Head and neck fascial spaces — MCQs

10 questions

A 3-year-old girl is brought to the emergency department by her parents with sudden onset shortness of breath. They tell the emergency physician that their daughter was lying on the bed watching television when she suddenly began gasping for air. They observed a bowl of peanuts lying next to her when they grabbed her up and brought her to the emergency department. Her respirations are 25/min, the pulse is 100/min and the blood pressure is 90/65 mm Hg. The physical findings as of now are apparently normal. She is started on oxygen and is sent in for a chest X-ray. Based on her history and physical exam findings, the cause of her current symptoms would be seen on the X-ray at which of the following sites?

A 26-year-old woman presents to the medicine clinic with swelling around the right side of her chin and neck (Image A). She reports pain when moving her jaw and chewing. Her symptoms developed two days after receiving an uncomplicated tonsillectomy. She has been followed by a general medical physician since birth and has received all of her standard health maintenance procedures. Vital signs are stable with the exception of a temperature of 38.4 degrees Celcius. The area in question on the right side is exquisitely tender. The remainder of her exam is benign. What is the most likely diagnosis?

A 12-year-old boy presents to the emergency room with difficulty breathing after several days of severe sore throat. Further history reveals that his family immigrated recently from Eastern Europe and he has never previously seen a doctor. Physical exam shows cervical lymphadenopathy with extensive neck edema as well as the finding shown in the image provided. You suspect a bacteria that causes the disease by producing an AB type exotoxin. Which of the following is the proper medium to culture the most likely cause of this infection?

A 63-year-old man comes to the physician for evaluation of fever and a nonproductive cough for the past 2 weeks. During this period, he has also had fatigue, myalgia, and difficulty breathing. Five weeks ago, he underwent an aortic prosthetic valve replacement due to high-grade aortic stenosis. The patient has a history of hypertension, asthma, and type 2 diabetes mellitus. A colonoscopy 2 years ago was normal. The patient has smoked one pack of cigarettes daily for the past 40 years. He has never used illicit drugs. Current medications include aspirin, warfarin, lisinopril, metformin, inhaled albuterol, and a multivitamin. The patient appears lethargic. Temperature is 38.6°C (101.5°F), pulse is 105/min, and blood pressure is 140/60 mm Hg. Rales are heard on auscultation of the lungs. A grade 2/6, diastolic blowing murmur is heard over the left sternal border and radiates to the right sternal border. A photograph of his right index finger is shown. Laboratory studies show a leukocyte count of 13,800/mm3 and an erythrocyte sedimentation rate of 48 mm/h. Which of the following is the most likely causal organism?

A 16-year-old boy comes to the physician because of a 1-week history of difficulty swallowing, a foreign body sensation at the back of his throat, and trouble breathing at night. He has just recovered from an upper respiratory tract infection that began 5 days ago. On questioning, he reports that he has had similar symptoms in the past each time he has had an upper respiratory tract infection. Physical examination shows a 3 x 2-cm, nontender, rubbery midline mass at the base of the tongue. His skin is dry and cool. An image of his technetium-99m pertechnetate scan is shown. Which of the following is the most likely underlying cause of this patient’s condition?

A 26-year-old G1P0 woman at 40 weeks estimated gestational age presents after experiencing labor pains. Pregnancy has been uncomplicated so far. Rupture of membranes occurs, and a transvaginal delivery is performed under epidural anesthesia, and the baby is delivered alive and healthy. The patient voids a few hours after the delivery and complains of mild irritation at the injection site on her back. On the second day, she complains of a severe headache over the back of her head. The headache is associated with pain and stiffness in the neck. Her headache is aggravated by sitting up or standing and relieved by lying down. The pain is relieved slightly by acetaminophen and ibuprofen. The patient is afebrile. Her vital signs include: pulse 100/min, respiratory rate 18/min, and blood pressure 128/84 mm Hg. Which of the following statements is the most accurate regarding this patient’s condition?

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

A 27-year-old woman comes to the physician because of a 3-day history of a sore throat and fever. Her temperature is 38.5°C (101.3°F). Examination shows edematous oropharyngeal mucosa and enlarged tonsils with purulent exudate. There is tender cervical lymphadenopathy. If left untreated, which of the following conditions is most likely to occur in this patient?

