MISCELLANEOUS FACTS FROM PASSMED

Question 1

A 61-year-old man presents with a two-week history of a sharp, stabbing pain over his right cheekbone. He describes the pain as ‘very severe’ and ‘coming in spasms’. It typical lasts for around one minute before subsiding. The pain can be triggered by shaving and eating. Examination of his eyes, cranial nerves and mouth is unremarkable. What is the most likely diagnosis?

Trigeminal neuralgia

Temporomandibular joint dysfunction

Temporal arteritis

Cluster headache

Herpes zoster ophthalmicus

Answer 1

Trigeminal neuralgia

Question 2

What is trigeminal neuralgia?

Answer 2

A unilateral disorder characterised by brief electric shock-like pains, abrupt in onset and termination, limited to one or more divisions of the trigeminal nerve.

Question 3

What are the precipitating factors for a painful attack in someone with trigeminal neuralgia?

Answer 3

Light touch, including washing, shaving, smoking, talking, and brushing the teeth (trigger factors)

Frequently occur spontaneously

Question 4

What are the areas of the face that are particularly susceptible to painful attacks associated with trigeminal neuralgia?

Answer 4

Small areas in the nasolabial fold or chin

Question 5

What is the first line treatment for trigeminal neuralgia?

Answer 5

Carbamazepine

Question 6

A 56-year-old woman presents with facial asymmetry. Whilst brushing her teeth this morning she noted that the right hand corner of her mouth was drooping. She is generally well but noted some pain behind her right ear yesterday and says her right eye is becoming dry. On examination she has a complete paralysis of the facial nerve on the right side, extending from the forehead to the mouth. Ear, nose and throat examination is normal. Clinical examination of the peripheral nervous system is normal. What is the most likely diagnosis?

Ramsey-Hunt syndrome

Bell’s palsy

Stroke

Multiple sclerosis

Parotid tumour

Answer 6

Bell’s palsy - the pain behind the ear makes it sounds like it could be Ramsay-Hunt syndrome, however this is actually quite common in Bell’s palsy as well with up to 50% of patients reporting this symptom. The normal ear exam also goes against this diagnosis.

Question 7

A 23-year-old man is diagnosed as having nasal polyps. Sensitivity to which medication is associated with this condition?

Answer 7

Aspirin

Question 8

A 25 year-old lady with no significant past medical history presents with 2 days of right ear discomfort, discharge and reduced hearing. She is systemically well and has not had a recent cold. On examination the auditory canal appears inflamed and there is a small amount of debris, but you can still see the tympanic membrane. What is the best management from the options below?

Start topical acetic acid 2% spray

Start oral amoxicillin

Refer to ENT

Take an ear swab and start a topical antibiotic

Start a combination topical antibiotic and steroid

Answer 8

Start a combination topical antibiotic and steroid.

She is showing signs of more than just mild otitis externa (discharge, hearing loss) therefore acetic acid spray is unlikely to be enough.

Question 9

A 14-year-old male presents to surgery with a 3 day history of a sore throat. Which one of the following features is not an indication for antibiotic therapy?

Temperature of 39.1ºC

A past history of diabetes mellitus

Two previous episodes in the past 5 months

Unilateral peritonsillitis on examination

A past history of rheumatic fever

Answer 9

Two previous episodes in the past 5 months

NICE indications for antibiotics:

• Features of marked systemic upset secondary to the acute sore throat
• Unilateral peritonsillitis
• A history of rheumatic fever
• An increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
• Patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present

Question 10

What are the Centor criteria used for and what are the four elements?

Answer 10

The Centor Criteria are a set of criteria which may be used to identify the likelihood of a bacterial infection in adult patients complaining of a sore throat.

• Presence of tonsillar exudate
• Tender anterior cervical lymphadenopathy or lymphadenitis
• History of fever
• Absence of cough

If 3 or more of the criteria are present there is a 40-60% chance the sore throat is caused by Group A beta-haemolytic Streptococcus. Phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic) should be given.

Question 11

A 37-year-old man presents with nasal obstruction and loud snoring. He has noticed these symptoms get gradually worse for the past two months. His left nostril feels blocked whilst his right feels clear and normal. There is no history of epistaxis and he is systemically well. On examination a large nasal polyp can be seen in the left nostril. What is the most appropriate action?

