IV. ENT End

1. A 28-year-old Caucasian male presents to the emergency department complaining of neck pain for the past two days. He states that a chicken bone scratched the back of his throat a week ago. Two weeks ago, he was in Arizona visiting his friends. He is otherwise healthy and has never been hospitalized. His temperature is 39°C (102.2F), blood pressure is 125/85 mmHg, and heart rate is 120/min. On examination, he refuses to fully open his mouth. Neck movements, especially neck extension, are restricted secondary to pain. Which of the following is the most likely diagnosis?

2. A 55-year-old female presents to the office with a one-week history of left-sided ear pain and itchiness. The pain is especially bothersome at night, and is exacerbated by chewing. She denies any hearing loss. Her past medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and gout. Current medications include lisinopril, allopurinol, and metformin. She has missed her last two appointments with her primary care physician. Her temperature is 38.3°C (101.0F), blood pressure is 140/90 mmHg, and pulse is 98/min. On examination, there is granulation tissue in the left ear canal with a scant amount of discharge. Which of the following is the best initial treatment for this patient?

3. A 7-year-old boy with a 6-day history of nasal discharge presents with a swollen and painful left eye. His blood pressure is 100/70 mm Hg, pulse is 92/min, respirations are 18/min, and temperature is 39.4°C (103F). Examination of the left eye reveals swollen and erythematous eyelids, mild protrusion of the eyeball, and pain with eye movements. The affected eye is tender and his visual acuity is decreased. Funduscopic examination is normal. Which of the following is the most likely diagnosis?

4. A 45-year-old Asian male complains of a progressively worsening sore throat and difficulty swallowing for the past 24 hours. You notice that his voice is muffled and he is drooling. He also has a harsh shrill associated with respiration. His temperature is 39.3°C (103F), blood pressure is 120/80 mmHg, pulse is 106/min, and respiratory rate is 22/min. On examination, a few cervical lymph nodes are palpable and there is tenderness to palpation over his larynx. Which of the following are the two most common organisms that cause this condition?

5. A 60-year-old man comes to your office complaining of difficulty hearing for the past few weeks. He has type 2 diabetes mellitus, which is well-controlled by diet alone. His past medical history is also significant for essential hypertension, congestive heart failure secondary to diastolic dysfunction, and chronic renal failure. Medications include aspirin, diuretics, an ACE inhibitor, and a beta-blocker. His pulse is 82/min, blood pressure is 140/90 mmHg, and respirations are 14/min. Examination reveals hearing loss in both ears Which of the following medication is a potential cause of this patient's hearing problems?

6. A 32-year-old male complains of difficulty hearing in his left ear for the past month. He denies any headaches, fever, chills, weight loss, or ear discharge. He is HIV positive, and is currently being treated with highly active antiretroviral therapy (HAART). He also takes trimethoprim/sulfamethoxazole daily. His most recent CD4 count was 425/ mm3. Examination of the affected ear shows a dull, hypomobile tympanic membrane. What is the most likely cause of hearing loss in this patient?

7. A 65-year-old female complains of difficulty eating over the last two days. She states that food drops out of her mouth. She has also been having some discharge in her left ear recently. She denies any sore throat, nasal discharge, chest pain, cough, or difficulty breathing. Her past medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. She has been poorly complaint with follow-up appointments. Her temperature is 38.8°C (101.7 F), pulse is 96/min, blood pressure is 140/90 mmHg, and respirations are 18/min. Examination of the left ear canal shows granulations. There is facial asymmetry, and the angle of the mouth on the left is deviated downward. Which of the following is the most likely causative organism for this patient's condition?

8. A 7 -year-old boy is brought to your office with a sore throat, decreased appetite, and nausea. His past medical history is insignificant. All of his vaccinations are up-to-date. He has no known allergies. His temperature is 39.0°C (102.5F), blood pressure is 110/70 mmHg, pulse is 104/min, and respirations are 16/min. On examination, the pharynx and tonsils are red, swollen, and have white exudates on their surface. There is also bilateral tender cervical lymphadenopathy. The rapid diagnostic test for streptococcal antigen is positive. What is the most appropriate next step in management?

9. A 37-year-old woman presents to your office with severe vertigo, postural instability, and vomiting. She also complains of "a buzzing sound" in her right ear. She has had two similar episodes over the previous year that lasted several hours and resolved spontaneously. She has no other medical problems. Her mother died of breast cancer at 55 years of age and her father is currently suffering from colon cancer. Her heart rate is 90/min and blood pressure is 130/80 mmHg. Her BMI is 25.3 kg/m2. Examination reveals horizontal nystagmus. Which of the following could have prevented this patient's symptoms?

10. A 36-year-old woman presents to your office with complaints of worsening throat pain for the past six days. She also has pain in her ears and neck as well as difficulty swallowing. On examination, she has excessive salivation and difficulty opening her mouth. Her temperature is 39°C (102.2F), blood pressure is 130/80 mmHg, pulse is 100/min, and respiratory rate is 18/min. Which of the following neck space infections carries the highest risk of mediastinal involvement?

