs of polyps or neoplasm. You notice on examination that the patient has some ankle oedema. There are no cutaneous features.
What is the likely diagnosis?
1) Systemic Lupus Erythematous
2) Sjogrens syndrome
3) Vasomotor rhinitis
4) Granulomatosis with polyangitis (Wegners)
5) Heart failure
The combination of upper respiratory tract symptoms, lower respiratory tract symptoms and ankle swelling indicates a multi system disorder. This rules out vasomotor rhinitis. Heart failure would cause the SOB and ankle swelling however the URT symptoms wouldn’t fit this diagnosis. Sjogrens syndrome would cause dryness rather than discharge so this is also unlikely. This leaves SLE and GPA.
SLE is likely to cause a malar (butterfly) rash (50% of patients). It can cause pleuritis and SOB therefore this would explain the LRT symptoms. However it is unlikely to cause nasal discharge. SLE can cause renal disease causing persistent proteinuria and therefore ankle swelling can also occur.
GPA presents with both URT symptoms and LRT symptoms along with renal disease (causing ankle swelling). Although SLE potentially fits the diagnosis, GPA is the better fit.
A 61 year old lady presents to the GP with nasal discharge. It is not purulent and does not change depending on the time of year. On further questioning she has suffered from recurrent epistaxis which resolves spontaneously. She describes being short of breath and experiencing some mild chest pain.
O/E of the lungs, there are bibasal crackles and reduced air entry bilaterally. Nasal mucosa reveals no signs of polyps or neoplasm. You notice on examination that the patient has some ankle oedema. There are no cutaneous features.
Which antibody is likely to be found on further investigation?
1) Anti-Ro/Anti-la
2) Anti-Jo-1
3) Anti DsDNA
4) Anti-cardiolipin antibody
5) cANCA
This patient is presenting with GPA with both URT symptoms and LRT symptoms along with renal disease (causing ankle swelling).
GPA is associated with cANCA.
Anti Ro and Anti la are associated with sjogrens syndrome.
Anti-jo-1 is associated with polymyositis or dermatomyositis
Anti DsDNA is associated with SLE.
Anti-cardiolipin antibodies are associated with antiphospholipid syndrome and SLE.
A 7-year-old girl presents with frequent nosebleeds, worse on the left. She is currently bleeding and has been for the past 20 minutes despite conservative management. Examination shows small blood vessels in the most anterior septal mucosa, bilaterally.
What is the most appropriate management of this child?
1) Apply pressure anteriorly on the nose for a further 20 minutes and ask the patient to sit forward
2) Apply lidocaine spray
3) Cauterise with silver nitrate
4) Use an anterior nasal pack (rapid-rhino) to stop the bleeding
5) Examination under anaesthesia
The management of epistaxis is as follows:
Initially ask the patient to grip anteriorly on the nose and sit forward. If this doesn’t resolve in 20 minutes, move on.
Prepare the patient for cauterisation of the nose, this involves spraying a topical anaesthetic (lidocaine) or adrenaline to cause vasoconstriction of the blood vessels. The bleeding needs to be stopped before silver nitrate cauterisation can occur. Never cauterise both sides of the septum.
If bleeding was to then continue, this is when you consider using nasal packing techniques.
Examination under anaesthesia is used for serious posterior epistaxis to identify the source of bleeding. The patient will then undergo endoscopic arterial ligation or embolisation.
A 13 year old girl presents to the GP complaining of a sore throat and associated difficulty swallowing. She has tender swelling in the anterior neck and an associated fever. There is no associated cough. On examination you notice exudate on the surfaces of the tonsils. Given her likely diagnosis, what is the most appropriate management?
1) Penicillin 500mg PO
2) Ceftriaxome IV
3) Supportive treatment
4) Supportive treatment and avoidance of contact sports
5) Penicillin IV
This patient is presenting with typical acute tonsillitis. Using the Centor criteria, they score 5 out of 5:
- fever (1)
-tonsillar exudate (1)
-No cough (1)
-Tender lymphadenopathy (1)
-Age 3-14 years (1)
This makes the diagnosis of a streptococcal bacterial infection likely and empirical antibiotic treatment should be initiated immediately. The treatment is oral penicillin (500mg for 10 days). Penicillin IV would not be needed unless patient has complete inability to swallow. Supportive treatment would be appropriate if the cantor criteria was 0-1 as bacterial infection is unlikely. Ceftriaxome IV is used for acute epiglottitis. Supportive treatment and avoidance of contact sports is used for glandular fever.
A 13 year old girl presented to the GP 7 days ago for a sore throat and associated difficulty swallowing. She had tender swelling in the anterior neck and an associated fever. There was no associated cough. On examination you noticed exudate on the surfaces of the tonsils.
She has come back in with persisting difficult and painful swallowing. On further examination you notice the uvula is displaced to the right. What is the likely diagnosis?
1) CN X left sided palsy
2) Quinsy
3) CN X right sided palsy
4) Glandular fever
5) Acute tonsillitis reoccurrence
This patient has presented with an abscess between the muscle and the tonsil causing painful, difficulty swallowing and displacement of the uvula (quinsy). It also occurred 3-7 days post tonsillitis episode. A 10th cranial nerve palsy on the left side would cause displacement of the uvula to the right, however there would be no associated fever symptoms. A 10th cranial nerve palsy on the right side would cause displacement of the uvula to the left and therefore this cannot be correct.
Glandular fever would not cause displacement of the uvula. Acute tonsillitis is unlikely to re-occur in such quick succession.
