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Questions and Answers
What is the relationship between sensitivity and specificity in diagnosing strep throat?
What is the relationship between sensitivity and specificity in diagnosing strep throat?
What is the primary purpose of this table?
What is the primary purpose of this table?
What is the purpose of the whisper test?
What is the purpose of the whisper test?
What is the affected ear in Alex's case?
What is the affected ear in Alex's case?
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What is the primary cause of conductive hearing loss?
What is the primary cause of conductive hearing loss?
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What is the function of the Eustachian tube?
What is the function of the Eustachian tube?
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What is the primary cause of sensorineural hearing loss?
What is the primary cause of sensorineural hearing loss?
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What is the structure that separates the outer ear from the middle ear?
What is the structure that separates the outer ear from the middle ear?
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What is the term for the pathway that connects the middle ear to the inner ear?
What is the term for the pathway that connects the middle ear to the inner ear?
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What is the term for the three parts of the ear?
What is the term for the three parts of the ear?
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What is the function of the ossicles in the middle ear?
What is the function of the ossicles in the middle ear?
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What is the purpose of determining the type of hearing loss?
What is the purpose of determining the type of hearing loss?
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What is the primary basis for the differential diagnosis of a rash?
What is the primary basis for the differential diagnosis of a rash?
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What is a primary lesion?
What is a primary lesion?
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What is a bulla?
What is a bulla?
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What is a macule?
What is a macule?
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What is a pustule?
What is a pustule?
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What is the next step in constructing a differential diagnosis for a rash after identifying the primary lesion?
What is the next step in constructing a differential diagnosis for a rash after identifying the primary lesion?
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What is the definition of a vesicle?
What is the definition of a vesicle?
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Why is it important to identify the primary lesion when constructing a differential diagnosis for a rash?
Why is it important to identify the primary lesion when constructing a differential diagnosis for a rash?
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What is the term for the description of a rash using medical terminology?
What is the term for the description of a rash using medical terminology?
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What is the primary basis for the diagnosis of osteoarthritis?
What is the primary basis for the diagnosis of osteoarthritis?
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What is the main indication for ordering X-ray in osteoarthritis?
What is the main indication for ordering X-ray in osteoarthritis?
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When is CT or MRI commonly used in the diagnosis of osteoarthritis?
When is CT or MRI commonly used in the diagnosis of osteoarthritis?
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What is the typical finding on X-ray in osteoarthritis?
What is the typical finding on X-ray in osteoarthritis?
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What is the role of laboratory testing in the diagnosis of osteoarthritis?
What is the role of laboratory testing in the diagnosis of osteoarthritis?
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What is the growing use of in the diagnosis of osteoarthritis?
What is the growing use of in the diagnosis of osteoarthritis?
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What is the primary purpose of X-ray in osteoarthritis?
What is the primary purpose of X-ray in osteoarthritis?
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What is the characteristic finding on X-ray in osteoarthritis?
What is the characteristic finding on X-ray in osteoarthritis?
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When is imaging not required in osteoarthritis?
When is imaging not required in osteoarthritis?
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What is the role of clinical history and physical examination in the diagnosis of osteoarthritis?
What is the role of clinical history and physical examination in the diagnosis of osteoarthritis?
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What is the primary goal of counseling patients with radicular symptoms?
What is the primary goal of counseling patients with radicular symptoms?
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What is the characteristic of severe radiculopathy?
What is the characteristic of severe radiculopathy?
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What is the recommendation for patients with radicular symptoms in terms of physical activity?
What is the recommendation for patients with radicular symptoms in terms of physical activity?
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What is the primary concern when a patient's symptoms worsen or are severe?
What is the primary concern when a patient's symptoms worsen or are severe?
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What is the typical outcome of most cases of lumbosacral radiculopathy?
What is the typical outcome of most cases of lumbosacral radiculopathy?
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What is the importance of discussing weight loss with patients with radicular symptoms?
What is the importance of discussing weight loss with patients with radicular symptoms?
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What is the role of pain management in patients with radicular symptoms?
What is the role of pain management in patients with radicular symptoms?
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What is the recommendation for patients with symptoms persisting for over six weeks?
What is the recommendation for patients with symptoms persisting for over six weeks?
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What is the category of radiculopathy characterized by sensory loss and pain without motor deficits?