A 42-year-old woman comes to the physician because of increasing pain in the right hip for 2 months. The pain is intermittent, presenting at the lateral side of the hip and radiating towards the thigh. It is aggravated while climbing stairs or lying on the right side. Two weeks ago, the patient was treated with a course of oral prednisone for exacerbation of asthma. Her current medications include formoterol-budesonide and albuterol inhalers. Vital signs are within normal limits. Examination shows tenderness to palpation over the upper lateral part of the right thigh. There is no swelling. The patient is placed in the left lateral decubitus position. Abducting the extended right leg against the physician's resistance reproduces the pain. The remainder of the examination shows no abnormalities. An x-ray of the pelvis shows no abnormalities. Which of the following is the most likely diagnosis?

Q10

A 47-year-old woman presents to the emergency department with a fever and a headache. Her symptoms started yesterday and have rapidly progressed. Initially, she was experiencing just a fever and a headache which she was treating with acetaminophen. It rapidly progressed to blurry vision, chills, nausea, and vomiting. The patient has a past medical history of diabetes and hypertension and she is currently taking insulin, metformin, lisinopril, and oral contraceptive pills. Her temperature is 104°F (40.0°C), blood pressure is 157/93 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 98% on room air. Upon further inspection, the patient also demonstrates exophthalmos in the affected eye. The patient's extraocular movements are notably decreased in the affected eye with reduced vertical and horizontal gaze. The patient also demonstrates decreased sensation near the affected eye in the distribution of V1 and V2. While the patient is in the department waiting for a CT scan, she becomes lethargic and acutely altered. Which of the following is the most likely diagnosis?

Head and neck fascial spaces US Medical PG Practice Questions and MCQs

Question 1: A 3-year-old girl is brought to the emergency department by her parents with sudden onset shortness of breath. They tell the emergency physician that their daughter was lying on the bed watching television when she suddenly began gasping for air. They observed a bowl of peanuts lying next to her when they grabbed her up and brought her to the emergency department. Her respirations are 25/min, the pulse is 100/min and the blood pressure is 90/65 mm Hg. The physical findings as of now are apparently normal. She is started on oxygen and is sent in for a chest X-ray. Based on her history and physical exam findings, the cause of her current symptoms would be seen on the X-ray at which of the following sites?

A. The superior segment of the right lower lobe
B. The posterior segment of the right lower lobe (Correct Answer)
C. The lingula of the left upper lobe
D. The apical segment of the right upper lobe
E. The apical segment of the left upper lobe

Explanation: ***The posterior segment of the right lower lobe*** - This is the **most common site for foreign body aspiration in a supine or lying down position** due to gravity and anatomical orientation. - The history explicitly states the child was **"lying on the bed watching television"** when aspiration occurred, making the **posterior segment of the right lower lobe** the most gravity-dependent and therefore most likely location. - The **right main bronchus** is wider, shorter, and more vertical than the left, making the right lung the predominant site for aspiration, and in supine position, the posterior segment is most dependent [1, 2]. *The superior segment of the right lower lobe* - The **superior segment of the right lower lobe** is the most common site for aspiration in **upright, standing, or semi-upright positions**, not in a supine position. - Since the child was lying down (supine), gravity would direct the aspirated peanut to the **posterior segment** rather than the superior segment. - This would be correct if the child had aspirated while sitting upright. *The lingula of the left upper lobe* - The **lingula** is an uncommon site for aspiration because the **left main bronchus** has a sharper angle and smaller diameter compared to the right bronchus [2]. - The anatomical differences make aspiration into the right lung significantly more common than the left lung [2]. - The lingula is not a gravity-dependent area in the supine position. *The apical segment of the right upper lobe* - The **apical segment of the right upper lobe** is associated with aspiration when the patient is in **Trendelenburg position** (head lower than feet) or in extreme head-down positions. - The described scenario of lying flat on the bed does not favor aspiration into apical segments, which are non-gravity-dependent in supine position. - This location would be contra-gravity in the supine position. *The apical segment of the left upper lobe* - Aspiration into the **left upper lobe** is less frequent than the right lung due to the sharper angle of the left main bronchus [2]. - The **apical segment** would require head-down positioning (Trendelenburg) that is not described in this clinical scenario. - This is the least likely location given both the supine position and left-sided anatomy.

