NMS Q&A Family Medicine

20 NMS Q&A Family MedicineExamination Answers1. The answer is B. The least likely cause of 10 days ofhoarseness and cough, even in a heavy smoker, is carcinoma.This is because of the short chronicity and thepresence of cough. These two factors favor an irritativephenomenon. The latter includes all the other choices,including irritation due to inhaled smoke. Although canceris a possibility in a smoker, there is no time urgency inthe present case.2. The answer is A. Laryngoscopy is the easiest, leastexpensive, and most sensitive of all the choices given fordiagnosis of long-standing hoarseness. The differentialdiagnosis of new onset hoarseness of some chronicityincludes carcinoma, granulomas, leukoplakia, nodules,and polyps. One arbitrary cut point for chronicity ofhoarseness as a criterion for decision to obtain laryngoscopyis 2 weeks. An MRI or CT scan at some point may beindicated, for example, in determining the extent ofspread contiguously or distantly. A diagnostic therapeutictrial of proton pump inhibitors may be useful after masslesions have been ruled out (by biopsy if necessary).Although hypothyroidism can be a cause of dysphonia,serum T 4 , T 3 , and TSH levels too would be useful afterruling out mass lesions.3. The answer is E. Prescribe amoxicillin 500 mg 3 timesper day. This patient has typical right ethmoid sinusitis(tenderness of the right orbital rim) as well as right maxillarysinusitis (based on the history of shifting fluid in thecheek area). Ethmoiditis seldom occurs without concurrentmaxillary sinusitis. Levofloxicin and ceftriaxone aretoo radical for this sinusitis that had not been treated forat least 3 years, hence not expected to involve exotic orresistant organisms. They should be held in reserve. Thesinusitis is likely a complication of allergic rhinitis, forwhich summer “cold” is a code word. Uncomplicated, itresponds to antihistamines throughout the season ofallergic symptoms, unlike viral colds, in which antihistaminesremediate symptoms for no more than 3 to 4 days.Allergists seldom have anything to offer during the acutephase of complications. ENT consultation would begrossly premature.4. The answer is D. This complication of ethmoid sinusitisis cavernous sinus thrombosis. At first glance, it maybe easily confused with orbital cellulitis, also a complicationof ethmoid sinusitis. The difference in clinical presentationis that orbital cellulitis manifests proptosis ofthe involved eye and edema of the eyelids, as opposed tochemosis and ophthalmoplegia. Both conditions aremedical emergencies and require rapid intervention withintravenous antibiotics (the outdoorsman in the vignettemust phone in for life flight out of the bush). Mucocele isrelatively benign by comparison and requires only aspirationand evacuation by an otolaryngologist. Brain abscesscan be a complication of sinusitis and would present withneurologic symptoms and signs. Osteomyelitis of thefrontal bone is a complication of frontal sinusitis andpresents with swelling of the frontal bone.5. The answer is A. Prescribe inhaled glucocorticoids toattempt to prevent recurrences of otitis media. Choices Band C, ventilation tubes and referral for adenoidectomy,would be the second and third choices in that order, if theforegoing measures do not result in a decreased frequencyof middle ear infections.6. The answer is A. Mist or warm moist towels for nasalinhalation combined with inhaled glucocorticoids for abrief period following withdrawal of the inhaled vasoconstrictionis an accepted rational approach to the treatmentof rhinitis medicamentosa . Other approaches are shorttermsystemic glucocorticoids. Prescription of longer lastingtopical decongestants is not a solution to this problem,which has been brought on by the overuse of such medications.When prescribed, topical decongestants shouldbe used only intermittently, most likely on one side of thenose only and at the time of sleep onset. Although thiscondition may be more prevalent in atopic individuals,allergy is not the proximate cause and the condition is notserved by skin testing at this point in the course.7. The answer is A. Atopic constitution is an underlyingfactor in recurrence of otitis media; in fact, probably, themost prevalent one in this disorder. Native American, butnot African American race, would be a factor. Contrary toearlier teaching, tonsillar hypertrophy and/or tonsillitisis/are not factor(s), although adenoidal hypertrophy isthe second most prevalent underlying risk factor. Congenitalpalatal deformity renders one susceptible to recurrentotitis media. Anterior attached frenulum, or “tonguetied” state, is not a risk factor for recurrent otitis media.As the most common precipitating insult is viral URI,superimposed on one of the foregoing risks, exposure to apopulation with increased incidence of viral URI is alsoan underlying risk factor.8. The answer is D. The child has a respiratory infectionand bronchiolitis caused by a respiratory syncytial virus(RSV), a member of the family Paromyxiviridae, speciespneumovirus . RSV carries a 30% to 60% risk of otitis mediaas a sequela, as compared with about 10% of cases