MRCGP AKT Category: Ear, Nose And Throat, Speech And Hearing

AKT-1706

A 63-year-old man presents to the clinic with a persistent sore throat. He had visited three weeks ago and was diagnosed with acute tonsillitis by another doctor, for which he was prescribed amoxicillin. At that time, some left submandibular swelling was observed.

The patient is a heavy smoker, consuming around 40 cigarettes per day. Upon further questioning, he reveals that he has been experiencing a sore throat and pain while swallowing for the past three months.

During the examination, his blood pressure is 145/82 mmHg, pulse is 85 and regular. He has heavily nicotine-stained fingers and appears very thin with a BMI of 20 kg/m2. There is noticeable left submandibular gland enlargement, which has apparently grown even more since his last consultation.

Investigations reveal:

– Hb 114 g/L (135-180)
– WCC 6.0 ×109/L (4.5-10)
– PLT 189 ×109/L (150-450)
– Na 138 mmol/L (135-145)
– K 4.8 mmol/L (3.5-5.5)
– Cr 122 µmol/L (70-110)

A chest x-ray taken three months earlier was normal.

What is the most appropriate course of action?

AKT-1707

A 60-year-old man comes to the clinic complaining of sudden hearing loss in his right ear. He reports that this occurred over the course of a few hours yesterday and has not improved since. He denies any other symptoms and has no significant medical history or prior ear issues. Upon examination, there are no visible abnormalities in the ear canal or tympanic membrane. What is the recommended course of action for managing this patient’s condition?

AKT-1708

A 16-year-old female presents with a four day history of fever, sore throat and rash on the front of her left leg. On examination she has tonsillar enlargement with cervical lymphadenopathy and has erythema nodosum on her left shin.

Which of the following is the most likely diagnosis?

AKT-1709

A 25-year-old woman comes to the clinic with a single enlarged lymph node on the left side of her neck. She reports first noticing it during a cold she had about four weeks ago, and it has since increased in size, causing her to become more worried. During the examination, you observe a cervical lymph node with a diameter of 3 cm. There are no other abnormal findings. Routine blood tests reveal mild normochromic normocytic anemia and an elevated ESR of 72, but are otherwise normal.

What is the most appropriate next step to confirm the diagnosis?

AKT-1710

A 25-year-old woman comes to the clinic complaining of headaches and unilateral sensorineural deafness. She reports that her headaches have started recently and are accompanied by vomiting and a change in posture. Additionally, she experiences pulse synchronous tinnitus and feels that her headaches are becoming more severe.

Upon examination, there is no papilloedema and her blood pressure is within normal limits. The patient has been taking oral contraceptive pills for the past five years.

What is the appropriate management plan for this patient?

AKT-1711

A 56-year-old woman presents to the clinic for evaluation. She has been experiencing bloody, serous discharge from her left nostril for the past three weeks and reports that her nose feels constantly congested. The patient has a 30-year history of smoking 20 cigarettes per day and a medical history of COPD. On examination, her blood pressure is 132/72 mmHg, pulse is regular at 85 beats per minute, and she is unable to breathe through her left nostril. Laboratory results show a hemoglobin level of 120 g/L (normal range 115-160), white blood cell count of 7.0 ×109/L (normal range 4.5-10), and platelet count of 199 ×109/L (normal range 150-450). Her sodium level is 138 mmol/L (normal range 135-145), potassium level is 4.5 mmol/L (normal range 3.5-5.5), and creatinine level is 105 µmol/L (normal range 70-110). An electrocardiogram reveals sinus rhythm. What is the most appropriate course of action?

AKT-1712

A 55-year-old man who gave up smoking ten years ago presents at surgery with hoarseness.

It has been present for four weeks and is not improving. He has no systemic illness to explain it and the only thing of note is that he is a heavy whisky drinker.

You suspect he may have laryngeal cancer.

Which of the following symptoms would augment that suspicion?

AKT-1713

A 27-year-old female comes to the clinic with a nodule in her neck that she has noticed for the past month.
Upon examination, a non-tender, 3.5 cm nodule is found on the right side of her neck, deep to the lower half of the right sternocleidomastoid. The nodule moves upwards on swallowing, and no other masses are palpable in the neck.
What is the nature of this mass?

AKT-1714

A 42-year-old man presents with a ‘neck lump’ that he has noticed over the past two months. On examination, you palpate a diffuse midline swelling which moves with swallowing but not with tongue protrusion. There are no other neck lumps or focal nodules, and the patient’s voice is normal with no hoarseness. There is no cervical lymphadenopathy or stridor. The patient has no significant past medical history or family history.
He reports feeling slightly more fatigued and has gained some weight over the past few months but otherwise feels well. He notes that the swelling in his neck has not changed in size since he first noticed it.
Thyroid function tests reveal hypothyroidism. What is the most appropriate management plan?

AKT-1715

You are reviewing a patient who presented to a colleague about eight weeks ago. He is a 65-year-old male with mild to moderate symptoms of nasal congestion and persistent feeling of a blocked nose. He reports ongoing problems of a similar nature. He informs you that as well as the above he gets intermittent clear nasal discharge which can alternate between nostrils and he has had periods of nasal and ocular ‘itch’.
At his last appointment he was prescribed a daily non-sedating antihistamine which he has been using regularly. He was also given advice on nasal douching. Despite these measures he is still suffering from persistent nasal symptoms. He has heard that steroid medication can be used to treat his symptoms and asks for a prescription.
Which of the following is the most appropriate next pharmacological option to add in to his treatment in trying to manage his symptoms?