ENT Patient Cases Flashcards
Kyle is a 35 YO male who presents w/ a persistent fever and chills for the last month and persistent fatigue. He has a history of IVDU for the past several years and has lost 15 lbs since his physical 1 year ago, though he hasn’t changed his diet or exercise habits. PE confirms that he is febrile - 100.5 degrees, and you note swollen lymph nodes. He is currently on no medications and has no allergies. What lab and what test would you run? If the results confirm your ddx, what is your dx and tx
Kyle has HIV. You could confirm with HIV antibody testing and you take a blood sample for a CD4 count to determine his baseline. Given his current state it’s very possible that he has AIDS - CD4 < 200. You would also run follow up tests following a positive HIV antibody test to determine the type of HIV, if he has the HLA-B*5701 allele, to determine his viral load, and possibly screening for STIs, HBV, and HVC. You would want to run baseline labs as well (CBC, BUN, etc.) to identify any comorbidities. If Kyle can commit to lifelong therapy, you would start him on ART - e.g. Biktarvy, a single pill he would take daily. Depending on his CD4 count, you may also treat him prophylactically to prevent certain other opportunistic infections. You refer Kyle to psych to address the emotional trauma of the dx, and also encourage him to treat his addiction. You impress upon him the importance of informing any sexual partners or people w/ whom he shared needles of his status so they can also be tested.
Theresa is a 16 YO female who presents w/ reddened eyelids off and on for the past month. She has a hx of rosacea. PE shows red, swollen eyelids with some crusting between the lashes. You notice she is wearing mascara and eyeliner. What is your dx and tx? What is the MC etiology?
Theresa has blepharitis, an inflammation of the upper eyelid that can accompany rosacea and is MC caused by S. aureus. It is also caused by poor eyelid hygiene. You tell Theresa that she may want to take a break from eye makeup until the infection resolves and she should use warm, moist compresses on her eyes to help w/ the sxs. Since she also has rosacea, you rx doxycycline PO to help clear the infection.
Dora is a 11 YO female who presents w/ a new mass on her neck, anterior to the sternocleidomastoid. She currently has a URI. You notice the mass is draining slightly and is soft and not fixed. Dora says it’s not painful. What imaging do you order? What is your dx and tx?
Dora has a branchial cleft cyst, a congenital mass. You order an ultrasound to help confirm your dx. Because the cyst is draining, you rx abx and your refer to ENT/surgery to discuss removal to prevent further infection, but you reassure Dora and her parents that the mass is benign.
Maggie is an 80 YO who presents w/ worsening hearing loss over the past several months. She is otherwise healthy and has no allergies and isn’t taking any medications. She hears you speak during the whisper test, but isn’t sure what you’ve said. She has no lateralization w/ the Weber test and Rinne shows that air conduction is louder than bone conduction. You refer her for an audiogram, which shows bilateral hearing loss at higher frequencies. What is your dx for Maggie? What type of hearing loss is she experiencing? How do you tx?
Maggie has presbycusis, or age-related hearing loss. The damage is sensorineural and unfortunately can’t be reversed w/ treatment but you tell Maggie that a hearing aid may help her accommodate the hearing loss.
Kyle is a 32 YO male who presents w/ high fever, headache, and nausea following his return from Kenya. His roommate says he’s been having spasms every day since the other sxs started. PE shows that his vitals are Temp 103.3 F, HR 105, RR 20, and BP 130/90. You also notice a petechial rash on his back that he wasn’t aware of and when you palpate his abdomen the you note hepatomegaly. Labs show mild coagulopathy and elevated BUN and creatinine and anemia as well as parasitemia. What is your dx and tx? What is the etiology and what is the vector?
Kyle has malaria, contracted during his visit to Kenya. This parasitic infection is caused by 5 species of plasmodium, in his case most likely P. falciparum. The parasite is transmitted by the bite of the female Anopheles mosquito. Tx is Malarone and probably admission for the next few days, given Kyle’s severe fever and spasms.
