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41 Cards in this Set
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- Back
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OT.8. – A 69 year old man who smokes and drinks and has rotten teeth has hoarseness that has persisted for six weeks in spite of antibiotic therapy.
OT.10. – A 69 year old man who smokes and drinks and has rotten teeth has a painless ulcer in the floor of the mouth that has been present for 6 weeks and has not healed.
OT.11. – A 69 year old man who smokes and drinks and has rotten teeth has unilateral ear ache that has not gone away in 6 weeks. Physical examination shows serious otitis media on that side, but not on the other.
What is it? |
These are all different ways for squamous cell carcinoma of the mucosa of the head and neck to show up. They all need triple endoscopy to find and biopsy the primary tumor and to look for synchronous second primaries. |
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A 52 year old man complains of hearing loss. When tested he is found to have unilateral sensory hearing los on one side only. He hoes not engage in any activity (such as sport shooting) that would subject that ear to noise that spares the other side. - What is it? - How to diagnose? |
What is it? - Unilateral versions of common ENT problems in the adult suggest malignancy. In this case, acoustic nerve neuroma. Note that if the hearing loss had been conductive, a cerumen plug would be the obvious first diagnosis.
How is it diagnosed? MRI looking for the tumor. |
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A 56 year old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full blown paralysis to become obvious, and it has been present now for three months. It affects both the forehead as well as the lower face. - What is it? - Work up? |
What is it? - Gradual, unilateral nerve paralysis suggests a neoplastic process.
Work-up: Gadolinium enhanced MRI. |
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A 45 year old man presents with a 2 cm. firm mass in front of the left ear, which has been present for four months. The mass is deep to the skin and it is painless. The patient has normal function of the facial nerve. - What is it? - How is it diagnosed? |
What is it? - Pleomorphic adenoma (mixed tumor) of the parotid gland.
How is it diagnoses? – FNA is appropriate, but the point of the question will be to bring out the fact that parotid masses are never biopsied in the office or under local anesthesia. Look for the option that offers referral to a head and neck surgeon for formal superficial parotidectomy. |
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A 65 year old man present with a 4 cm. hard mass in front of the left ear, which has been present for six months. The mass is deep to the skin and it is fixed. He has constant pain in the area, and for the past two months has had gradual progression of left facial nerve paralysis. He has rock-hard lymph nodes in the left neck. - What is it? - Management? |
What is it? - Cancer of the parotid gland.
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OT.16. – A two year old by has unilateral ear ache.
OT.17. – A two year old has unilateral foul smelling purulent rhinorrhea.
OT.18. – A two year old has unilateral wheezing and the lung on that side looks darker on X-Rays (more air) than the other side.
What is it? What do you do? |
What is it? - Unilateral versions of common bilateral ENT conditions in toddlers suggest foreign body.
Appropriate X-Rays, physical examination or endoscopies and extraction –typically under anesthesia. |
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A 4 year old child is brought by his mother to the emergency room because “she is sure that he must have swallowed a marble”. The kid was indeed playing with marbles and apparently completely healthy when he was put to bed, but four hours later he had developed inspiratory stridor, a fever of 103 and obvious respiratory distress. The kid is sitting up, leaning forward, drooling at the mouth and looking very sick indeed. - What is it? - Management? |
What is it? – Acute epiglotitis.
Management: A real emergency where expert help is needed! The diagnosis is confirmed with lateral X- rays of the neck, but be sure experts go with the kid to the X-Ray dept., ready to use bag and mask if needed. Then it’s off to the OR for nasotracheal intubation. If bradychardia develops, the kid is in real trouble: atropine will help, but hypoxia is the problem. Along the way, start IV antibiotics for H.Influenzae. |
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A 45 year old lady with a history of a recent tooth infection shows up with a huge, hot, red, tender, fluctuant mass occupying the left lower side of her face and upper neck, including the underside of the mouth. The mass pushes up the floor of the mouth on that side. She is febrile. - What is it? - Management? |
What is it? – Ludwigs’ Angina. (An abscess of the floor of the mouth)
Management: Tracheostomy and incision drainage of the abscess. |
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A 29 year old lady calls your office at 10 AM with the history that she woke up that morning with one side of her face paralyzed. - What is it? - Management? |
What is it? - Bell’s palsy.