What is the category of radiculopathy characterized by sensory loss and pain without motor deficits?
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What is the primary concern when a patient presents with Red Flag symptoms?
What is the primary concern when a patient presents with Red Flag symptoms?
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Which of the following laboratory tests is used to diagnose Systemic Lupus Erythematosus (SLE)?
Which of the following laboratory tests is used to diagnose Systemic Lupus Erythematosus (SLE)?
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A patient presents with persistently depressed or irritable mood. What is a possible cause of this symptom?
A patient presents with persistently depressed or irritable mood. What is a possible cause of this symptom?
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What is the primary purpose of a subjective history in a patient's evaluation?
What is the primary purpose of a subjective history in a patient's evaluation?
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Which of the following medications can cause depression or irritable mood?
Which of the following medications can cause depression or irritable mood?
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What is the laboratory test used to diagnose Addison disease?
What is the laboratory test used to diagnose Addison disease?
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What is the characteristic of Parkinson's disease?
What is the characteristic of Parkinson's disease?
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What is the purpose of the Widespread Pain Index (WPI) scale and Symptom Severity (SS) scale?
What is the purpose of the Widespread Pain Index (WPI) scale and Symptom Severity (SS) scale?
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What is the laboratory test used to diagnose Pernicious anemia?
What is the laboratory test used to diagnose Pernicious anemia?
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What is the characteristic of Multiple sclerosis?
What is the characteristic of Multiple sclerosis?
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What is the laboratory test used to diagnose Diabetes mellitus?
What is the laboratory test used to diagnose Diabetes mellitus?
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What is the typical clinical presentation of Acute Epiglottitis?
What is the typical clinical presentation of Acute Epiglottitis?
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What is the most common deep infection of the head and neck?
What is the most common deep infection of the head and neck?
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What is the characteristic voice of a patient with Peritonsillar Abscess?
What is the characteristic voice of a patient with Peritonsillar Abscess?
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Why should a tongue depressor not be used when examining the oropharynx of a patient with Acute Epiglottitis?
Why should a tongue depressor not be used when examining the oropharynx of a patient with Acute Epiglottitis?
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What is the typical oropharyngeal exam finding in a patient with Peritonsillar Abscess?
What is the typical oropharyngeal exam finding in a patient with Peritonsillar Abscess?
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What is the primary method to confirm the diagnosis of a peritonsillar abscess?
What is the primary method to confirm the diagnosis of a peritonsillar abscess?
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What is the age group most affected by retropharyngeal abscess?
What is the age group most affected by retropharyngeal abscess?
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What is a common symptom of retropharyngeal abscess?
What is a common symptom of retropharyngeal abscess?
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What is the primary treatment for retropharyngeal abscess?
What is the primary treatment for retropharyngeal abscess?
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What is the significance of fever in a patient with a sore throat?
What is the significance of fever in a patient with a sore throat?
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What is a complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis?
What is a complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis?
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What is a suppurative complication of pharyngitis?
What is a suppurative complication of pharyngitis?
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What is a characteristic of viral pharyngitis?
What is a characteristic of viral pharyngitis?
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What is a rare complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis in North America?
What is a rare complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis in North America?
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What is a complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis that can develop 1-2 weeks after infection?
What is a complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis that can develop 1-2 weeks after infection?
