NAME: BHANDERI AKASHKUMAR H.

Clinical clerk BCCM.

ROTATION: OCT. 11-20, 2020

Case 1: AR, 8 year-old, boy came in at the ENT-OPD complaining of otalgia 5/10 on pain
scale accompanied by intermittent fever of 38°C and tinnitus from right ear for 2 weeks
duration. He had history of colds 2 weeks PTC but has now subsided. Physical examination
showed AD: bulging hyperemic tympanic membrane. With displaced cone of light. AS:
intact tympanic membrane, no discharge, good cone of light.

1. List 3 differential diagnosis for the patient. Enumerate the signs and symptoms in the
case.
Diagnosis Rule In Rule Out
Otitis media Ear pain, trouble Avoiding exposure to
sleeping, fussiness, household tobacco
loss of balance. smoke, get flu shots
and pneumococcal.
Trauma of ear Ear pain, hearing loss, Loud noise, Using ear
spinning sensation. plug and cotton swab
Bullous myringitis Hearing loss, fluid Inner ear infection,
draining from ear, Loss of balance,
Tugging or pulling ear.
Good night sleep.

2. What are the stages of otitis media? On the case above, what stage of otitis media is
the patient experiencing?
:- Possible stage 4 (Resolution stage)

3. What is the primary tool in the diagnosis of middle ear effusion? Explain.
:- pneumatic otoscope
:- Pneumatic otoscopy is an examination that allows determination of the mobility of a
patient's tympanic membrane (TM) in response to pressure changes.
4. What is the 1st line treatment for this patient? Explain the mechanism of action.
:- Amoxicillin
:- Exerts bactericidal activity via inhibition of bacterial cell wall synthesis by binding one
or more of the penicillin binding proteins (PBPs). Exerts bacterial autolytic effect by
inhibition of certain PBPs related to the activation of a bacterial autolytic process.

5. What management options can you give to this patient when he complains of
worsening symptoms or failure to respond to medications? Explain.
:- As we had start with analgesic and antibiotic (amoxicillin) and if still worsening then
change antibiotic therapy if still symptoms persist switch to ceftriaxone, clindamycin.

Case 2: VN, 27 year old, female complained of recurrent rhinorrhea accompanied by

nasal itchiness and hyposmia occurring for more than 4 days per week for one month
duration. Patient does not have difficulty sleeping and has no problems at school. On
anterior rhinoscopy, bilateral boggy reddish turbinates with minimal watery nasal
discharge.

6. What is the diagnosis of the patient? Enumerate the signs and symptoms in the case.
:- Diagnosis for this case is most probably allergic rhinitis. And about the sign and
symptoms pertinent positive are major hyposmia and in anterior rhinoscopy there is seen
boggy reddish turbines with minimal watery nasal discharge.

7. Enumerate the ARIA Classification in a table. Based on the ARIA classification, the
patient is classified as having what symptoms?
:- ARIA is allergic rhinitis and is impact on asthma is the development of classification in
which allergic rhinitis is divided in 4 classes. mild or moderate to severe intermittent and
mild or moderate to severe persistent. According to criteria of ARIA classification of
allergic rhinitis our patients in this case is classified as mild persistent allergic rhinitis.

8. What are the most common aeroallergens found in the Philippines?

:- grasses
:- house dust mites
:- pollens
:- trees
:- rye
:- weeds
:- fur
:- mould and fungal spores
:- cosmic including perfume

9. What is the best initial pharmacologic treatment for the patient? Explain the
mechanism of action.
:- patients with allergies rhinitis should be advised to avoid or minimize exposure to
trigger factors allogems and for allergies rhinitis with persistent symptoms and long term
exposure to allergens topical nasal steroid given for one month.

10. What is an effective treatment of allergic rhinitis that may prevent the development of
new allergen sensitizations and reduce the risk for future development of asthma in
patients with allergic rhinitis?
:- Antihistamines + pseudoephedrine

Case 3: KP, 21 year old, male, complained of dysphagia to both solids and liquids. He had
fever of 39 °C. He claimed that he had been having 3 episodes per year of recurrent
tonsillitis for the past 3 years. On PE, there is noted peritonsillar swelling, right.

11. What are the most common organisms that can cause the infection?
:- Group A beta hemolytic streptococcus (GABHS).

12. What is the 1st line antibiotic to be given to this patient? Explain the mechanism of
action.
:- Amoxicillin
:- Amoxicillin is similar to penicillin in its bactericidal action against susceptible bacteria
during the stage of active multiplication. It acts through the inhibition of cell wall
biosynthesis that leads to the death of the bacteria.