Klaus is a 4 YO male who presents w/ reduced vision in his left eye. He has no pain and no other significant sxs. He was recently dx’d w/ myopia and given corrective glasses. His parents say his vision has improved overall but his left eye seems to lag. PE confirms reduced visual acuity in his left eye and you notice esotropia in that eye as well. He often squints w/ his left eye. What do his myopic hx and strabismus indicate could be a cause of his vision loss? How do you tx Klause?
Klaus has amblyopia, a loss of vision d/t abnormal development in his left eye that leaves his vision poor even after correcting for his myopia. His recent glasses will likely improve his amblyopia, but you also suggest PT to retrain his extraocular muscles and you suggest that he wears a patch over his right eye to incentivize his left eye to be strengthened and trained by his brain.
Kendra is a 35 YO female who presents w/ hearing loss in her left ear that’s developed over the past 2 weeks. She has also noticed some drainage from the ear. She has a hx of recurrent otitis media infections. Weber lateralizes sound to the left ear. Rinne shows she is able to better hear the tuning fork placed behind her left ear than next to it. Otoscopy shows a pearly substance just behind her tympanic membrane. What is your dx and tx? What kind of hearing loss is Kendra experiencing? What would an audiogram show?
Kendra has a cholesteatoma, a condition that can follow frequent otitis media infections. Hearing tests shows that her hearing loss is conductive. An audiogram would show normal hearing in her right ear and reduced air conduction in her left ear. Tx involves abx (e.g. ciprodex), aeration under microscopy, and weekly cleaning. If this is ineffective, surgery can be an option.
Gwen is a 24 YO female who presents w/ constant sneezing, congestion, and itchy nose for the past three weeks. She recently adopted a cat from Kenzie and has a hx of asthma. PE shows pale, edematous nasal mucosa, conjunctival erythema, tearing, and wheezing. You also notice folds beneath her lower lids. What are these called? What is your dx and tx for Gwen?
Gwen has allergic rhinitis, likely d/t pet dander from her cat. The lines you noted beneath her eyes are called Dennie-Morgan lines. Tx involves environmental controls (vaccuming, cleaning frequently, humidifier) as well as nasal corticosteroids - e.g. flonase. If this doesn’t help, you suggest taking a second generation antihistamine like loratadine. She is very insistent about keeping the cat, so if they tx’s don’t help, you can refer her to an allergist and discuss allergen immunotherapy.
Joe is an 8 YO male who presents w/ difficulty swallowing. He currently has a URI. PE reveals a midline anterior neck mass that is somewhat tender and swollen located at the hyoid. What imaging do you order? How do you dx and tx?
Joe has a thyroglossal duct cyst, a typically benign neck mass MC in children. You order a US to confirm your dx. You rx abx to tx the infection and you refer to ENT/surgery to discuss surgical removal of the cyst to prevent further infection. You reassure Joe and his parents that the mass is typically benign.
Mandy is an 8 YO female who presents w/ fever, headache, and sore throat for the past 3 days. Her father says that she hasn’t been eating much because it hurts to swallow. PE confirms she has a fever- 100.4 and her throat is bright red w/ exudates. You see petechiae on her palate as well. You run a rapid test and it comes back positive. What did you test for? What is your dx and tx? If you’d noted a sandpaper-like rash on Mandy’s skin, what would your dx be?
Mandy has bacterial pharyngitis, and you ran a rapid strep test, confirming the cause to be GABHS. If you’d found a sandpaper-like rash on Mandy’s skin, your dx would be Scarlet fever. Tx can be natural course - allow the infection to resolve on its own - or you can rx penicillin.
Angela is a 37 YO female who presents w/ pain, photosensitivity, and blurred vision that has developed over the morning and afternoon. She says she noticed some discomfort last night, but the pain got significantly worse over the course of today. She wears contact lenses and said she’s been reusing the same pair until her new ones arrive. PE shows a white spot on the cornea and fundoscopic exam shows iritis. What is your dx and tx for Angela? What is the most likely etiology?