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Study Notes
Acute Pharyngitis
- Definition: Inflammation of the pharynx, which can be acute (<2 weeks) or chronic (>2 weeks)
- Causes:
- Infectious causes: viruses, bacteria, fungi
- Non-infectious causes: allergies, gastroesophageal reflux disease, acute thyroiditis, neoplasm, smoking
Viral Pharyngitis
- Most common cause of sore throat
- Causes:
- Rhinovirus, Coronavirus, Adenovirus, Herpes Simplex Virus (HSV), Influenza A and B, Parainfluenza virus, Epstein-Barr virus, Cytomegalovirus, Human herpesvirus (HHV) 6, HIV
- Frequency: 20-30% of sore throats in children (ages 5-15), 5-15% of sore throats in adults
Bacterial Pharyngitis
- Causes:
- Group A beta-hemolytic streptococci (GABHS), Fusobacterium necrophorum, Group C beta-hemolytic streptococci, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Mycoplasma pneumoniae, Chlamydophila pneumoniae
- Frequency: 15-30% of sore throats in children (ages 5-15), 5-15% of sore throats in adults
Non-Infectious Pharyngitis
- Causes:
- Persistent cough, upper airway cough syndrome, gastroesophageal reflux disease, acute thyroiditis, neoplasm, allergies, smoking
Red Flags/Alarm Symptoms
- History of recent foreign body impaction or oropharyngeal procedure, fever, rash, diffuse adenopathy, sore throat, recent cocaine smoking, weight loss, fevers, night sweats
Complications
- Non-suppurative complications:
- Acute rheumatic fever (ARF), poststreptococcal glomerulonephritis, pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal (PANDAS) infection
- Suppurative complications:
- Peritonsillar abscess, retropharyngeal abscess, otitis media, sinusitis, mastoiditis, cervical lymphadenitis, meningitis, bacteremia
Diagnostic Approach
- Rule out serious diagnoses and red flags/alarm symptoms
- Identify acute sore throat caused by group A beta-hemolytic streptococcal (GABHS) pharyngitis
- Antibiotic treatment may be indicated
Evidence-Based Diagnosis
- Best history questions to ask:
- No cough, no coryza, myalgias, history of sore throat, headache, pharynx injected, measured temperature >38.3°C, nausea
- Sensitivity, specificity, likelihood ratios (LR+ and LR-), and accuracy for each symptom/sign
Week 2: Clinical Medicine - Pharyngitis
- Pharyngitis is the inflammation of the pharynx
- Can be classified as acute pharyngitis (less than 2 weeks duration) or chronic pharyngitis (more than 2 weeks duration)
General Approach to Acute Pharyngitis
- Rule out serious diagnoses and red flags/alarm symptoms that prompt emergent/urgent management
- Most cases of acute pharyngitis are due to infectious causes, specifically viral or bacterial
- Identify acute sore throat caused by group A beta-hemolytic streptococcal (GABHS) pharyngitis, which may require antibiotic treatment
Causes of Pharyngitis
- Viral causes: rhinovirus, coronavirus, adenovirus, herpes simplex virus (HSV), influenza A and B, parainfluenza virus, Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpesvirus (HHV) 6, and HIV
- Bacterial causes: group A beta-hemolytic streptococci (GABHS), fusobacterium necrophorum, group C beta-hemolytic streptococci, neisseria gonorrhoeae, corynebacterium diphtheriae, mycoplasma pneumoniae, and chlamydophila pneumoniae
- Non-infectious causes: allergies, smoking, gastroesophageal reflux disease, acute thyroiditis, and neoplasm
Frequency and Clinical Syndrome of Infectious Causes of Sore Throat
- Viral causes: rhinovirus (20%), coronavirus (5%), adenovirus (5%), herpes simplex virus (HSV) (4%), influenza A and B (2%), parainfluenza virus (2%), Epstein-Barr virus (EBV) (<1%), cytomegalovirus (CMV) (<1%), and HIV (<1%)
- Bacterial causes: group A beta-hemolytic streptococci (GABHS) (15-30%), fusobacterium necrophorum (10%), group C beta-hemolytic streptococci (5%), neisseria gonorrhoeae (<1%), corynebacterium diphtheriae (<1%), mycoplasma pneumoniae (<1%), and chlamydophila pneumoniae (unknown)
Case of Alex Best
- 15-year-old adolescent with recent onset of sore throat
- Associated symptoms: productive cough, sneezing, runny nose, slight fatigue, muscle aches, and headache
- Physical exam findings: posterior oropharynx mildly inflamed and erythematous, no exudate present, posterior cervical nodes are enlarged and tender to palpation, nasal turbinates are red and swollen
Common Cold
- Prevention: avoid sick contacts, respiratory etiquette, and proper hygiene
- Treatment: cool-mist humidifiers, saline nasal drops, and bulb suctioning for children
Influenza
- Threshold model for diagnosis of influenza: 4-6 points, 59% probability
- Risk of influenza is low for Alex Best, below the test threshold
- If influenza, watch for complications such as pneumonia, especially in susceptible populations (young children, elderly > 65 yoa, people residing in long-term care facilities, those with diabetes or heart/lung conditions, and weakened immune systems)
Hearing Loss
- Types of hearing loss: conductive hearing loss (dysfunction in the external ear canal, tympanic membrane, and/or ossicles) and sensorineural hearing loss (dysfunction in the inner ear, auditory nerve, and/or auditory processing pathway)
- Conductive hearing loss example: dysfunction of the external ear canal, tympanic membrane, and/or ossicles
- Sensorineural hearing loss example: dysfunction of the cochlea, auditory nerve, and/or auditory processing pathway in the central nervous system
Anatomy of the Human Ear
- Divided into three parts: outer, middle, and inner ear
- Outer ear: auricle (or pinna) and ear canal
- Middle ear: middle ear cavity and ossicles (malleus, incus, and stapes) attached to the tympanic membrane
- Inner ear: semicircular ducts and cochlea
Diagnostic Approach to Undifferentiated Rash in a Young Adult
- A rash is an inflammatory skin eruption.