13. What are the absolute indications for a patient to undergo tonsillectomy?
1.Recurrent episode of acute tonsillitis
:- a-3 episodes/yr for 3 consecutive yr
:- b-5 episodes/yr for 2 consecutive yr
:- c-7 episodes/yr for single yr
2. febrile seizures due to fever in tonsillitis
3. chronic tonsillitis
4. peritonsillar abscess
5. obstructive sleep apnoea and dysphagia due to hypertrophied tonsil.
6.unilateral enlargement of tonsils with suspected malignancy.

14. Explain the Paradise the criteria for tonsillectomy.

:- Relative indication
1. Styalgia
2. Glossopharyngeal neuralgia
3. UPPP(uvulo palate pharyngoplasty)

Case 4. A 2-year-old male came in with a chief complaint of 2 episodes of vomiting of

previously ingested food after a witnessed episode of ingestion of a one-peso coin. He was
brought to the emergency with no cough, no further episodes of vomiting, and no difficulty
breathing.

15. What is your initial impression?

:- Foreign body ingestion
16. What diagnostic procedure would you request?
:- Intial Chest and Abdominal X-Ray in PA and Lateral view can be requested, since the
one-peso coin is radio-opaque it can be easily identified in radiographs.

17. What are the different phases of foreign body ingestion?

:- Initial Phase: Vomiting, retching while the ingested foreign body lodges in the
esophagus.
:- Asymptomatic Phase: Subsequent lodging of the of the foreign body with relaxation of
reflexes that often results in a reduction or cessation of symptoms, lasting hours to
weeks.
:- Complications Phase: Foreign body if non-irritant and small enough might be excreted,
if not excreted prior to this stage, it may cause GI disturbance, infections and GI
obstruction.

18. What are the different constrictions of the esophagus?

:- At the start of the esophagus, where the laryngopharynx joins the esophagus, behind
the cricoid cartilage, Where it is crossed on the front by the aortic arch in the superior
mediastinum, Where the esophagus is compressed by the left main bronchus in the
posterior mediastinum, The esophageal hiatus where it passes through the diaphragm in
the posterior mediastinum.

19. Which constriction is the most common site where foreign bodies lodge?
:- The most common site for foreign bodies to lodge is at the upper esophagus at the level
of the thoracic inlet.

20. What is the gold standard procedure for this patient?

:- Endoscopy is considered to be the gold standard in retrieving foreign bodies with a
reported positive extraction in 83% of the cases.
LABEL THE LEVELS OF THE CERVICAL LYMPH
NODES AND ENUMERATE THEIR BORDERS

IA – Submental triangle
It contains one or two lymph glands, the
submental lymph nodes (three or four in
number) and Submental veins and
commencement of anterior jugular veins.

IIB – Submandibular Triangle

It contains contains the submandibular gland,
superficial to which is the anterior facial vein, while imbedded in the gland is the facial
artery and its glandular branches.

IIA – Beneath the gland, on the surface of the Mylohyoideus, are the submentalartery and
the mylohyoid artery and nerve.

IIB – Carotid Triangle

It contains superior thyroid artery, lingual artery, facial artery, occipital artery, internal
jugular vein, lingual vein, superior thyroid vein.

III – Muscular Triangle

It contains descending filaments from the ansa cervicalis; behind the sheath are the inferior
thyroid artery, the recurrent nerve, and the sympathetic trunk; and on its medial side, the
esophagus, the trachea, the thyroid gland, and the lower part of the larynx.

IV – lower deep cervical

The deep cervical lymph nodes are a group of cervical lymph nodes found near the internal
jugular vein. They can be divided into upper and lower groups, or superior and inferior
groups. Alternatively, they can be divided into deep anterior cervical lymph nodes and deep
lateral cervical lymph nodes.
VA – Occipital Triangle
It contains cutaneous nerves of cervical plexus and the external jugular vein and platysma
muscle. A chain of lymph glands is also found running along the posterior border of the
Sternocleidomastoideus, from the mastoid process to the root of the neck.

VB – Subclavian Triangle
It contains the brachial plexus of nerves which lies above the artery, and in close contact
with it passing transversely behind the clavicle are the transverse scapular vessels; and
traversing its upper angle in the same direction, the transverse cervical artery and vein. The
external jugular vein runs vertically downward behind the posterior border of the
Sternocleidomastoids, to terminate in the subclavian vein; it receives the transverse
cervical and transverse scapular veins.

VI –Anterior Triangle
The anterior triangle is the triangular area of the neck found anteriorly to the
sternocleidomastoid muscle. It is formed by the anterior border of sternocleidomastoid
laterally, the median line of the neck medially and by the inferior border of the mandible
superiorly.