Question 2: A 26-year-old woman presents to the medicine clinic with swelling around the right side of her chin and neck (Image A). She reports pain when moving her jaw and chewing. Her symptoms developed two days after receiving an uncomplicated tonsillectomy. She has been followed by a general medical physician since birth and has received all of her standard health maintenance procedures. Vital signs are stable with the exception of a temperature of 38.4 degrees Celcius. The area in question on the right side is exquisitely tender. The remainder of her exam is benign. What is the most likely diagnosis?

A. Superior vena cava syndrome
B. Mumps
C. Acute bacterial parotitis (Correct Answer)
D. Sjogren's syndrome
E. Pleomorphic adenoma

Explanation: **Acute bacterial parotitis** - The patient's presentation with **unilateral swelling** around the chin and neck, **pain with jaw movement and chewing**, fever, and **exquisite tenderness** in the area, particularly after a recent **tonsillectomy** (which can predispose to dehydration or salivary gland dysfunction), is highly characteristic of acute bacterial parotitis. - The elevated temperature further supports an infectious etiology, and the **post-operative setting** increases the risk for this condition due to potential retrograde infection from the oral cavity. *Superior vena cava syndrome* - This syndrome typically presents with **facial and neck edema**, distended neck veins, and dyspnea, resulting from obstruction of the superior vena cava, usually by a mass. - It does not typically cause localized, **exquisitely tender swelling** or pain with jaw movement, and a recent tonsillectomy is not a risk factor. *Mumps* - While mumps causes **parotid gland swelling**, it is a viral infection that usually presents with **bilateral parotitis**, although unilateral cases can occur. - The patient's history of receiving **all standard health maintenance procedures** suggests she has likely been vaccinated against mumps, making it less probable, and the rapid onset post-tonsillectomy points more towards a bacterial process. *Sjogren's syndrome* - This is a **chronic autoimmune disease** primarily affecting the exocrine glands, leading to **dry eyes and dry mouth**, and can cause recurrent enlargement of the parotid glands. - It would not explain the **acute, painful, and tender swelling with fever** in a patient with no prior history of autoimmune disease, nor would it typically follow a tonsillectomy. *Pleomorphic adenoma* - This is a common **benign salivary gland tumor** that typically presents as a **slow-growing, painless mass** in the parotid gland. - It would not explain the **acute onset, pain, tenderness, and fever** described in the patient, which are indicative of an inflammatory or infectious process.

Question 3: A 12-year-old boy presents to the emergency room with difficulty breathing after several days of severe sore throat. Further history reveals that his family immigrated recently from Eastern Europe and he has never previously seen a doctor. Physical exam shows cervical lymphadenopathy with extensive neck edema as well as the finding shown in the image provided. You suspect a bacteria that causes the disease by producing an AB type exotoxin. Which of the following is the proper medium to culture the most likely cause of this infection?

A. Thayer-Martin Agar
B. Charcoal Yeast Agar
C. Tellurite Agar (Correct Answer)
D. Eaton's Agar
E. Bordet-Gengou Agar

Explanation: ***Tellurite Agar*** - The clinical picture (sore throat, neck edema, cervical lymphadenopathy, difficulty breathing, recent immigration from Eastern Europe, unvaccinated) is highly suggestive of **diphtheria**, caused by *Corynebacterium diphtheriae*. - **Tellurite agar** (e.g., cysteine-tellurite blood agar or Tinsdale medium) is the selective medium used to isolate *Corynebacterium diphtheriae*, which forms characteristic **gray-black colonies** due to the reduction of tellurite. *Thayer-Martin Agar* - This is a selective medium primarily used for the isolation of **Neisseria gonorrhoeae** and **Neisseria meningitidis**. - It contains antibiotics to inhibit the growth of other bacteria and fungi, which would not be appropriate for *Corynebacterium diphtheriae*. *Charcoal Yeast Agar* - **Buffered Charcoal Yeast Extract (BCYE) agar** is the specific medium used for the isolation of **Legionella species**, particularly *Legionella pneumophila*. - *Legionella* requires **L-cysteine** and **iron salts** for growth, which are provided in BCYE agar. *Bordet-Gengou Agar* - This medium is specifically designed for the isolation of **Bordetella pertussis**, the causative agent of **whooping cough**. - It contains potato extract, glycerol, and blood, which are necessary for the fastidious *Bordetella pertussis* to grow. *Eaton's Agar* - **Eaton's agar** is a specialized liquid or semi-solid medium used for the cultivation of **Mycoplasma pneumoniae**. - *Mycoplasma pneumoniae* is a common cause of **atypical pneumonia** and lacks a cell wall, making it difficult to culture on standard media.