Reassure + provide patient information leaflet on nasal polyps

Enquire about cocaine use

Refer to ENT

Trial of intranasal steroids

Nasal cautery

Answer 11

Refer to ENT

Given that his symptoms are unilateral it is important he is referred to ENT for a full examination.

Question 12

A patient presents due to a ‘brown coating’ on his tongue. He is 34-years-old and has no significant medical history. The coating has been present for the past few weeks. He is asymptomatic other than a slight ‘tickling’ sensation on his tongue. What is the most likely diagnosis?

Lichen Planus

Oral Candida

Iron-deficiency anaemia

Hairy leukoplakia

Black hairy tongue

Answer 12

Black hairy tongue

Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour.

Question 13

What are the predisposing factors for black hairy tongue?

Answer 13

Poor oral hygiene

Antibiotics

Head and neck radiation

HIV

IV drug use

Question 14

How do we treat black hairy tongue?

Answer 14

Tongue scraping

Tongue antifungals if Candida

Question 15

A 20-year-old girl presents with a thyroid cancer, she is otherwise well with no significant family history. On examination she has a nodule in the left lobe of the thyroid with a small discrete mass separate from the gland itself. Which of the following is the most likely cause?

Follicular carcinoma

Anaplastic carcinoma

Medullary carcinom

Papillary carcinoma

B Cell Lymphoma

Answer 15

Papillary carcinoma is the most common subtype and may cause lymph node metastasis (mass separate from the gland itself) that is rare with follicular tumours. Anaplastic carcinoma would cause more local symptoms and would be rare in this age group.

Question 16

A 21-year-old man presents with halitosis and mouth pain. Examination reveals very poor dental hygiene with bleeding gums and widespread gingival ulceration. He has a temperature of 38.0ºC. You advise him to see a dentist. What other treatment options should be offered?

Paracetamol + oral phenoxymethylpenicillin

Paracetamol + oral phenoxymethylpenicillin + chlorhexidine mouthwash

Paracetamol + chlorhexidine mouthwash

Paracetamol + oral metronidazole + chlorhexidine mouthwash

Paracetamol + oral metronidazole

Answer 16

Paracetamol + oral metronidazole + chlorhexidine mouthwash

This man has acute necrotizing ulcerative gingivitis with systemic upset. Treatment should be commenced whilst he is awaiting to see a dentist.

Question 17

A 48-year-old female presents to the GP with a lump in throat. She can swallow foods and liquids normally if she tries, although she has noticed the discomfort is worse on swallowing saliva. She does not have any pain on swallowing, chest pain or heart burn. Her appetite is normal.

What is the most likely diagnosis?

Achalasia

Oesophageal spasm

Oesophageal carcinoma

Benign oesophageal stricture

Globus pharyngis

Answer 17

Globus pharyngis

Globus pharyngis (also known as globus hystericus) is the persistent sensation of having a ‘lump in the throat’, when there is none. Symptoms are often intermittent and relieved by swallowing food or drink. Swallowing of saliva is often more difficult.

Question 18

A 62 year old man presents 2 days after receiving a punch to his head on the right side. Since the injury he feels his hearing has been muffled on the right side. On examination there is no bruising. Both his ears are obscured by a thin translucent layer of wax. On the right, Rinne’s test demonstrates the tuning fork is easier to hear when pressed on the mastoid bone. On Weber’s test the sound is heard best on the right hand side. What is the most likely diagnosis?

Otosclerosis

Base of skull fracture

Otitis media

Earwax

Perforated eardrum

Answer 18

Perforated eardrum

Tympanic membrane perforation is a relatively common complication from trauma to the skull. It is important to distinguish this from sensorineural hearing loss resulting from a base of skull fracture.

Rinne’s test her shows that there is a conductive hearing loss in the affected ear. Weber’s test confirms that there is no sensorineural hearing loss on the right.

Question 19

Which one of the following patients is most likely to have nasal polyps?

A 40-year-old man

A 40-year-old woman

An 8-year-old girl

An 80-year-old woman

An 8-year-old boy

Answer 19

A 40-year-old man

Question 20

A 24-year-old man who is suffering from sinusitis asks about using Sudafed (pseudoephedrine). Which one of the following medications would make the use of Sudafed contraindicated?

Sodium valproate

Monoamine oxidase inhibitor

Salbutamol

Triptan

Selective serotonin reuptake inhibitor

Answer 20

Monoamine oxidase inhibitor

A monoamine oxidase inhibitor combined with pseudoephedrine could potentially cause a hypertensive crisis.

