CMS150 midterm

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Questions and Answers

What is the relationship between sensitivity and specificity in diagnosing strep throat?

They are inversely proportional (correct)

They are directly proportional

They are dependent on the population

They are unrelated

What is the primary purpose of this table?

To evaluate the accuracy of history and physical examination elements in the diagnosis of strep throat (correct)

To determine the diagnosis of strep throat

To provide treatment options for strep throat

To list the symptoms of strep throat

What is the purpose of the whisper test?

To screen for hearing loss (correct)

To measure the sensitivity of hearing

To diagnose strep throat

To determine the type of hearing loss

What is the affected ear in Alex's case?

Left ear Signup and view all the answers

What is the primary cause of conductive hearing loss?

Dysfunction in one or more parts of the auditory pathway from the external ear to the middle ear Signup and view all the answers

What is the function of the Eustachian tube?

To connect the middle ear to the nasopharynx Signup and view all the answers

What is the primary cause of sensorineural hearing loss?

Dysfunction in one or more parts of the auditory pathway between the inner ear and auditory cortex Signup and view all the answers

What is the structure that separates the outer ear from the middle ear?

Tympanic membrane Signup and view all the answers

What is the term for the pathway that connects the middle ear to the inner ear?

Oval window Signup and view all the answers

What is the term for the three parts of the ear?

Inner, middle, and outer ear Signup and view all the answers

What is the function of the ossicles in the middle ear?

To transmit sound waves from the outer ear to the inner ear Signup and view all the answers

What is the purpose of determining the type of hearing loss?

To determine the appropriate treatment for hearing loss Signup and view all the answers

What is the primary basis for the differential diagnosis of a rash?

Morphology of the lesion Signup and view all the answers

What is a primary lesion?

The initial lesion that has not been altered by trauma or manipulation and has not regressed Signup and view all the answers

What is a bulla?

A circumscribed, elevated lesion that measures ≥ 1 cm and contains serous or hemorrhagic fluid Signup and view all the answers

What is a macule?

A circumscribed, nonpalpable discolouration of the skin that measures 0.3 cm Signup and view all the answers

What is a pustule?

A lesion that contains pus and is centered around a hair follicle Signup and view all the answers

What is the next step in constructing a differential diagnosis for a rash after identifying the primary lesion?

Determine the global reaction pattern Signup and view all the answers

What is the definition of a vesicle?

A circumscribed, elevated lesion that measures < 0.3 cm and contains serous or hemorrhagic fluid Signup and view all the answers

Why is it important to identify the primary lesion when constructing a differential diagnosis for a rash?

Because it is the initial lesion that has not been altered by trauma or manipulation and has not regressed Signup and view all the answers

What is the term for the description of a rash using medical terminology?

Morphology Signup and view all the answers

What is the primary basis for the diagnosis of osteoarthritis?

Clinical history and physical examination Signup and view all the answers

What is the main indication for ordering X-ray in osteoarthritis?

To confirm diagnosis and rule out other conditions Signup and view all the answers

When is CT or MRI commonly used in the diagnosis of osteoarthritis?

When diagnosis is in doubt or strong suspicion for other etiology Signup and view all the answers

What is the typical finding on X-ray in osteoarthritis?

Joint space narrowing Signup and view all the answers

What is the role of laboratory testing in the diagnosis of osteoarthritis?

Not usually required Signup and view all the answers

What is the growing use of in the diagnosis of osteoarthritis?

Ultrasound Signup and view all the answers

What is the primary purpose of X-ray in osteoarthritis?

To confirm diagnosis and rule out other conditions Signup and view all the answers

What is the characteristic finding on X-ray in osteoarthritis?

All of the above Signup and view all the answers

When is imaging not required in osteoarthritis?

In patients with risk factors and typical symptoms Signup and view all the answers

What is the role of clinical history and physical examination in the diagnosis of osteoarthritis?

Primary basis for diagnosis Signup and view all the answers

What is the primary goal of counseling patients with radicular symptoms?

To reassure patients about the low likelihood of serious pathology Signup and view all the answers

What is the characteristic of severe radiculopathy?

