MISCELLANEOUS FACTS FROM PASSMED Flashcards
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
Trigeminal neuralgia
What is trigeminal neuralgia?
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.
What are the precipitating factors for a painful attack in someone with trigeminal neuralgia?
Light touch, including washing, shaving, smoking, talking, and brushing the teeth (trigger factors)
Frequently occur spontaneously
What are the areas of the face that are particularly susceptible to painful attacks associated with trigeminal neuralgia?
Small areas in the nasolabial fold or chin
What is the first line treatment for trigeminal neuralgia?
Carbamazepine
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
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.
A 23-year-old man is diagnosed as having nasal polyps. Sensitivity to which medication is associated with this condition?
Aspirin
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
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.
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
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
What are the Centor criteria used for and what are the four elements?
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.
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
Refer to ENT
Given that his symptoms are unilateral it is important he is referred to ENT for a full examination.
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
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.
What are the predisposing factors for black hairy tongue?
Poor oral hygiene
Antibiotics
Head and neck radiation
HIV
IV drug use
How do we treat black hairy tongue?
Tongue scraping
Tongue antifungals if Candida
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
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.
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
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.
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
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.
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
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.
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
A 40-year-old man
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
Monoamine oxidase inhibitor
A monoamine oxidase inhibitor combined with pseudoephedrine could potentially cause a hypertensive crisis.
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
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
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
Cyclizine
Motion sickness - hyoscine is better than cyclizine, and cyclizine is better than promethazine
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
The pain is commonly triggered by touching the skin
Carbamazepine is first-line
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
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.
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
Tachyphylaxis
After using topical decongestants for prolonged periods increasing doses are needed to provide the same effect, a phenomenon known as tachyphylaxis.
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
Intranasal decongestants
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
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.
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
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.