Primary and Secondary Lesions
- Primary lesion: the initial lesion that has not been altered by trauma or manipulation, and has not regressed.
- Secondary lesion: develops as the disease evolves or as the patient damages the lesion, e.g. rubbing, scratching, infections.
Types of Primary Lesions
- Bulla: a circumscribed, elevated lesion that measures ≥ 1 cm and contains serous or hemorrhagic fluid (i.e., a large blister).
- Macule: a circumscribed, nonpalpable discoloration of the skin that measures ≤ 0.3 cm.
- Pustule: a lesion that contains pus; may be follicular (centered around a hair follicle) or nonfollicular.
- Vesicle: a circumscribed, elevated lesion that measures < 1 cm.
Steps in Constructing a Differential Diagnosis for a Rash
- Identify the primary lesion, which is the typical element of the eruption.
- Determine the global reaction pattern.
- Determine the distribution of the lesions (diffuse, isolated, localized, regional, universal?).
Joint Pain Classification
- Inflammatory joint pain: characterized by redness, swelling, warmth, tenderness, and joint stiffness or "gelling" in the morning
- Non-inflammatory joint pain: may or may not present with swelling and tenderness, but other signs are notably absent
Types of Joint Pain
- Monoarticular: involves a single joint
- Oligoarticular: involves 2-4 joints
- Polyarticular: involves 5 or more joints
- Symmetrical polyarthritis: both sides of the body are affected equally
- Asymmetrical polyarthritis: one side of the body is more affected than the other
Joints Involved
- Vertebral joints: involved in spondyloarthritides, ankylosing spondylitis, and psoriatic arthritis
- Sacroiliac joint: involved in spondyloarthritides, ankylosing spondylitis, and psoriatic arthritis
- Wrists, carpometacarpals, MCP, PIP, DIP: involved in rheumatoid arthritis
- Ankle, MTP: involved in rheumatoid arthritis, gout, and osteoarthritis
- Shoulders, elbows, hips, knees: involved in various types of joint pain
Causes of Joint Pain
- Inflammatory joint pain: infection, gout, calcium pyrophosphate deposition disease, rheumatoid arthritis, juvenile RA, systemic lupus erythematosus, spondyloarthritides
- Non-inflammatory joint pain: osteoarthritis, trauma, polymyalgia rheumatica, sarcoidosis, ankylosing spondylitis, enteropathic arthritis
History and Physical Examination
- Evaluate the number and types of joints affected and symmetry if polyarthritis is present
- Assess the onset (sudden vs. gradual) and duration of pain or restriction
- Investigate previous medical history, including GI or sexually transmitted diseases, obesity, hypertension, diabetes, and kidney stones
- Examine joints for range of motion, effusion, redness, swelling, and restricted AROM and PROM
Laboratory Tests
- Synovial fluid analysis: white blood cell count, Gram stain, and culture
- Blood tests: complete blood count, ESR, CRP, serum uric acid, RF, and ACPA
Septic Arthritis
- Risk factors: skin infection, cutaneous ulcers, osteomyelitis, septic bursitis, abscess, previous intraarticular injection, arthrocentesis, arthroscopy, prosthetic joint, recent joint surgery, trauma
- Clinical features: acute joint swelling, pain, erythema, warmth, and joint immobility, usually monoarticular
- Laboratory tests: synovial fluid analysis, blood tests, and imaging studies
Rheumatoid Arthritis (RA)
- Classification criteria: ACR/EULAR 2010 criteria
- Lab findings: radiography, inflammatory markers (ESR, CRP), serology markers (RF, ACPA)
- Radiography: periarticular erosions, osteopenia, joint space narrowing
- Serology: 75-85% of RA patients test positive for RF, ACPA, or both
Osteoarthritis (OA)
- Primarily a clinical diagnosis based on history and physical examination
- Imaging not required in patients with risk factors and typical symptoms
- X-ray: joint space narrowing, osteophyte formation, subchondral sclerosis, and joint destruction
- Laboratory testing not usually required
Lumbar Radiculopathy
- Lumbar radiculopathy can be caused by herniated discs, osteophytes, facet hypertrophy, or neuroforaminal narrowing.