Question 4: A 63-year-old man comes to the physician for evaluation of fever and a nonproductive cough for the past 2 weeks. During this period, he has also had fatigue, myalgia, and difficulty breathing. Five weeks ago, he underwent an aortic prosthetic valve replacement due to high-grade aortic stenosis. The patient has a history of hypertension, asthma, and type 2 diabetes mellitus. A colonoscopy 2 years ago was normal. The patient has smoked one pack of cigarettes daily for the past 40 years. He has never used illicit drugs. Current medications include aspirin, warfarin, lisinopril, metformin, inhaled albuterol, and a multivitamin. The patient appears lethargic. Temperature is 38.6°C (101.5°F), pulse is 105/min, and blood pressure is 140/60 mm Hg. Rales are heard on auscultation of the lungs. A grade 2/6, diastolic blowing murmur is heard over the left sternal border and radiates to the right sternal border. A photograph of his right index finger is shown. Laboratory studies show a leukocyte count of 13,800/mm3 and an erythrocyte sedimentation rate of 48 mm/h. Which of the following is the most likely causal organism?

A. Staphylococcus epidermidis (Correct Answer)
B. Enterococcus faecalis
C. Streptococcus gallolyticus
D. Streptococcus pyogenes
E. Viridans streptococci

Explanation: ***Staphylococcus epidermidis*** - This patient's **recent prosthetic valve replacement** makes him highly susceptible to infective endocarditis caused by *Staphylococcus epidermidis*, a common pathogen in **nosocomial infections** and on implanted devices. - **Early prosthetic valve endocarditis** (within 2 months post-surgery, as in this case at 5 weeks) is most commonly caused by coagulase-negative staphylococci, particularly *S. epidermidis*, which colonize the valve during the perioperative period. - The symptoms of fever, cough, fatigue, myalgia, difficulty breathing, and a new diastolic murmur, along with peripheral manifestations (shown in the photograph) and elevated inflammatory markers, are all consistent with infective endocarditis. *Enterococcus faecalis* - While *Enterococcus faecalis* can cause endocarditis, it is more commonly associated with **gastrointestinal or genitourinary procedures**, which are not indicated here. - No recent urinary tract infection or GI instrumentation (colonoscopy was 2 years ago) points away from this organism. *Streptococcus gallolyticus* - Previously known as *Streptococcus bovis*, this organism is strongly associated with **colon cancer, inflammatory bowel disease, and colonic polyps**. - The patient had a normal colonoscopy recently (2 years ago), making this less likely. *Streptococcus pyogenes* - *Streptococcus pyogenes* is known for causing **pharyngitis, scarlet fever, and rheumatic fever**, but it is a relatively uncommon cause of infective endocarditis, especially on prosthetic valves. - There is no history of a recent streptococcal infection to suggest this pathogen. *Viridans streptococci* - **Viridans streptococci** are the most common cause of **native valve endocarditis**, often following dental procedures, but are less common in early prosthetic valve endocarditis compared to *S. epidermidis*. - This patient had a prosthetic valve replacement 5 weeks ago, pointing more towards a nosocomial organism like *S. epidermidis*.

Question 5: A 16-year-old boy comes to the physician because of a 1-week history of difficulty swallowing, a foreign body sensation at the back of his throat, and trouble breathing at night. He has just recovered from an upper respiratory tract infection that began 5 days ago. On questioning, he reports that he has had similar symptoms in the past each time he has had an upper respiratory tract infection. Physical examination shows a 3 x 2-cm, nontender, rubbery midline mass at the base of the tongue. His skin is dry and cool. An image of his technetium-99m pertechnetate scan is shown. Which of the following is the most likely underlying cause of this patient’s condition?

