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  • Question 1 - A 32-year-old man visits the general practice surgery as he is experiencing sudden-onset...

    Correct

    • A 32-year-old man visits the general practice surgery as he is experiencing sudden-onset vertigo when standing up from a seated position. Episodes last about 30 seconds and he denies any ear pain or hearing loss. His examination is unremarkable.
      Which of the following is the most appropriate treatment option?

      Your Answer: Epley’s manoeuvre

      Explanation:

      Understanding BPPV and Treatment Options

      Benign paroxysmal positional vertigo (BPPV) is a common condition that causes dizziness and vertigo. The Epley manoeuvre is a recommended treatment option for BPPV, involving repositioning the patient’s head and neck to remove calcium crystals from the semicircular canals. However, it should not be performed in patients with certain medical conditions. Symptomatic drug treatment is not recommended for BPPV, and patients should seek further medical advice if symptoms persist. The Dix-Hallpike manoeuvre is a diagnostic test for BPPV, while Brandt-Daroff exercises can be considered as an alternative treatment option. Understanding these options can help healthcare professionals provide appropriate care for patients with BPPV.

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  • Question 2 - A 38-year-old factory worker undergoes a routine hearing assessment as part of his...

    Correct

    • A 38-year-old factory worker undergoes a routine hearing assessment as part of his annual work-based medical. He is noted to have a positive Rinne’s test (normal) and Weber’s test localising to the left ear.
      What is the most likely defect in this patient?

      Your Answer: Right sensorineural hearing loss

      Explanation:

      For a man with a positive Rinne’s test and sound localization to the left ear on Weber’s testing, the diagnosis is likely to be right-sided sensorineural hearing loss. If the Rinne’s test had been negative, it would have indicated left-sided conductive hearing loss. Similarly, if the sound had been localized to the right ear, it would have suggested left-sided sensorineural hearing loss. In the case of bilateral hearing loss, the Rinne’s test would be negative on both sides, and the Weber test would not localize to either ear. Finally, if the man had right-sided conductive hearing loss, the Rinne’s test would be negative on the right side, and the Weber test would localize to the right side.

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  • Question 3 - A 49-year-old woman presents to the acute medical unit with a sudden onset...

    Correct

    • A 49-year-old woman presents to the acute medical unit with a sudden onset of dizziness, describing the sensation of the room spinning around her. The dizziness persists and does not improve with rest, accompanied by severe nausea and vomiting. She reports hearing loss in her left ear and has recently experienced a cough and coryza episode. The patient has no prior medical history.

      Upon examination, Rinne's test reveals air conduction greater than bone conduction in both ears, and Weber's test lateralizes to her right ear. The patient displays normal eye movements with mild horizontal nystagmus on lateral gaze and intact coordination.

      What is the most likely diagnosis?

      Your Answer: Labyrinthitis

      Explanation:

      A typical scenario for viral labyrinthitis involves a person who has recently had a respiratory infection and suddenly experiences vertigo, vomiting, and hearing loss. The symptoms are usually severe and persistent, and rest may not provide relief. This is likely caused by a viral infection in the inner ear, which is known as labyrinthitis. Given the patient’s history, this is the most probable diagnosis.

      Understanding Vertigo and Its Causes

      Vertigo is a condition characterized by a false sensation of movement in the body or environment. It can be caused by various factors, including viral infections, vestibular neuronitis, benign paroxysmal positional vertigo, Meniere’s disease, vertebrobasilar ischaemia, and acoustic neuroma.

      Viral labyrinthitis and vestibular neuronitis are often associated with recent viral infections and can cause sudden onset vertigo, nausea, and vomiting. While hearing may be affected in viral labyrinthitis, vestibular neuronitis does not cause hearing loss. Benign paroxysmal positional vertigo, on the other hand, has a gradual onset and is triggered by changes in head position. Each episode typically lasts for 10-20 seconds.

      Meniere’s disease is characterized by vertigo, hearing loss, tinnitus, and a sensation of fullness or pressure in one or both ears. Vertebrobasilar ischaemia, which is more common in elderly patients, can cause dizziness when the neck is extended. Acoustic neuroma, which is associated with neurofibromatosis type 2, can cause hearing loss, vertigo, and tinnitus. An absent corneal reflex is an important sign of this condition.