- It can also be caused by systemic diseases affecting the spine, such as neoplasms, infections, osteoporotic compression fractures, inflammatory arthritis, and cauda equina syndrome.
Classification of Lumbar Radiculopathy
- Mechanical: spinal fracture, lumbar disc herniation, cauda equina syndrome, piriformis syndrome, and iliotibial band syndrome.
- Degenerative: spinal stenosis, spondylosis, spondylolisthesis, facet arthropathy, and pseudoclaudication.
- Inflammatory: sacroiliitis, greater trochanter bursitis, and ankylosing spondylitis.
- Oncologic: spinal neoplasms, mostly metastatic.
- Infectious: vertebral lesions, infections, e.g., considered a subtype of "extruded disc".
Prognosis
- Regression: 96%
- Complete disappearance: 43%
Physical Exam Findings Associated with Lumbar Disc Herniation
- Weak ankle dorsiflexion: sensitivity 54%, LR+ 4.9, LR- 0.5
- Calf wasting: sensitivity 29%, LR+ 5.2, LR- 0.8
- Abnormal ankle reflex: sensitivity 48%, LR+ 4.3, LR- 0.6
- Straight Leg Raise (SLR) test: sensitivity 73-98%, LR+ NS, LR- 0.2
- Crossed SLR test: sensitivity 23-43%, LR+ 4.3, LR- 0.8
Hancock Rule: Clinical Prediction Rule for Lumbar Disc Herniation
- Diagnostic accuracy improves with multiple neurologic findings, especially if at least 3 of 4 findings are in concordance with a specific nerve root:
- Dermatomal pain location
- Sensory deficit
- Reduced reflex
- Motor weakness
L2, L3, and L4 Radiculopathy
- Distribution of pain: marked overlap of innervation of anterior thigh muscles
- An acute injury in the distribution of L2, L3, and L4 will most commonly present with radiating back pain to the anterior aspect of the thigh, which may progress into the knee, and possibly radiate to the medial aspect of the lower leg, into the foot.
- Diagnosis: imaging is diagnostic
Spinal Stenosis
- Subjective and physical findings associated with spinal stenosis:
- No pain when seated: sensitivity 47%, LR+ 7.4, LR- 0.57
- Unexplained urinary disturbance: sensitivity 14%, LR+ 6.9, LR- 0.88
- Symptoms improve with bend forward: sensitivity 52%, LR+ 6.4, LR- 0.52
- Bilateral buttock or leg pain: sensitivity 51%, LR+ 6.3, LR- 0.54
- Neurogenic claudication: sensitivity 82%, LR+ 3.7, LR- 0.23
- Wide-based gait: sensitivity 42%, LR+ 13, LR- 0.60
- Abnormal rhomberg test: sensitivity 40%, LR+ 4.2, LR- 0.67
Spondylolysis
- A unilateral or bilateral defect through the pars interarticularis (most commonly affects L5, 90%)
- Asymptomatic (90% of patients); insidious onset, recurrent axial low back pain exacerbated with activity or lumbar hyperextension, +/- radiculopathy
- Diagnosis: imaging is diagnostic
Spondylolisthesis
- The slippage of one vertebral body with respect to the adjacent vertebral body from degenerative, lytic (isthmic), traumatic, dysplastic, or pathologic causes
- Adults, female > male, obesity, fHx (spondylolisthesis, scoliosis, spina bifida)
- Intermittent and localized low back pain that radiates into buttock or posterior thigh; paresthesia, sensory change, loss of strength or reflexes (depends on affected nerve root)
- Diagnosis: imaging is diagnostic (used to grade as well)
Evaluation and Management
- Initial imaging is not indicated in the majority of patients with low back pain, due to high prevalence of abnormal neuroimaging findings even in asymptomatic patients
- Conservative management for 6 weeks is typically recommended before considering imaging (radiography, MRI, CT)
- UNLESS presenting with severe symptom intensity (causing disability) or red flag findings for conditions that require timely diagnosis to prevent serious consequences (e.g., cauda equina syndrome, malignancy, fracture, and infection)
Panic Disorder
- Recurrent, unexpected panic attacks with 4 or more of the following symptoms:
- Palpitations, pounding heart or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, light-headed, or faint
- Chills or heat sensations
- Paresthesias (numbness or tingling sensations)
- Derealization (feelings of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or "going crazy"
- Fear of dying
- At least one attack followed by 1 month (or more) of:
