27 28 29 - showman

[ArchivalUser]

An 18-year-old white high school student comes to the office in late August because of a stuffy nose for 1 week. He reminds you
that he has had severe hay fever in the fall for the past 10 years. Review of his chart shows that he has positive skin tests to
ragweed, dust and dust mites, and he is receiving maintenance immunotherapy with extracts of these antigens. He also takes
over-the-counter antihistamines for symptomatic relief. This regimen has not provided relief so far this season. Physical
examination is normal, apart from clear rhinorrhea. He is afebrile, and there is normal transillumination of the frontal and
maxillary sinuses. In reviewing his medical records you note that smears of his nasal mucus contained large numbers of
eosinophils. There is no record of any extensive immunologic work-up. You tell him that he now has either an early viral upper
respiratory tract infection or the beginnings of his seasonal allergic rhinitis. You suggest that he use a corticosteroid nasal spray plus
his usual antihistamines as needed. The appropriate treatment is undertaken, but 4 days later he returns because of a toothache and
fever. On physical examination he has right facial fullness and pain below his eye when he leans forward. There is tenderness in the
region of the upper premolar and molar teeth on the right side. His temperature is 38.7EC (101.6EF), orally. He has bloody, thick,
green mucus coming from his right nostril. The remainder of his physical examination is normal. You suspect maxillary sinusitis
on the basis of the clinical findings.
27. Before beginning antibiotic treatment in this patient, it is necessary to first do which of the following?
(A) Confirm the diagnosis with CT films of the sinus
(B) Confirm the diagnosis with plain x-ray films of the sinus
© Confirm the diagnosis with transillumination of the sinus
(D) Request consultation with a dentist
(E) No additional steps are necessary
28. The appropriate steps are taken. In prescribing antibiotic therapy for this patient, it is most important to remember which of
the following?
(A) Antibiotics are ineffective unless there is a concomitant surgical drainage procedure
(B) He is likely to be allergic to penicillin
© He needs to take medication for more than 7 days
(D) Only bactericidal antibiotics are effective
(E) Ordinarily at least two antibiotics are given
He is treated and initially feels much better. However, soon thereafter he developed a headache, right ear pain and painful stiff
neck; he spikes a temperature to 39.3EC (102.7EF), orally. Extraocular movements are normal.
29. Which of the following is the most likely explanation for these new symptoms?
(A) Allergic reaction to the antibiotic(s)
(B) Associated meningeal inflammation or infection
© Development of cavernous sinus thrombosis
(D) Direct spread of infection from the maxillary to the mastoid sinus
(E) Obstruction of the orifice of the maxillary sinus with a mucous plug

[ArchivalUser]

D ( apical tooth abscess may be)
B ( he has history of atopy)
B

[ArchivalUser]

27. The correct answer is E. Sinusitis is a clinical diagnosis and for that reason, no additional testing is mandated when therapy is to be undertaken. This patient has the cardinal manifestations of acute sinusitis: tooth ache, sinus fullness, pain on palpation and
purulent discharge. He requires therapy aimed at the most common offending organisms Streptococcus pneumonia and Haemophilus influenza type B.
A CT scan of the sinuses (choice A) is not necessary. This imaging test is usually reserved for patients that are unable to be subjected to an adequate physical examination such as patients in an ICU that have fever of unknown origin.
Plain films of the head (choice B) are not sensitive for opacification of the sinuses and are therefore not routinely done.
Transillumination of the sinus (choice C) is not a confirmatory test since it is not 100% sensitive (has some false negatives) or specific (has some false positives). In the setting of a highly suspicious physical exam such as this patient™s, sinus trans-illumination, if positive, further supports the diagnosis, but if negative, fails to detract from its likelihood.


Consultation with a dentist (choice D) is unnecessary since the patient does not have an isolated tooth ache but it is in association with sinus tenderness and nasal discharge; hallmarks of sinusitis.
28. The correct answer is C. Sinusitis is an infection loculated within the chambers of the sinuses and longer courses of therapy of 2-3 weeks are often necessary to achieve sufficient penetration.
Surgery (choice A) is seldom required.
Rates of penicillin allergy (choice B) are generally only around 10%.
(Choice D) is wrong because many antibiotics such as macrolides like clarithromycin are useful for sinusitis even though they are bacteriostatic, not bactericidal.
Two antibiotics (choice E) are seldom needed and usually only with refractory cases of previously treated sinusitis.
29. The correct answer is B. Headache, fever and stiff neck are all signs of meningeal infection, choice B. Sinusitis is known to occasionally lead to meningitis.
There is no description of a rash such as would be found with an allergic reaction