      Other causes of vertigo include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin. Understanding the different causes of vertigo can help in the diagnosis and management of this condition.

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  • Question 4 - A 45-year-old woman visits her primary care physician (PCP) complaining of bilateral tinnitus....

    Correct

    • A 45-year-old woman visits her primary care physician (PCP) complaining of bilateral tinnitus. She denies any changes in her hearing or other ear-related symptoms. The PCP conducts ear and cranial nerve examinations, which reveal no abnormalities. The patient's medication list is reviewed.
      Which ONE medication from the following list is most likely responsible for the patient's tinnitus?

      Your Answer: Quinine

      Explanation:

      Medication and Tinnitus: Understanding the Association

      Tinnitus, the perception of sounds in the ears or head without an external source, can be distressing and may indicate an underlying condition. While it is often considered a minor symptom, certain medications have been associated with tinnitus. Quinine, commonly used to treat malaria, is one such medication. Other medications that may cause tinnitus include aspirin, aminoglycosides, loop diuretics, and non-steroidal anti-inflammatory drugs. However, medications like spironolactone, salbutamol, metformin, and nifedipine are not associated with tinnitus. It is important to understand the potential side effects of medications and to consult with a healthcare provider if experiencing tinnitus or any other concerning symptoms.

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  • Question 5 - A 45-year-old woman attends the general practice surgery with her husband who is...

    Correct

    • A 45-year-old woman attends the general practice surgery with her husband who is concerned that since she has started working from home several months ago, she has had a continuous cold. She reports frequent sneezing, clear nasal discharge and a terrible taste in her mouth in the morning. Her eyes look red and feel itchy. She has noticed that the symptoms improve when she is at the office or when they have been on vacation. She has a history of migraines and is otherwise well. She has not yet tried any treatment for her symptoms.
      Which of the following is the most likely diagnosis?

      Your Answer: Allergic rhinitis

      Explanation:

      Understanding Allergic Rhinitis: Symptoms, Causes, and Differential Diagnosis

      Allergic rhinitis is a common condition that presents with a range of symptoms, including sneezing, itchiness, rhinorrhea, and a blocked nose. Patients with allergic rhinitis often experience eye symptoms such as bilateral itchiness, redness, and swelling. While the diagnosis of allergic rhinitis is usually based on characteristic features, it is important to exclude infectious and irritant causes.

      In this case, the patient’s symptoms and medical history suggest an allergic cause for his condition. It would be prudent to inquire about his new home environment, as the allergen may be animal dander from a pet or house dust mites if there are more soft furnishings and carpets than in his previous home.

      Other possible diagnoses, such as acute infective rhinitis, acute sinusitis, rhinitis medicamentosa, and nasopharyngeal carcinoma, can be ruled out based on the patient’s symptoms and medical history. For example, acute infective rhinitis would present more acutely with discolored nasal discharge and other upper respiratory tract infection symptoms. Acute sinusitis would present with facial pain or pressure and discolored nasal discharge. Rhinitis medicamentosa is caused by long-term use of intranasal decongestants, which is not the case for this patient. Nasopharyngeal carcinoma is rare and typically presents with unilateral symptoms and a middle-ear effusion.

      Overall, understanding the symptoms, causes, and differential diagnosis of allergic rhinitis is crucial for proper management and treatment of this common condition.

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  • Question 6 - A 30-year-old woman presents to surgery with a complaint of not having a...

    Incorrect

    • A 30-year-old woman presents to surgery with a complaint of not having a regular menstrual cycle for the past year, despite a negative pregnancy test. You order initial tests to establish a baseline. Which of the following is not included in your list of possible diagnoses?

      Your Answer: Thyrotoxicosis

      Correct Answer: Turner's syndrome

      Explanation:

      Primary amenorrhoea is caused by Turner’s syndrome instead of secondary amenorrhoea.