- Persistent concern or worry about additional panic attacks or their consequences
- Significant maladaptive change in behavior related to the attacks
Mental Status Examination (MSE)
- Appearance and behavior: well-kempt or disheveled
- Motor activity: psychomotor agitation
- Speech: fast or pressured; difficulty speaking (stammering, vocal tremor) during an attack
- Affect and mood: anxious, afraid, tense, exhausted, frustrated, "on edge", or irritable; depressed
- Thought process: ruminations
- Thought content: extreme fear, sense of impending doom; anticipatory anxiety about having another attack
- Perception: negative view of themselves and the world
- Sensorium and cognition: difficulty concentrating, mind blank or confused during an attack
- Insight: often aware fears are out of proportion to the actual threat
- Judgment: tend to use avoidance behaviors
PHQ-PD Module
- Questions to assess panic disorder:
- Have you had an anxiety attack with sudden fear or panic in the last 4 weeks?
- Has this ever happened before?
- Do some of these attacks come suddenly, out of the blue, in situations where you do not expect nervousness?
- Do these attacks bother you a lot or are you worried about having another attack?
- Have you had symptoms during your last bad anxiety episode (e.g. shortness of breath, heart palpitation, chest pain or pressure, etc.)
Autonomic Nervous System (ANS) Questionnaire
- Questions to assess panic disorder:
- Have you ever had a spell or attack when you felt frightened, anxious, or very uneasy?
- Have you ever had a spell or attack when your heart suddenly began to race, you felt faint, or you couldn't catch your breath?
Panic Disorder Screening Questionnaires Scoring
- PHQ-PD and ANS can be used to screen for panic disorder
- Severity often assessed using a different questionnaire (e.g. PDSS-SR)
- Likelihood ratios to identify panic disorder:
- PHQ-PD 1: sensitivity 71-83%, LR+ 2.42-4.4, LR- 0.26-0.34
- PHQ-PD 5: sensitivity 81%, LR+ 78, LR- 0.20
- ANS: sensitivity 94-100%, LR+ 1.25-2.44, LR- 0-0.24
Stress
- Physical or mental response to an external stressor
- Can be positive or negative
- Considered a risk factor, an exacerbating factor, and a treatment target – not a diagnosis itself
- Risk: life events, impact can be estimated via the Life-Stress Inventory
- Management: patient education, possibly refer for counseling
Adjustment Disorder
- Maladaptive emotional and/or behavioral response to an identifiable psychosocial stressor
- Prevalence: 1-2% (general), 5-20% (outpatient mental health visit), 27% (recently unemployed), 18% (bereaved)
- Risk: significant life event(s)
- Dx: by clinical interview (according to DSM-5 criteria), no validated assessment tools
- Timeline: onset shortly after stressor, typically resolves within 6 months after stressor has stopped (or becomes classified as 'chronic adjustment disorder')
- Character: with anxiety, depressed mood (may include suicide attempt), mixed, with misconduct or unspecified
- Management: patient education, referral to psychotherapy, psychiatry
- Prognosis: 71% recover within 5 years; 76% comorbidity with substance abuse
Adjustment Disorder - DSM-5 Diagnostic Criteria
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
- Trouble falling asleep, staying asleep, or sleeping too much
- Feeling tired or having little energy
- Poor appetite or overeating
- Feeling bad about yourself or that you're a failure or have let yourself or your family down
- Trouble concentrating on things, such as reading the newspaper or watching TV
- Moving or speaking so slowly that other people could have noticed or the opposite, being so fidgety and restless that you have been moving around a lot more than usual
Red Flags in Patient History and Clinical Examination
- Red flags are signs and symptoms that may indicate possible serious underlying pathology
- Red flags prompt further investigation and/or referral
- Examples of red flags include:
- Sore throat, dysphagia, or odynophagia with respiratory distress, inability to open mouth fully, muffled voice, stiff neck, or erythema of neck
- Fever, rash, diffuse adenopathy, and sore throat