Management: The latest trend is to start these patients right away on anti-viral medication. Pick that answer if offered. If the question has been lingering in the item pool for years, the correct choice will be that the process is idiopathic and will resolve spontaneously in most cases. |
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A patient with multiple trauma from a car accident is being attended to in the emergency room. As multiple invasive things are done to him, he repeatedly grimaces with pain. The next day it is noted that he has a facial nerve paralysis on one side. - What is it? |
Trauma to the temporal bone can certainly transect the facial nerve, but when that happens the nerve is paralyzed right there and then. Paralysis appearing late is from edema. The point of the vignette is that nothing needs to be done. |
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Your office receives a phone call from Mrs. Rodriguez. You know this middle aged lady very well because you have repeatedly treated her in the past for episodes of sinusitis. In fact, six days ago you started her on decongestants and oral antibiotics for what you diagnoses as frontal and ethmoid sinusitis. Now she tells you over the phone that ever since she woke up this morning, she has been seeing double. - What is it? - Management? |
What is it? - Cavernous sinus thrombosis, or orbital cellulitis.
Management: This is a real emergency. She needs immediate hospitalization, high dose IV antibiotic treatment and surgical drainage of the paranasal sinuses or the orbit. A CT scan will be needed to guide the surgery, but I expect that the thrust of the question will be directed at your recognition of the serous nature of this problem, rather than the therapy. |
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A 10 year old girl has epistaxis. Her mother says that she picks her nose all the time. - What is it? - Management? |
What is it? - Bleeding from the anterior part of the septum.
Management: Phenylephrine spray and local pressure. |
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An 18 year old boy has epistaxis. The patient denies picking his nose. No source of anterior bleeding can be seen by physical examination. - What is it? - Management? |
What is it? - Either septal perforation from cocaine abuse, or posterior juvenile nasopharyngeal angiofibroma.
Management: Get your ENT friends to take care of this one. You can not do it. |
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A 72, hypertensive male, on aspirin for arthritis, has a copious nosebleed. His blood pressure is 220/15 when seen in the E.R. He says he began swallowing blood before it began to come out through the front of his nose. - What is it? - Management? |
What is it? - Obviously epistaxis secondary to hypertension.
Management: These are serious problems that can end up with death. Medical Rx. To lower the blood pressure is clearly needed, and may be the option offered in the answers, but getting the ENT people right away should also be part of the equation. |
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OT.27. – A 57 year old man seeks help for “dizziness”. On further questioning he explains that he gets light and work-up in that direction.
OT.28. – A 57 year old man seeks help for “dizziness”. On further questioning, he explains that the room spins around him.
What is it? |
What is it? - This one is in the vestibular apparatus. I could not even begin to tell you how to work it up, but seek the answers that look like either symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup. |
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During a school physical exam, a 12 year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognized that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a fixed split second heart sound. A history of frequent colds and upper respiratory infections is elicited. - What is it? - Management? |
What is it? - Atrial septal defect.
Management: Echocardiography to establish the diagnosis. Surgical closure of the defect. Closure by way of catheterization is till experimental. |
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A three month old boy is hospitalized for ‘failure to thrive”. He has a loud, pansystolic heart murmur best heard at the left sternal border. Chest X-Ray shows increased pulmonary vascular markings. - What is it? - Management? |
What is it? - Ventricular septal defect.
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A three day old premature baby has trouble feeding and pulmonary congestion. Physical exam shows bounding peripheral pulses and a continuous, machinery-like heart murmur. - What is it? - Management? |
What is it? - Patent ductus arteriosus.
Management: Echocardiography and surgical closure or indomethacin. |
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A patient known to have a congenital heart defect requires extensive dental work. - What is the point? |
Pretty brief vignette, but the point is that somewhere along the line, you might be expected to remember that these patients need antibiotic prophylaxis for subacute bacterial endocarditis. |
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A 6 year old boy is brought to the U.S. by his new adoptive parents, from an orphanage in Eastern Europe. The kid is small for his age, and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis relieved with squatting. He has a systolic ejection murmur in the left third intercostal space. Chest X-Ray shows a small heart, and diminished pulmonary vascular markings. EKG shows right ventricular hypertrophy. - What is it? - Management? |
What is it? - Tetralogy of Fallot. Cyanotic kids could have any of the 5 conditions that begin with the latter “T”: Tetralogy or Transportation of the great vessels, which are common; or Truncus arteriosus, Total anomalous pulmonary venous connection or Tricuspid atresia, which are rare. If the kid went home after birth, and later was found to be cyanotic, bet on tetralogy. If he was blue from the moment of birth, bet on transposition.
Management: Even if all you can recognize in the vignette is that a child has cyanosis, start with an Echocardiogram as a good diagnostic test. The intricate details of surgical correction, and the need the surgeons might have for cardiac catheterization prior to surgery are bound to b beyond the level of knowledge expected of you in this examination. |
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A 72 year old man has a history of angina and exertional syncopal episodes. He has a harsh midsystolic heart murmur best heard at the second intercostal space and along the left sternal border. - What is it? - Management? |
What is it? - Aortic stenosis.