      Understanding Amenorrhoea: Causes, Investigations, and Management

      Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls with no secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

      There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.

      The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.

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  • Question 7 - A 45-year-old man visits his General Practitioner (GP) with a concern that he...

    Incorrect

    • A 45-year-old man visits his General Practitioner (GP) with a concern that he has been experiencing hearing loss in his right ear. He occasionally hears a buzzing sound in this ear, but it is not bothersome and does not affect his daily life. He is worried about the hearing loss as his mother had to use hearing aids at a young age. Otoscopy of his right ear is performed and is normal except for a slightly pinkish tympanic membrane. The GP decides to conduct some tuning fork tests. What is the most likely set of findings that will be observed?

      Your Answer: Right ear Rinne’s test air conduction > bone conduction; Weber’s test lateralises to the left

      Correct Answer: Webers test lateralises to the left ear. Rinnes test would shows bone conduction > air conduction on the left

      Explanation:

      Tuning Fork Tests for Different Types of Hearing Loss

      When conducting a hearing assessment, tuning fork tests can provide valuable information about the type and location of hearing loss. Here are some examples of tuning fork test results and what they may indicate:

      Weber’s and Rinne’s Tests for Different Types of Hearing Loss

      Example 1:
      – Weber’s test lateralizes to the left ear
      – Rinne’s test shows bone conduction > air conduction on the left

      These results suggest conductive hearing loss, which is typical of otosclerosis. This condition affects young adults and involves the replacement of normal bone with spongy bone, leading to stapes fixation and progressive hearing loss.

      Example 2:
      – Weber’s test lateralizes to the right ear
      – Rinne’s test shows air conduction > bone conduction on the left

      These results also suggest conductive hearing loss, but in this case, it is likely due to a different cause than otosclerosis. Unilateral hearing loss, tinnitus, a positive family history, and a pinkish tympanic membrane on examination are all typical features of otosclerosis, which is not present in this patient.

      Example 3:
      – Weber’s test lateralizes to the right ear
      – Rinne’s test shows bone conduction > air conduction on the right

      These results suggest conductive hearing loss on the right side, which could be due to a variety of causes. However, the clinical features reported in this patient suggest a possible diagnosis of otosclerosis, which would give a conductive hearing loss on the left side rather than the right.

      Example 4:
      – Weber’s test lateralizes to the left ear
      – Rinne’s test shows air conduction > bone conduction on the right

      These results suggest sensorineural hearing loss on the right side, which could be due to conditions such as vestibular schwannoma or viral labyrinthitis. However, this does not match the reported hearing loss on the left side in this patient.

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  • Question 8 - A 42-year-old woman presents to her General Practitioner with a 4-month history of...

    Incorrect

    • A 42-year-old woman presents to her General Practitioner with a 4-month history of nasal congestion and coughing. Over the previous few days, she has also been experiencing a persistent headache which seems to be worse when she leans forward.
      Which of the following is the most probable diagnosis?

      Your Answer: Postnasal drip (PND)

      Correct Answer: Chronic rhinosinusitis

      Explanation:

      Differentiating Chronic Rhinosinusitis from Other Headache Disorders

      Chronic rhinosinusitis is a condition characterized by inflammation of the paranasal sinuses and nasal passages that lasts for 12 weeks or longer. Patients with chronic rhinosinusitis typically present with symptoms such as nasal congestion, coughing, persistent headache that worsens on bending forwards, facial pain, nasal discharge, and postnasal drip. Predisposing factors for chronic rhinosinusitis include atopy, nasal obstruction, recent local infection, swimming or diving, and smoking. Management of chronic rhinosinusitis involves avoidance of allergens, intranasal corticosteroids, and nasal irrigation with saline.

      Acute sinusitis shares many features with chronic rhinosinusitis, but the history of symptoms is much shorter. Treatment for acute sinusitis includes analgesia, intranasal decongestants or nasal saline, and intranasal corticosteroids if symptoms persist for more than ten days. Oral antibiotics may be given for severe presentations.