- Weight loss, fevers, night sweats, and sore throat
- Recent foreign body impaction or oropharyngeal procedure (trauma)
- Recent cocaine smoking
Serious Diagnoses and Potential Complications
- Acute epiglottitis or supraglottitis: airway obstruction, sepsis, and spread to parapharyngeal or retropharyngeal spaces
- Peritonsillar abscess: airway obstruction, sepsis, and spread to mediastinum, pleural space, or pericardium
- Retropharyngeal abscess: airway obstruction, sepsis, and spread to mediastinum, pleural space, or pericardium
- Primary HIV infection: transmission of disease
- Lymphoma, head and neck cancers: advanced malignancy
Acute Epiglottitis
- Rare but potentially fatal condition
- Inflammation of epiglottis and adjacent tissues
- Bacterial infection primarily caused by Haemophilus influenzae
- Most commonly seen in children aged 2-6, but incidence has decreased with HiB vaccination
- Positive thumb sign on lateral radiograph of the neck is diagnostic
- Medical emergency requiring referral
Peritonsillar Abscess
- Culture of pus from abscess drainage confirms diagnosis
- Imaging not necessary to confirm diagnosis
- Treatment includes drainage, antibiotic therapy, and supportive care
Retropharyngeal Abscess
- Retropharyngeal edema due to cellulitis and suppurative adenitis of lymph nodes in retropharyngeal space
- Preceded by upper respiratory infection, pharyngitis, otitis media, or wound infection following penetrating injury to posterior pharynx
- Peak incidence in 3-5 year olds
- Observed as prevertebral soft-tissue thickening on lateral X-ray of neck
- Treat as impending airway emergency
- Requires antibiotic therapy, possible surgical consultation for needle aspiration or incision and drainage
Clinical Presentation of Retropharyngeal Abscess
- Sore throat and dysphagia
- Fever
- Drooling
- Dysphonia (muffled voice)
- Neck stiffness; limited neck ROM (especially hyperextension)
- Stridor
- May see bulging of the posterior wall of oropharynx on clinical examination
Complications of Pharyngitis
- Non-suppurative complications:
- Acute rheumatic fever (ARF)
- Poststreptococcal glomerulonephritis
- Pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal (PANDAS) infection
- Suppurative complications:
- Peritonsillar abscess
- Retropharyngeal abscess
- Otitis media
- Sinusitis
- Mastoiditis
- Cervical lymphadenitis
- Meningitis
- Bacteremia
Likelihood Ratios for GAS Infection
- Reported fever: 0.75-2.6 (LR+), 0.66-0.94 (LR-)
- Absence of cough: 1.1-1.7 (LR+), 0.53-0.89 (LR-)
- Absence of runny nose: 0.86-1.6 (LR+), 0.51-1.4 (LR-)
- Presence of myalgias: 1.4 (LR+), 0.93 (LR-)
- Presence of headache: 1.0-1.1 (LR+), 0.55-1.2 (LR-)
- Presence of nausea: 0.76-3.1 (LR+), 0.91 (LR-)
- Duration of symptoms < 3 days: 0.72-3.5 (LR+), 0.15-2.2 (LR-)
- Streptococcal exposure in previous 2 weeks: 1.9 (LR+), 0.92 (LR-)
Accuracy for History and Physical Examination Elements in the Diagnosis of Strep Throat
- Any exudates: 0.21-0.58 (sensitivity), 0.69-0.92 (specificity), 1.5-2.6 (LR+), 0.66-0.94 (LR-)
- Reported fever: 0.3-0.92 (sensitivity), 0.23-0.90 (specificity), 0.97-2.6 (LR+), 0.32-1.0 (LR-)
- Measured temperature >37.8°C: 0.11-0.84 (sensitivity), 0.43-0.96 (specificity), 1.1-3.0 (LR+), 0.27-0.94 (LR-)
- Anterior cervical nodes swollen/enlarged: 0.55-0.82 (sensitivity), 0.34-0.73 (specificity), 0.47-2.9 (LR+), 0.58-0.92 (LR-)
- Pharyngeal exudates: 0.03-0.48 (sensitivity), 0.76-0.99 (specificity), 2.1 (1.4-3.1) (LR+), 0.90 (0.75-1.1) (LR-)
- Tonsillar swelling/enlargement: 0.56-0.86 (sensitivity), 0.56-0.86 (specificity), 1.4-3.1 (LR+), 0.63 (0.56-0.72) (LR-)
- Tonsillar or pharyngeal exudates: 0.28-0.61 (sensitivity), 0.62-0.88 (specificity), 1.8 (1.5-2.3) (LR+), 0.74 (0.66-0.82) (LR-)
- Anterior cervical nodes tender: 0.32-0.66 (sensitivity), 0.53-0.84 (specificity), 1.2-1.9 (LR+), 0.60 (0.49-0.71) (LR-)
- Tonsillar exudates: 0.36 (0.21-0.52) (sensitivity), 0.71-0.98 (specificity), 3.4 (1.8-6.0) (LR+), 0.72 (0.60-0.88) (LR-)
Peritonsillar Abscess
- Acute peritonsillar abscess shows medial displacement of the uvula, palatine tonsil, and anterior pillar.