Management: The diagnostic test is echocardiogram. Surgical valvular replacement is indicated if there is a gradient of more than 50 mm.Hg., or at the first indication of congestive heart failure, angina or syncope. |
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A 72 year old man has ben known for years to have a wide pulse pressure and a blowing, high- pitched, diastolic heart murmur best heard at the second intercostal space and along the left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in the most recent one there is evidence of beginning left ventricular dilatation. - What is it? - Management? |
What is it? - Chronic aortic insufficiency.
Management: Aortic valve replacement. |
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A 26 year old drug-addicted man develops congestive heart failure over a short period of a few days. He has a loud, diastolic murmur at the right, second intercostal space. A physical exam done a few weeks ago, when he had attempted to enroll in a detoxification program was completely normal. - What is it? - Management? |
What is it? - Acute aortic insufficiency due to endocarditis.
Management: Emergency valve replacement, and antibiotics for a long time. |
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A 35 year old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptisis. She has had these progressive symptoms for about 5 years. She looks thin and cachectic, has atrial fibrillation and a low-pitched, rumbling distolic apical heart murmur. At age 15 she had rheumatic fever. - What is it? - Management? |
What is it? - Mitral stenosis.
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A 55 year old lady has been known for years to have mitral valve prolapse. She now has developed exertional dyspnea, orthopnea and atrial fibrillation. She has an apical, high pitched, holosystolic heart murmur that radiates to the axilla and back. - What is it? - Management? |
What is it? - Mitral regurgitation.
Management: Start with the echocardiogram, eventually surgical repair of the valve (annuloplasty), or possibly valve replacement. |
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A 55 year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type two diabetes mellitus and has high cholesterol. - What is it?
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What is it? - It’s a heart attack waiting to happen...but the point of this vignette is the management: this man needs a cardiac catheterization to see if he is suitable candidate for coronary revascularization. |
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A 55 year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brother died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit overweight, has type two diabetes mellitus and has high cholesterol. Cardiac catheterization demonstrates 70% occlusion of three coronary arteries, with good distal vessels. His left ventricular ejection fraction is 65%. - Management? |
Management: He is lucky. He has good distal vessels (smokers and diabetics often do not) and enough cardiac function left. He clearly needs coronary bypass, and with 3 vessel disease there should be no argument for angioplasty instead of surgery. |
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On a routine pre-employment physical examination, a chest X-Ray is done on a 45 year old chronic smoker. A “coin lesion” is found in the upper lobe of the right lung. - What is it? - Workup? |
The concern of course, is cancer of the lung. Next best thing to do: Find and older chest X- Ray if one is available (from one or more years ago). The work up for cancer of the lung is expensive and invasive. On the other hand, cancer of the lung grows and kills in a predictable way, over a matter of several months. If an older X-Ray has the same unchanged lesion, it is not likely cancer. No further work up is needed now, but the lesion should be followed with periodic X-Rays. |
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A 54 year old man with a 40 pack/year history of smoking gets a chest X-Ray because of persistent cough. A peripheral, 2 cm. “coin lesion” is found in the right lung. A chest X-Ray taken two years ago had been normal. CT scan shows no calcifications in the mass and no enlarged peribronchial or peritracheal lymph nodes. Bronchoscopy and percutaneous needle biopsy have not been able to establish a diagnosis. The man has good pulmonary function and is otherwise in good health. - What to do? |
What to do? - In dealing with cancer of the lung, there is an interplay of three issues: establishing the diagnosis – which sometimes requires very invasive steps; ascertaining if surgery can be done – i.e.: will the patient still be functional after some lung tissue is removed?; and third, does the surgery have a fair chance to cure him? Here is an example of a man who could stand lung resection (peripheral lesion, good function) and who stands a good change for cure (no node mets). Diagnosis steps should be pushed to the limit. Start with bronchoscopy and washings, if unrewarding go to percutaneous needle biopsy, and if still unsuccessful go to open biopsy, i.e.: thoracotomy and wedge resection. |
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A 72 year old chronic smoker with sever COPD is found to have a central, hilar mass on chest X- Ray. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 1100, and a ventilation/perfusion scan shows that 60% of his pulmonary functions comes from the affected lung. - Management? |
It takes an FEV1 of at least 800 to survive surgery and not be a pulmonary cripple afterwards. If this fellow got a pneumonectomy (which he would need for a central tumor) he would be left with an FEV1 of 440. No way. Don’t do any more tests. He is not a surgical candidate. You already have a diagnosis to pursue chemotherapy and radiation. |
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A 62 year old chronic smoker has an episode of hemoptysis. Chest X-ray shows a central hilar mass. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 2200, and a ventilation/perfusion scan shows that 30% of his pulmonary function comes from the affected lung. - Management? |
Management: This fellow could tolerate a pneumonectomy. CT scan and mediastinoscopy are in order, to ascertain if surgery has a decent chance to cure him. |
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A 33 year old lady is undergoing a diagnostic work-up because she appears to have Cushing’s syndrome. Chest X-Ray shows a central, 3 cm. round mass on the right lung. Bronchoscopy and biopsy confirm a diagnosis of small cell carcinoma of the lung. - Management? |
Management: Radiation and chemotherapy. Small cell lung cancer is not treated with surgery, and thus we have no need to determine FEV1 or nodal status. |
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A 54 year old right handed laborer notices coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. What really concerned him, though, is that in the last few episodes he also experienced transitory vertigo, blurred vision and difficulty articulating his speech. Angiogram demonstrates retrograde flow through the vertebral artery. - What is it? - Management? |
What is it? – Subclavian steal syndrome. A combination of “claudication of the arm” with posterior brain neurological symptoms is classical for this rare, but fascinating (and thus favorite question condition.