11. A 23-year-old male comes to your office with a 10-day history of severe headaches. He states that they are sharp in character and are mostly right-sided involving the frontal area. The headaches interfere with his sleep, and he also complains of double vision, nausea, and malaise. His blood pressure is 120/80 mm Hg, pulse is 103/min, respirations are 14/min, and temperature is 38.0°C (100.5F). Examination reveals bilateral periorbital edema. There is subtle right-sided lateral gaze palsy. Which of the following is the most likely diagnosis?

12. A 24-year-old Caucasian female complains of recurrent painful ulcers in her mouth and occasional abdominal pain. She has also unintentionally lost 5 pounds over the last six months. She is not sexually active, and denies use of tobacco, alcohol, or drugs. Past medical history is noncontributory and she takes no regular medications. Her mother suffers from asthma and her father has prostate cancer. She is afebrile with a blood pressure of 118/69 mmHg and pulse of 71/min. Physical examination reveals mild abdominal tenderness primarily in the lower abdomen without guarding or rebound. Several shallow ulcers are seen on the buccal mucosa. A biopsy of one of the ulcers demonstrates granulomatous inflammation. Her hematocrit is 42%. Which of the following is the most likely cause of this patient's complaints?

13. A 70-year-old man comes to your office with complaints of difficulty hearing. His wife says that he has been raising the television volume much louder recently. The patient claims that he can hear well when he talks to his family members at home, but he has significant difficulty hearing in restaurants or during other family gatherings, which is why he prefers to stay at home most of the time. He worked in a shipbuilding yard for 30 years, and retired five years ago. He has no history of significant noise exposure. What is the most likely diagnosis?

14. A 12-year-old girl comes to the office complaining of a small amount of left-sided ear discharge that has persisted for the last three weeks. She has completed two courses of antibiotics that were prescribed during her previous visits. She also complains of hearing loss on the left side. On examination, she is afebrile. Otoscopy reveals an intact left tympanic membrane with peripheral granulation and some skin debris. The patient should be evaluated for which of the following?

15. A 33-year-old Caucasian female has suffered from recurrent episodes of dizziness over the last six months. She describes the episodes as a sensation of severe spinning that last one to two hours and are accompanied by intense nausea. She also feels unsteady during the episode, and has to lie down with her eyes closed for relief. There is no particular factor that precipitates the episodes. She denies any headaches, but complains of fullness in her right ear. She has no ear pain or ear discharge. She has used some over-the-counter ear drops with minimal relief of the fullness sensation. She prefers holding her cell phone on the left side. Which of the following is the most likely cause of this patient's condition?

16. A 62-year-old male comes to your office for a routine follow-up appointment. He has smoked one pack of cigarettes per day for the past 30 years and adamantly refuses to quit. He also drinks six to ten beers each weekend. His past medical history is significant for type 2 diabetes mellitus and hypertension. His last hemoglobinA1c was 8.3%. He is overweight with a current BMI of 27.5 kg/m2. While examining him, you notice a whitish patch over the anterior floor of his mouth. The lesion appears to have a granular texture and is not removed by scraping with a tongue depressor. Which of the following is most likely cause of his oral lesion?

17. 6-year-old boy is brought to the office by his mother due to a decreased appetite and irritability for the past three days. He also had an episode of diarrhea yesterday. Lately, he has been sitting close to the television with the volume turned up very loudly. His temperature is 38.1°C (100.5.F), blood pressure is 110/60 mmHg, and heart rate is 110/min. On examination, there is left-sided yellowish ear discharge. His nasal mucosa appears boggy and postnasal drip is present. What is the most likely diagnosis?

18. A 28-year-old African American female complains of recurrent nasal discharge and increasing nasal congestion. She has a constant sensation of dripping in the back of her throat, and states that food has tasted bland to her recently. She is known to have sickle cell trait. She came to the emergency department for severe wheezing after taking naproxen for menstrual cramping one year ago. She has no history of head trauma. She does not smoke cigarettes, but she admits to smoking marijuana occasionally. Which of the following is the most likely diagnosis?

19. A 26-year-old man comes to your office with a one-week history of right-sided ear pain. The pain often wakes him up at night, and increases in severity when he chews food. He cannot recall any recent episodes of pharyngitis. He denies having any ear discharge, sinus tenderness, or skin rash. He exercises by swimming frequently at a local club. He is sexually active and uses condoms "quite regularly." He lives with his brother, who often comments on his habit of grinding his teeth at night. On examination, his ears are normal with a mild amount of wax. Pain is not elicited by pulling on the pinna. There are no hearing deficits appreciated. Mobility of the tympanic membrane is normal, and the Weber and Rinne test results are within normal limits. What is the most likely diagnosis?

20. A 30-year-old school teacher presents with a three-day history of fever, chills, and sore throat. He also complains of difficulty swallowing that started yesterday. He denies any cough, chest pain, or difficulty breathing. He is married and denies any new sexual encounters. His temperature is 39°C (102.2F), blood pressure is 118/76 mmHg, pulse is 102/min, and respirations are 19/min. On examination, his voice is muffled. Enlarged, tender cervical lymph nodes are palpated on the left, and his uvula is deviated to the right. What is the most appropriate treatment for this patient?