- Diagnosis is confirmed by culturing pus from abscess drainage.
- Imaging is not necessary to confirm diagnosis, but options include CT with IV contrast and intraoral ultrasonography.
- Treatment involves drainage, antibiotic therapy, and supportive care.
Retropharyngeal Abscess
- Caused by retropharyngeal edema due to cellulitis and suppurative adenitis of lymph nodes in the retropharyngeal space.
- Preceded by upper respiratory infection, pharyngitis, otitis media, or wound infection following penetrating injury to the posterior pharynx.
- Peak incidence is in 3-5 year olds.
- Observed as prevertebral soft-tissue thickening on lateral X-ray of the neck.
- Treat as an impending airway emergency, requiring antibiotic therapy and possible surgical consultation for needle aspiration or incision and drainage.
Clinical Presentation of Retropharyngeal Abscess
- Sore throat and dysphagia
- Fever
- Drooling
- Dysphonia (muffled voice)
- Neck stiffness and limited neck ROM (especially hyperextension)
- Stridor
- May see bulging of the posterior wall of the oropharynx on clinical examination
Back to the Case of Alex Best
- 14-year-old adolescent with recent onset of sore throat and no red flags present
- Fever strongly suggests an infectious cause of pharyngitis
- Airway management is key to prevent airway compromise, and may require intubation
- Requires antibiotic therapy
Acute Epiglottitis
- Clinical presentation: acute onset fever, severe sore throat, toxic appearance
- The 4 Ds: dysphagia, drooling, dysphonia, and distress
- Do not use a tongue depressor when examining the oropharynx as it can precipitate airway obstruction
Peritonsillar Abscess
- Also known as quinsy
- Most common deep infection of the head and neck (30% of abscesses of the head and neck)
- Most common in young adults (ages 20-40), with increased risk in immunocompromised and diabetics
- Usually begins as acute tonsillitis → cellulitis → abscess formation
- Polymicrobial infection with common organisms including Group A streptococci, Staphylococcus aureus, Haemophilus influenzae, Fusobacterium, Peptostreptococcus, Pigmented Prevotella species, and Veillonella
Clinical Presentation of Peritonsillar Abscess
- Severe unilateral sore throat
- Dysphagia and odynophagia → pooling of saliva or drooling
- Fever and malaise
- Dysphonia: muffled “hot potato” voice
- Rancid or fetor breath
- Otalgia
- Trismus (66% of patients)
- Oropharyngeal exam: erythematous enlarged tonsil and bulging soft palate on affected side, uvular deviation to contralateral side
- May have severely tender cervical lymphadenopathy
Complications
- Non-suppurative complications: acute rheumatic fever (ARF), poststreptococcal glomerulonephritis, and pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal (PANDAS) infection
- Suppurative complications: peritonsillar abscess, retropharyngeal abscess, otitis media, sinusitis, mastoiditis, cervical lymphadenitis, meningitis, and bacteremia
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Description
Learn about the causes and types of pharyngitis, including acute and viral pharyngitis. Understand the infectious and non-infectious causes of sore throat.