A. Chronic infection of the palatine and lingual tonsils
B. Ductal obstruction of the sublingual salivary glands
C. Arrested endodermal migration from pharyngeal floor (Correct Answer)
D. Persistent epithelial tract between the foramen cecum and thyroid isthmus
E. Failure of obliteration of the second branchial cleft

Explanation: ***Arrested endodermal migration from pharyngeal floor*** - This describes the embryological origin of a **lingually ectopic thyroid gland** (also known as a **lingual thyroid**), which results from the thyroid's failure to descend from its embryonic origin at the foramen cecum. - The symptoms of globus sensation, dysphagia, and trouble breathing, especially exacerbated during URI due to swelling of the ectopic thyroid tissue, alongside the midline tongue mass and positive **technetium-99m pertechnetate scan** (which highlights thyroid tissue), are highly indicative of this condition. *Chronic infection of the palatine and lingual tonsils* - While chronic tonsillitis can cause symptoms like dysphagia and foreign body sensation, it typically presents with recurrent sore throats, pus, and tender lymphadenopathy. - It would not explain a distinct midline mass at the base of the tongue that shows uptake on a technetium-99m scan, which specifically targets thyroid tissue. *Ductal obstruction of the sublingual salivary glands* - Obstruction of sublingual ducts (e.g., ranula) would typically present as a soft, bluish, fluid-filled mass in the floor of the mouth, not a rubbery midline mass at the base of the tongue. - This condition is unrelated to URIs and would not show uptake on a technetium-99m pertechnetate scan. *Persistent epithelial tract between the foramen cecum and thyroid isthmus* - This describes a **thyroglossal duct cyst**, which is typically a midline neck mass that moves with tongue protrusion. - While embryologically related to thyroid development, the mass in this patient is described as being at the "base of the tongue," not a mobile neck mass, and represents a completely ectopic thyroid gland rather than a cystic remnant of the duct. *Failure of obliteration of the second branchial cleft* - This leads to the formation of a **branchial cleft cyst**, which is usually found laterally in the neck, anterior to the sternocleidomastoid muscle. - It is not typically a midline mass at the base of the tongue and is generally not associated with symptoms of dysphagia or respiratory distress exacerbated by URIs in this specific manner.

Question 6: A 26-year-old G1P0 woman at 40 weeks estimated gestational age presents after experiencing labor pains. Pregnancy has been uncomplicated so far. Rupture of membranes occurs, and a transvaginal delivery is performed under epidural anesthesia, and the baby is delivered alive and healthy. The patient voids a few hours after the delivery and complains of mild irritation at the injection site on her back. On the second day, she complains of a severe headache over the back of her head. The headache is associated with pain and stiffness in the neck. Her headache is aggravated by sitting up or standing and relieved by lying down. The pain is relieved slightly by acetaminophen and ibuprofen. The patient is afebrile. Her vital signs include: pulse 100/min, respiratory rate 18/min, and blood pressure 128/84 mm Hg. Which of the following statements is the most accurate regarding this patient’s condition?

A. A blockage of CSF is the cause of this patient’s headache
B. An infection is present at the epidural injection site
C. This patient’s condition can resolve on its own (Correct Answer)
D. Excessive bed rest will worsen this patient’s condition
E. Immediate intervention is required

Explanation: ***This patient’s condition can resolve on its own*** - The symptoms describe a **post-dural puncture headache (PDPH)**, a common complication of epidural anesthesia, which is often **self-limiting** within days to weeks. - Initial management involves conservative measures like bed rest, hydration, and analgesics, as many cases resolve without specific interventions. *A blockage of CSF is the cause of this patient’s headache* - PDPH is caused by a **leakage of cerebrospinal fluid (CSF)** through the dura mater, leading to **intracranial hypotension**, not a blockage of CSF flow. - The leakage reduces CSF pressure, causing the brain to sag when upright, stretching pain-sensitive structures like meninges and blood vessels. *An infection is present at the site of epidural injection site* - While localized irritation is mentioned, there are no signs of infection such as **fever**, **erythema**, or **purulent discharge** at the injection site, making infection less likely. - The headache characteristics (positional, severe, neck stiffness) are classic for PDPH, not typically seen in local epidural infections, which would also present with systemic signs. *Excessive bed rest will worsen this patient’s condition* - **Bed rest** typically **improves** the symptoms of PDPH by reducing the gravitational pull on the intracranial structures, thereby alleviating the headache. - Prolonged bed rest is generally recommended in the acute phase, often combined with hydration and caffeine, to help manage symptoms, not worsen them. *Immediate intervention is required* - While severe PDPH can be debilitating, immediate invasive intervention (like an **epidural blood patch**) is usually reserved for cases that are **severe and refractory to conservative management** after 24-48 hours. - Many patients experience spontaneous resolution or significant improvement with conservative measures, making immediate invasive intervention typically unnecessary.