Angela has a corneal ulcer, likely d/t wearing her lenses for an extended period of time. Because she’s a contact lens wearer, the likely cause is pseudomonas. You take a swab to culture to be sure. Tx is ofloxacin drops (2 gtts q 30 minutes while awake day 1, 2 gtts hourly while awake days 2-10). You tell Angela she needs to keep her lenses out while she gets tx’d and you also refer her urgently to ophthalmology.
Clark is a 45 YO male who presents w/ tooth pain. He said he recently got a filling and it hurt when he bites down. You perform a thermal test and find he is sensitive to cold in that tooth. You see no other abnormalities. What is your dx and tx for Clark?
Clark has reversible pulpalgia, probably caused by hyperocclusion from his new filling. You tell him to take NSAIDs for the pain and you refer him to his dentist for possible alteration to the filling.
Brad is a 22 YO male who presents w/ a swollen lump on lateral left eyelid. He said he’s had these before but this is the worst one yet. You notice his left eye is tearing and the lid is swollen and erythematous around the lump, which is TTP. How do you dx and tx? What is the most likely etiology?
Brad has an external hordeolum, or stye, a blockage of the accessory glands of Zeis or Moll, MC caused by S. aureus. Tx is to use warm, moist compresses on the affected eye 4-6 times/day.
Colton is an 80 YO male who presents w/ headache, myalgia, and chills for the past 3 days. He said he also recently started coughing and feeling short of breath. He just got back from a 2-wk cruise up the Norwegian coast - he said it was beautiful but cold, so he was in the ship’s hot tub every night to warm up before bed. He is in otherwise good health and isn’t on any meds. He has no allergies. How do you dx and tx Colton? What is the etiology? How do you confirm the dx? What imaging might you order?
Colton has Legionnaire’s disease, a type of pneumonia caused by Legionella pneumophilia that he likely contracted from the hot tub on his cruise ship. You can confirm your dx w/ a UA to look for antigens. You may also take a chest X-ray to see how the infection has progressed to his lungs. Tx is erythromycin.
Damien is a 32 YO male who presents pain in his left eye and a gritty sensation. He said it’s been bothering him since he got back from the beach last night. He said he’s been rubbing his eye, trying to get the “junk” in his eye out. PE shows a red, tearing left eye. To inspect more closely, you apply topical anesthesia, which he says totally relieves the pain. You evert his lid and see nothing, but on fluorescein exam, you notice ice rink sign. What is your dx and tx for the pt?
Damien has a conjunctival foreign body that has caused a corneal abrasion. Tx is removal w/ a moistened cotton-tip applicator or eye spud. You also rx abx drops d/t corneal involvement and make sure that Damien’s tetanus vaccinations are up to date.
Clarice is a 48 YO female who presents w/ a lump in her eyelid that developed over the past 2 weeks. PE shows a firm, pea-like nodule w/in her lid. It isn’t tender and you notice no tearing. What is your dx and tx? What gland is involved?
Clarice has a chalazion, a granulomatous inflammation of the meibomian gland that blocks its drainage duct. You tell Clarice that it may spontaneously resolve and since it’s not causing her pain you’d like to observe it for a while. If it doesn’t get better, you can refer to an ophthalmologist for surgical removal and possibly steroid injection
Anika is a 12 YO female who presents w/ a sore throat, fever, and persistent fatigue for the past month. She came in 2 weeks ago and was tested for strep, but it came back negative. Her doctor thought a viral infection would’ve cleared by now, but it hasn’t. PE shows exudative tonsils and cervical lymphadenopathy. You palpate her abdomen and both her liver and spleen feel enlarged. What is your dx and tx for Anika? What is the etiology? What would happen if you tx’d her w/ penicillin?
Anika has pharyngitis associated with mononucleosis caused by Epstein-Barr virus (HHV4). If you rx’d penicillin, it would give her a characteristic rash (which you wouldn’t, knowing that it’s viral). Tx is symptomatic, you recommend ibuprofen or acetaminophen and you tell her to get lots of rest and fluids. It will likely take her 3+ months to fully recover.