      Cluster headaches are characterized by intense, sharp, stabbing pain around one eye, accompanied by eye redness, lacrimation, lid swelling, nasal stuffiness, skin erythema, miosis or ptosis. Cluster headaches occur in clusters lasting between four and 12 weeks, with patients feeling completely fine in between clusters. Tension headaches are described as a band-like headache that does not impair activities of daily living.

      Postnasal drip (PND) typically presents with a chronic cough and bad breath, unlike the presentation in chronic rhinosinusitis. It is important to differentiate chronic rhinosinusitis from other headache disorders to ensure appropriate management and treatment.

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  • Question 9 - A 35-year-old man presented to his GP with bilateral deafness. Rinne’s test was...

    Incorrect

    • A 35-year-old man presented to his GP with bilateral deafness. Rinne’s test was found to be negative bilaterally. Weber's test was referred to both sides. On examination of his tympanic membrane, Schwartz's sign was visible.
      Which of the following is the MOST likely cause of his symptoms?

      Your Answer:

      Correct Answer: Otosclerosis

      Explanation:

      Understanding the Causes of Hearing Loss: A Comparison of Otosclerosis, Cholesteatoma, Ménière’s Disease, Otitis Externa, and Otitis Media

      Hearing loss can be caused by a variety of factors, including otosclerosis, cholesteatoma, Ménière’s disease, otitis externa, and otitis media. When conducting a differential diagnosis, it is important to consider the patient’s age, symptoms, and medical history.

      Otosclerosis is a common cause of hearing loss in young adults, typically presenting as unilateral conductive hearing loss that progresses bilaterally. A negative Rinne’s test is indicative of conductive deafness, and a pink tinge on the tympanic membrane (Schwartz’s sign) is a diagnostic indicator for otosclerosis.

      Cholesteatoma, on the other hand, typically presents with unilateral conductive hearing loss and/or ear discharge. Given the patient’s bilateral symptoms and young age, cholesteatoma is less likely to be the cause of her hearing loss.

      Ménière’s disease is characterized by sudden attacks of tinnitus, vertigo, a sensation of fullness in the ear, and fluctuating sensorineural hearing loss. This is not the likely cause of the patient’s conductive hearing loss.

      Otitis externa is inflammation of the external ear canal, which can cause hearing loss in rare cases due to occlusion of the ear canal from inflammation. Otitis media, on the other hand, is inflammation of the middle ear and is more commonly seen in children. It may present with unilateral conductive deafness, but is unlikely to be the cause of the patient’s bilateral symptoms.

      In conclusion, when considering the causes of hearing loss, it is important to take into account the patient’s age, symptoms, and medical history. Otosclerosis is the most likely cause of conductive hearing loss in young adults, while cholesteatoma, Ménière’s disease, otitis externa, and otitis media may also be potential causes depending on the individual case.

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  • Question 10 - A 7-year-old girl is seen in clinic after falling off her scooter two...

    Incorrect

    • A 7-year-old girl is seen in clinic after falling off her scooter two hours ago. She fell forward and used her right arm to break her fall. Upon examination, she has minor scrapes on her right forearm but no indication of a fracture. Her nose is red and has some scrapes. Upon examination of her nostrils, there is a bilateral red swelling in the middle that is slightly soft. There are no other indications of a head injury. What is the best course of action?

      Your Answer:

      Correct Answer: Arrange an urgent ENT review

      Explanation:

      Nasal Septal Haematoma: A Complication of Nasal Trauma

      Nasal septal haematoma is a serious complication that can occur after even minor nasal trauma. It is characterized by the accumulation of blood between the septal cartilage and the surrounding perichondrium. The most common symptom is nasal obstruction, but pain and rhinorrhoea may also be present. On examination, a bilateral, red swelling arising from the nasal septum is typically seen. It is important to differentiate this from a deviated septum, which will be firm to the touch.

      If left untreated, nasal septal haematoma can lead to irreversible septal necrosis within just a few days. This occurs due to pressure-related ischaemia of the cartilage, which can result in necrosis and a saddle-nose deformity. To prevent this, surgical drainage and intravenous antibiotics are necessary. It is important to be vigilant for this complication after any nasal trauma, no matter how minor.

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