Question 7: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

A. "Does the diarrhea typically precede the constipation, or vice-versa?"
B. "Is the diarrhea foul-smelling?"
C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
D. "Are the symptoms worse in the morning or at night?"
E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Question 8: A 27-year-old woman comes to the physician because of a 3-day history of a sore throat and fever. Her temperature is 38.5°C (101.3°F). Examination shows edematous oropharyngeal mucosa and enlarged tonsils with purulent exudate. There is tender cervical lymphadenopathy. If left untreated, which of the following conditions is most likely to occur in this patient?

A. Rheumatic fever (Correct Answer)
B. Rheumatoid arthritis
C. Erythema multiforme
D. Toxic shock syndrome
E. Post-streptococcal glomerulonephritis

Explanation: ***Rheumatic fever*** - The patient presents with classic symptoms of **streptococcal pharyngitis** (sore throat, fever, tonsillar exudate, tender cervical lymphadenopathy), which, if left untreated, is a major risk factor for developing **acute rheumatic fever**. - **Acute rheumatic fever** is a serious inflammatory disease that can affect the **heart valves**, joints, brain, and skin, occurring in approximately **3% of untreated cases** of Group A Streptococcal pharyngitis. *Rheumatoid arthritis* - This is a **chronic autoimmune inflammatory disease** primarily affecting the synovial joints, not typically associated with an acute streptococcal infection. - It involves a different pathophysiological mechanism and is not a direct complication of untreated streptococcal pharyngitis. *Erythema multiforme* - This is an **acute, self-limiting skin condition** often triggered by infections (e.g., Herpes simplex virus) or medications, resulting in target lesions. - While infections can cause it, **streptococcal pharyngitis** is not a common or direct cause, and it's not a systemic complication similar to rheumatic fever. *Toxic shock syndrome* - This is a **rapidly progressing infectious disease** characterized by fever, rash, hypotension, and multi-organ failure, most often caused by toxins produced by *Staphylococcus aureus* or *Streptococcus pyogenes*. - While *Streptococcus pyogenes* (Group A Strep) can cause it, toxic shock syndrome is an **acute complication** rather than a late sequela of untreated infection, making **rheumatic fever** the more characteristic delayed complication. *Post-streptococcal glomerulonephritis* - While this is another serious immune-mediated complication of **streptococcal infections**, it **more commonly follows skin infections (impetigo)** than pharyngitis. - **Rheumatic fever** is the most characteristic and clinically significant late complication of untreated streptococcal **pharyngitis** specifically, with greater emphasis in clinical practice due to its potential for permanent cardiac valve damage.

Question 9: A 42-year-old woman comes to the physician because of increasing pain in the right hip for 2 months. The pain is intermittent, presenting at the lateral side of the hip and radiating towards the thigh. It is aggravated while climbing stairs or lying on the right side. Two weeks ago, the patient was treated with a course of oral prednisone for exacerbation of asthma. Her current medications include formoterol-budesonide and albuterol inhalers. Vital signs are within normal limits. Examination shows tenderness to palpation over the upper lateral part of the right thigh. There is no swelling. The patient is placed in the left lateral decubitus position. Abducting the extended right leg against the physician's resistance reproduces the pain. The remainder of the examination shows no abnormalities. An x-ray of the pelvis shows no abnormalities. Which of the following is the most likely diagnosis?