Clarissa is a 5 YO female who presents for her physical. When you look inside her mouth, you notice some discoloration on the tops of a few of her teeth. You notice she’s drinking apple juice from her sippy cup. You ask her mother about it and she says it’s the only thing she can get Clarissa to drink lately. You notice no other abnormalities, but you suggest that Clarissa should go to the dentist and stop drinking juice, or at least not drink so much. Her mother asks if it’s a big concern since Clarissa hasn’t lost any teeth yet. What is your concern for Clarissa? What is your response to her mother? What would tx for Clarissa’s issue be?
You’re worried that Clarissa has dental caries d/t drinking so much juice (so much sugar). You tell her mother that poor health of primary teeth can lead to poor health of permanent teeth, so it’s important to take care of them. You refer them to a dentist for possible filling and closer evaluation by a dentist.
Carla is a 5 YO female who presents with a mass above her right eye. The lump is painless, moveable, firm, and slightly discolored. She has no other sxs or findings. How do you dx and tx?
Carla has a periorbital dermoid cyst, a mass caused by entrapment of organic material in the deep epithelium. Tx is surgical resection.
Miranda is a 35 YO female who presents w/ a needle in her eye. She said she was carrying her cross-stitch with her down the stairs when she tripped and the needle ended up in her eye. It appears to be embedded at least 1 inch. How do you image the injury? What is your dx and tx?
Miranda has an intraocular foreign body. Ideally you take a CT to image the needle, but an x-ray will also work since the object is metallic. (Do NOT take an MRI). Tx is broad-spectrum IV abx and an immediate ophthalmology consult.
April is a 27 YO female who presents w/ nasal congestion for the past 7 days. She said she was using over-the counter decongestant that helped about 2 weeks ago, but then the congestion came back, no matter how much decongestant she used. What med is she using? What is your dx and tx?
April has rhinitis medicamentosa, d/t her overuse of Afrin (oxymetazoline). You suggest that she stop using the med and her sxs should resolve in 2-3 wks. She might try a second generation oral antihistamine like loratadine to address her sxs now.
Kara is a 45 YO female who presents w/ high fever, pain behind her eyes, and nausea for the past 2 days. She returned recently from a trip to Puerto Rico w/ her husband. PE shows that she has a high-grade fever of 104 F and a petechial rash on her neck and arms. You insert a BP cuff on her arm and inflate it for 5 minutes then deflate it. What test are you performing? What are you looking for? What is your dx and tx? What is the etiology? What is the vector?
Kara has dengue fever, a viral infection transmitted by the Aedes aegypti mosquito. You are performing a tourniquet test on Kara, and you’re looking for the formation of 10 + new petechiae in one square inch on her arm, below where the tourniquet was placed. Tx is supportive.
Greg is a 62 YO male who presents w/ headache, fever, and neck pain for the past 8 hours. He says he’s been feeling more nauseated since this morning. He has a hx of HIV/AIDS and he says he hasn’t taken his ART in the past 5 years. During the exam you notice that he immediately closes his eyes when you use your penlight to check PERRLA. What tests would you perform during PE? What imaging do you order? How do you dx and tx Greg?
Greg has meningitis, you suspect caused by Cryptococcus neoformans d/t his sensitivity to light and his HIV+ status. You perform Brudzinski’s and Kernig’s to support your ddx. You also order a CT, and you can confirm your dx w/ a culture or microscopy using a blood sample. You rx amphotericin B and flucytosine to tx the infection, to be followed by a course of fluconazole. You also discuss the need to resume ART w/ Greg.
Micah is 14 YO male who presents w/ pain in his mouth. He got in a fight at school today and took a punch to the mouth. He says it hurts tremendously somewhere on the upper right side of his mouth if he bites or clenches his jaw You notice his gums and buccal mucosa are bleeding near the site of the trauma. You see a well defined crack down the middle of one of his right molars. What might help with his pain? What is your next step? Is this a dental emergency?