Question 21

A 7-year-old girl is brought to surgery due to a sore throat. She has a temperature of 39.2ºC and is not eating due to the pain, although she is tolerating fluids. She has had no other related symptoms such as a cough or a rash. Her heart rate is 120/min and auscultation of the chest is unremarkable. The tonsils are covered in exudate bilaterally. Examination of the ears is unremarkable. Other than supportive treatment, what is the most appropriate management?

Erythromycin for 10 days

Amoxicillin for 7 days

Antibiotics are not indicated

Phenoxymethylpenicillin for 10 days

Aciclovir for 5 days

Answer 21

Phenoxymethylpenicillin for 10 days

This girl has marked systemic upset and should be treated with antibiotics. A 7 or 10 day course of antibiotics is appropriate to ensure eradication of possible Streptococcus infection. Phenoxymethylpenicillin is the first-line antibiotic choice in the BNF

Question 22

A 44-year-old man asks for advice. He is due to go on a long bus journey but suffers from debilitating motion sickness. Which one of the following medications is most likely to prevent motion sickness?

Cyclizine

Chlorpromazine

Metoclopramide

Prochlorperazine

Domperidone

Answer 22

Cyclizine

Motion sickness - hyoscine is better than cyclizine, and cyclizine is better than promethazine

Question 23

Which one of the following statements regarding trigeminal neuralgia is correct?

Duloxetine is the first-line treatment

All patients with suspected trigeminal neuralgia should be referred to secondary care

The pain is commonly triggered by touching the skin

The pain is usually constant

It is bilateral in 30% of cases

Answer 23

The pain is commonly triggered by touching the skin

Carbamazepine is first-line

Question 24

A 28-year-old Bangladeshi woman presents with a three day history of sweats, headache, lethargy and muscle aches. On examination she has bilateral tender swellings in the submandibular region. What is the most likely diagnosis?

Lymphoma

Tuberculosis

Reactive lymph nodes

Cystic hygroma

Branchial cyst

Answer 24

Reactive lymph nodes

The flu is still the most likely diagnosis here. Just because she is Bangladeshi doesn’t mean she is more likely to have TB than the flu.

Question 25

You review a 25-year-old man who has allergic rhinits. He has been using intranasal oxymetazoline which he bought from the local chemist for the past 10 days. What is the main side-effect of using topical decongestants for prolonged periods?

Permanent loss of smell

Infective sinusitis

Post-nasal drip

Tachyphylaxis

Necrosis of the nasal septum

Answer 25

Tachyphylaxis

After using topical decongestants for prolonged periods increasing doses are needed to provide the same effect, a phenomenon known as tachyphylaxis.

Question 26

A 30-year-old man presents with facial pain and a ‘heavy head’ sensation after having a cold. A diagnosis of acute sinusitis is suspected. Which one of the following should be considered for symptomatic relief?

Intranasal decongestants

Intranasal corticosteroids

Oral antihistamine

Oral mucolytics

Steam inhalation

Answer 26

Intranasal decongestants

Question 27

A 21-year-old man presents with halitosis and mouth pain. Examination reveals very poor dental hygiene with bleeding gums and widespread gingival ulceration. He has a temperature of 38.0ºC. You advise him to see a dentist. What other treatment options should be offered?

Paracetamol + oral phenoxymethylpenicillin

Paracetamol + oral phenoxymethylpenicillin + chlorhexidine mouthwash

Paracetamol + chlorhexidine mouthwash

Paracetamol + oral metronidazole + chlorhexidine mouthwash

Paracetamol + oral metronidazole

Answer 27

Paracetamol + oral metronidazole + chlorhexidine mouthwash

This man has acute necrotizing ulcerative gingivitis with systemic upset. Treatment should be commenced whilst he is awaiting to see a dentist.

Question 28

A 50-year-old female presents with bilateral parotid gland swelling and symptoms of a dry mouth. On examination she has bilateral facial nerve palsies. This improved following steroid treatment. What is the most likely diagnosis?

Sialectasis

Pleomorphic adenoma

Sjogren’s syndrome

Adenoid cystic carcinoma

Sarcoidosis

Answer 28

Sarcoidosis

Sarcoid occurs bilaterally in 70% of cases and facial nerve involvement is recognised. Treatment is conservative in most cases although individuals with facial nerve palsy will usually receive steroids with good effect.