A. Osteoarthritis of the hip
B. Osteonecrosis of femoral head
C. Lumbosacral radiculopathy
D. Greater trochanteric pain syndrome (Correct Answer)
E. Iliotibial band syndrome

Explanation: ***Greater trochanteric pain syndrome*** - The patient's symptoms of **lateral hip pain** radiating to the thigh, aggravated by activity and lying on the affected side, and **tenderness over the greater trochanter** are classic for **greater trochanteric pain syndrome** (GTPS). - Pain reproduction with **abduction against resistance** (a specific test for GTPS) and normal X-rays further support this diagnosis. *Osteoarthritis of the hip* - Typically causes **groin pain** that can radiate to the buttock or knee, not primarily lateral hip pain. - X-rays would likely show signs of **joint space narrowing**, osteophytes, or subchondral sclerosis, which are absent here. *Osteonecrosis of femoral head* - While **corticosteroid use** is a risk factor, osteonecrosis usually presents with **groin or buttock pain** and would likely show abnormalities on X-ray (advanced stages) or MRI (early stages). - The specific tenderness and pain reproduction with abduction against resistance are not typical for osteonecrosis. *Lumbosacral radiculopathy* - Would typically present with pain radiating **down the leg** in a dermatomal pattern, often accompanied by **neurological deficits** such as sensory loss, weakness, or reflex changes. - The examination findings of isolated lateral hip tenderness and pain with resisted abduction do not support radiculopathy. *Iliotibial band syndrome* - More commonly affects **runners** or cyclists and causes pain along the **lateral aspect of the knee**, although it can present as lateral hip pain. - While it can manifest with lateral hip pain, the focal tenderness over the greater trochanter and pain on resisted abduction make **GTPS** a more precise diagnosis.

Question 10: A 47-year-old woman presents to the emergency department with a fever and a headache. Her symptoms started yesterday and have rapidly progressed. Initially, she was experiencing just a fever and a headache which she was treating with acetaminophen. It rapidly progressed to blurry vision, chills, nausea, and vomiting. The patient has a past medical history of diabetes and hypertension and she is currently taking insulin, metformin, lisinopril, and oral contraceptive pills. Her temperature is 104°F (40.0°C), blood pressure is 157/93 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 98% on room air. Upon further inspection, the patient also demonstrates exophthalmos in the affected eye. The patient's extraocular movements are notably decreased in the affected eye with reduced vertical and horizontal gaze. The patient also demonstrates decreased sensation near the affected eye in the distribution of V1 and V2. While the patient is in the department waiting for a CT scan, she becomes lethargic and acutely altered. Which of the following is the most likely diagnosis?

A. Acute closed angle glaucoma
B. Cavernous sinus thrombosis (Correct Answer)
C. Brain abscess
D. Periorbital cellulitis
E. Intracranial hemorrhage

Explanation: ***Cavernous sinus thrombosis*** - The rapid progression of symptoms, **exophthalmos**, decreased extraocular movements (involving cranial nerves III, IV, and VI that pass through the cavernous sinus), and V1/V2 sensory deficits (trigeminal nerve branches) are classic signs of **cavernous sinus thrombosis**. The patient's acute alteration and lethargy point to CNS involvement. - The patient's oral contraceptive use is a risk factor for **thrombosis**, and her diabetic and hypertensive status may contribute to her vulnerability to infections, which can lead to cavernous sinus thrombosis. *Acute closed angle glaucoma* - Acute closed-angle glaucoma typically presents with sudden, severe eye pain, blurred vision, and halos, often without systemic symptoms like fever or rapid progression to altered mental status. - While it causes blurry vision, it does not typically cause **exophthalmos**, multiple extraocular muscle palsies, or deficits in V1/V2 sensation. *Brain abscess* - A brain abscess can cause fever, headache, and altered mental status, but it less commonly presents with the specific combination of **exophthalmos**, multiple cranial nerve palsies affecting eye movement, and V1/V2 sensory deficits. - It would typically cause focal neurological deficits related to the specific brain region affected, rather than a constellation of orbital and systemic symptoms like this. *Periorbital cellulitis* - Periorbital cellulitis causes eyelid swelling, redness, and pain, and can be associated with fever, but it typically does not cause **exophthalmos**, decreased extraocular movements, or sensory deficits in the V1/V2 distribution as seen in this patient. - Infection is limited to tissues anterior to the orbital septum and generally resolves with antibiotics without progression to severe neurological symptoms. *Intracranial hemorrhage* - Intracranial hemorrhage can cause sudden headache, altered mental status, and focal neurological deficits, but it rarely presents with **fever**, **exophthalmos**, or the specific cranial nerve palsies described without other clear signs of a stroke (e.g., sudden weakness or speech changes). - The presence of fever and the constellation of orbital signs make hemorrhage less likely as the primary diagnosis.

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