Sensory loss and pain with marked motor deficits Signup and view all the answers

What is the recommendation for patients with radicular symptoms in terms of physical activity?

Stay active at a moderate level and return to normal activities as soon as possible Signup and view all the answers

What is the primary concern when a patient's symptoms worsen or are severe?

The need for earlier imaging and/or emergent surgical intervention Signup and view all the answers

What is the typical outcome of most cases of lumbosacral radiculopathy?

Self-limited and resolution within 6-8 weeks Signup and view all the answers

What is the importance of discussing weight loss with patients with radicular symptoms?

Because the majority of patients will have an elevated body mass index Signup and view all the answers

What is the role of pain management in patients with radicular symptoms?

Both nonpharmacologic and pharmacologic options are recommended Signup and view all the answers

What is the recommendation for patients with symptoms persisting for over six weeks?

Consider additional interventions such as injections Signup and view all the answers

What is the category of radiculopathy characterized by sensory loss and pain without motor deficits?

Mild radiculopathy Signup and view all the answers

What is the primary concern when a patient presents with Red Flag symptoms?

The need for immediate emergent evaluation and potential surgical consultation Signup and view all the answers

Which of the following laboratory tests is used to diagnose Systemic Lupus Erythematosus (SLE)?

Positive anti-nuclear antibodies (ANA) Signup and view all the answers

A patient presents with persistently depressed or irritable mood. What is a possible cause of this symptom?

Amphetamine withdrawal Signup and view all the answers

What is the primary purpose of a subjective history in a patient's evaluation?

To identify the clinical syndrome Signup and view all the answers

Which of the following medications can cause depression or irritable mood?

All of the above Signup and view all the answers

What is the laboratory test used to diagnose Addison disease?

Cortisol and aldosterone levels Signup and view all the answers

What is the characteristic of Parkinson's disease?

Bradykinesia and resting tremor or limb rigidity Signup and view all the answers

What is the purpose of the Widespread Pain Index (WPI) scale and Symptom Severity (SS) scale?

To diagnose fibromyalgia Signup and view all the answers

What is the laboratory test used to diagnose Pernicious anemia?

Serum B12 levels Signup and view all the answers

What is the characteristic of Multiple sclerosis?

Demyelinating lesions Signup and view all the answers

What is the laboratory test used to diagnose Diabetes mellitus?

Fasting blood sugar (FBS) and hemoglobin A1c (HbA1c) Signup and view all the answers

What is the typical clinical presentation of Acute Epiglottitis?

Acute onset fever, severe sore throat, toxic appearance Signup and view all the answers

What is the most common deep infection of the head and neck?

Peritonsillar Abscess Signup and view all the answers

What is the characteristic voice of a patient with Peritonsillar Abscess?

Hot potato voice Signup and view all the answers

Why should a tongue depressor not be used when examining the oropharynx of a patient with Acute Epiglottitis?

It can precipitate airway obstruction Signup and view all the answers

What is the typical oropharyngeal exam finding in a patient with Peritonsillar Abscess?

Erythematous enlarged tonsil and bulging soft palate on the affected side Signup and view all the answers

What is the primary method to confirm the diagnosis of a peritonsillar abscess?

Culture of pus from abscess drainage Signup and view all the answers

What is the age group most affected by retropharyngeal abscess?

Children between 3-5 years old Signup and view all the answers

What is a common symptom of retropharyngeal abscess?

Drooling Signup and view all the answers

What is the primary treatment for retropharyngeal abscess?

Surgical consultation for needle aspiration or incision and drainage Signup and view all the answers

What is the significance of fever in a patient with a sore throat?

It strongly suggests an infectious cause Signup and view all the answers

What is a complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis?

All of the above Signup and view all the answers

What is a suppurative complication of pharyngitis?

All of the above Signup and view all the answers

What is a characteristic of viral pharyngitis?

Both A and B Signup and view all the answers

What is a rare complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis in North America?

Acute rheumatic fever Signup and view all the answers

What is a complication of Group A beta-hemolytic streptococcal (GABHS) pharyngitis that can develop 1-2 weeks after infection?

Poststreptococcal glomerulonephritis Signup and view all the answers

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.