Micah has a complete tooth fracture, caused by the trauma from the fight. Removement of the fragments may help w/ his pain. You suggest NSAIDs for pain and you refer him to the dentist for evaluation ant tx - possible filling or crown. This is considered a dental emergency if the pulp of the cracked tooth is exposed.
Heath is a 50 YO male who presents w/ a “spot in his right eye” that he noticed 2 days ago. He said it doesn’t hurt or cause him any pain, but he’s worried that it’s something cancerous. PE shows a small, elevated nodule in his right conjunctiva. There are no signs of inflammation. What is your dx and tx?
Heath has a pinguecula, a typically asymptomatic nodule in the conjunctiva. It is benign, but may become problematic if it becomes inflamed. You tell Heath you want to wait and observe it, and that he should come back if he develops any new sxs or notices any changes in the nodule.
Jill is a 32 YO female who presents w/ painful urination for the past 2 days. She says she “always feels like she has to go” and never feels like she is fully emptying her bladder. She rates the pain a 5 and says the discomfort bothers her more than anything. You get a urine sample from her and see that it is cloudy. When you order a UA, what is the most likely etiology for her condition? What is your dx and tx for Jill? What other conditions can the bacteria in Jill’s urine cause?
Jill has a urinary tract infection most likely caused by E. Coli. Tx options include ciprofloxacin or bactrim. E. Coli is also a common culprit of food poisoning that can cause enterotoxigenic (traveler’s) diarrhea, enterohemorrhagic diarrhea that can lead to HUS, and enteroinvasive diarrhea.
Dan is a 48 YO male who presents w/ pain and double vision in his left eye following a racquetball accident. He forgot his goggles at home but wanted to play the match anyways. He took a ball directly to his face. PE shows swelling, ecchymosis, and limited upward gaze. You order a CT - what characteristic sign do you see? What is your dx and tx for Dan? What pt education is important?
Dan has a blowout fracture, caused by the direct blow to his orbit. CT shows a characteristic teardrop on his lower left orbit. You rx prophylactic abx and arrange an ophthalmology consult for the next day. You tell Dan not to blow his nose and to ice and elevate his head when he goes to bed to decrease swelling.
Dennis is a 58 YO male who presents w/ a painful rash that began yesterday on is posterior and anterior upper, left trunk. He said the area felt “numb and tingly” two days ago, but he figured it would go away. PE shows two crops of vesicles on an erythematous base. Dennis is extremely sensitive to touch during the examination and rates his pain an 8. How do you dx and tx Dennis? What is the etiology?
Dennis has herpes zoster, or shingles, an infection caused by the varicella zoster virus and typically presents w/ a dermatomal rash. Because Dennis saw you so soon after his sxs began, you rx Acyclovir to help resolve the rash sooner. You also suggest capsaicin topical cream and rx Neurontin to help w/ his pain.
Thomas is a 44 YO male who presents w/ a swollen neck that began this morning. He is a post-op pt at your hospital and was recovering well from an appendectomy but the pain meds have killed his appetite and he hasn’t been eating or drinking much. PE shows a firm, swollen, tender parotid gland and he is slightly febrile and diaphoretic. Labs show that urinary amylase is elevated. What is your dx and tx for Thomas?
Thomas has parotitis, an inflammation or the parotid gland. Tx involves encouraging him to eat and hydrate properly as well as IV abx.
Jonas is a 2 YO male who presents w/ fever, stridor, and a barking cough for the past 4 days. Prior to that, his parents say he had a stuffy nose. They think he might have picked it up at daycare. PE confirms his fever and you notice sternal retractions as well. What is your dx and tx for Jonas. What is the most likely etiology? If you took an x-ray, what would you see?
Jonas has croup, a viral infection MC caused by parainfluenza virus. Dx is typically clinical, but if you took an x-ray, you would see Steeple sign - subglottic narrowing that causes he sxs. You tell his parents to tx w/ humidity, ibuprofen, and fluids to start, but if it worsens you can tx nebulized epinephrine and/or dexamethasone.