Management: If you had been given the vignette without the angiographic study, you would have asked for it. Now that you have it, you are ready for vascular surgery. |
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A 62 year old man is found on physical exam to have a 6 cm. pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus. - What is it? - Management? |
What is it? – Abdominal aortic aneurysm. Management: Needs elective surgical repair. |
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A 62 year old man has vague, poorly described epigastric and upper back discomfort. He has been found on physical exam to have a 6 cm. pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus. The mass is tender to palpation. - What is it? - Management? |
What is it? - An abdominal aortic aneurysm that is beginning to leak.
Management: Get a consultation with the vascular surgeons today. |
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A 68 year old man is brought to the ER with excruciating back pain that began suddenly 45 minutes ago. He is diaphoretic and has a systolic blood pressure of 90. There is an 8 cm., pulsatile mass palpable deep in his abdomen, between the xiphoid and the umbilicus. - What is it? - What does he need? |
What is it? - Abdominal aortic aneurysm, rupturing right now.
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A retired businessman has claudication when walking more than 15 blocks. - Management? |
Management: Vascular surgery, or angioplasty and stenting are palliative procedures. They do not cure arteriosclerotic occlusive disease. Claudication has an unpredictable course, thus there is no advantage to an “early operation”. This man needs nothing. If he smokes, he should quit. |
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A 56 year old postman describes severe pain in his right calf when he walks two or three blocks. The pain is relieved by resting 10 or 15 minutes, but recurs if he walks again the same distance. He can not do his job this way, and he does not qualify yet for retirement, so he is most anxious to have this problem resolved. He does not smoke. - Management? |
Management: This fellow needs help. Start with Doppler studies. If he has significant gradient, arteriogram comes next, followed by bypass surgery or stenting. |
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A patient consults you because he “can not sleep”. On questioning it turns out that he has pain in the right calf, which keeps him from falling asleep. He relates that the pain goes away if he sits by the side of the bed and dangles the leg. His wife adds that she has watched him do that, and she has noticed that the leg which was very pale when he was lying down becomes deep purple several minutes after he is sitting up. On physical exam the skin of that leg is shiny, there is no hair and there are no palpable peripheral pulses. - What is it? |
What is it? - Another version of the same problem. In this case rest pain. Definitively he needs the studies to see if vascular surgery could help him. |
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A 45 year old man shows up in the ER with a pale, cold, pulseless, paresthetic, painful and paralytic lower extremity. The process began suddenly two hours ago. Physical exam shows no pulses anywhere in that lower extremity. Pulse at the wrist is 95 per minute, grossly irregular. - What is it? - What does he need? |
What is it? - Embolization by the broken-off tail of a clot from the left atrium.
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A 74 year old man has sudden onset of extremely severe, tearing chest pain that radiates to the back and migrates down shortly after it’s onset. His blood pressure is 220/100, he has unequal pulses in the upper extremities and he has a wide mediastinum on chest X-Ray. Electrocardiogram and cardiac enzymes show that he does not have a myocardial infarction. - What is it? - Management? |
What is it? - Dissecting aneurysm of the thoracic aorta.
Management: Arteriogram first, but the forces that dissected the vessel plus the force of the dye injection could further shear the aorta, thus study is done with beta blockers or IV nitrates to lower blood pressure. If the aneurysm is in the ascending aorta, emergency surgery will be done. If it is in the descending, intensive therapy (in the ICU) for the hypertension will be the preferable option. |
