30 Which of the following patients is most likely to have group A streptococcal infection? A. An 11-month-old male infant with fever and red throat B. An 8-year-old girl with fever and sore throat C. A 27-year-old man with a temperature of 38.9°C (102°F), pharyngitis, and cough D. A 52-year-old woman who complains of fever of 39.2°C (102.5°F) and sore throat ANSWER: 31. An 18-year-old woman presents with fever and a sore threat. She is sitting up drooling, with some stridor. Her temperature is 39.4°C (103°F) and she appears ill. Which of the following is your next step? A. Examine the pharynx and obtain a rapid B. Throat culture and treatment based on results. btain a rapid antigen test. C. Send the patient to radiology for an anteroposterior (AP) neck radiograph D. Prepare for emergent airway management ANSWER: 40. Which of the following is the most common serious complications of cirrhosis? A.Coagulopathy B. Portal hypertention C.Hepatopulmonary syndrome. D.Hepatic encephalopathy
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Here are the detailed answers with textbook-backed explanations:
Question 30 - Group A Streptococcal Infection
Answer: B - An 8-year-old girl with fever and sore throat
Explanation:
GAS pharyngitis has a well-defined epidemiology that makes the answer clear:
- Age 5-15 years is the peak incidence for GAS pharyngitis. As confirmed by Rosen's Emergency Medicine: "GAS pharyngitis is most common in children aged 5-15 years."
- Option A (11-month-old infant): Children under 3 years rarely get classic GAS pharyngitis, and complications are rare in this age group. The Family Medicine textbook states: "In children younger than 3 years of age, symptoms are atypical..." Goldman-Cecil also notes providers can avoid testing in children under age 3 due to low rates of streptococcal complications.
- Option C (27-year-old with cough): The presence of cough strongly argues against GAS - it is a hallmark of viral pharyngitis. GAS pharyngitis classically presents WITHOUT cough (this is one of the Centor criteria).
- Option D (52-year-old woman): Adults can get GAS, but it is far less common than in school-age children, and no other features (exudates, lymphadenopathy, absence of cough) are mentioned.
Key teaching point - Centor Criteria for GAS:
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough
- History of fever
Question 31 - Emergent Airway Management
Answer: D - Prepare for emergent airway management
Explanation:
This presentation is classic epiglottitis (now more broadly termed supraglottitis):
- Drooling + stridor + high fever + toxic appearance = imminent airway obstruction
Symptom to Diagnosis (4th ed.) confirms: "Because epiglottitis can rapidly cause airway compromise, the diagnosis should always be considered an airway emergency. The classic presentation is a patient with sore throat, muffled 'hot potato' voice, drooling, and stridor."
Rosen's Emergency Medicine states early consultation with otolaryngology and anesthesia is recommended given the high risk of airway failure, with emergency intubation risk increasing in patients with dyspnea, stridor, drooling, and tachypnea.
Why the other options are wrong/dangerous:
- A - Examining the pharynx: In epiglottitis, direct pharyngeal examination (especially in children) can provoke complete airway obstruction - this is a classic "do NOT do" teaching point.
- B - Throat culture: Wastes precious time when the airway could close at any moment.
- C - AP neck X-ray: While a lateral neck X-ray can show the classic "thumbprint sign" of epiglottitis, sending an unstable, drooling patient to radiology risks losing the airway in an uncontrolled setting.
The priority is airway, airway, airway - get the team ready for immediate intubation or surgical airway.
Question 40 - Most Common Serious Complication of Cirrhosis
Answer: B - Portal Hypertension
Explanation:
Portal hypertension is both the most common serious complication of cirrhosis AND the underlying driver of most other complications. However, this question has a nuance worth noting:
- Ascites is actually the most common single complication of cirrhosis (occurs in ~50% of patients). Current Surgical Therapy states: "Ascites is the most common complication of cirrhosis with approximately 50% of patients developing..." Ascites itself is a consequence of portal hypertension.
- Portal hypertension is the underlying pathophysiologic process that drives varices, ascites, hepatic encephalopathy, and hepatorenal syndrome.
Given the answer choices, B (Portal hypertension) is the best answer because:
- It is the root cause of the most serious downstream complications (variceal bleeding causes mortality)
- It is present in virtually all patients with advanced cirrhosis
- Coagulopathy (A) and hepatic encephalopathy (D), while serious, occur less universally
- Hepatopulmonary syndrome (C) is relatively uncommon (~5-32%)
Hierarchy of complications from portal hypertension:
- Esophageal/gastric varices → variceal bleeding (life-threatening)
- Ascites → spontaneous bacterial peritonitis
- Hepatic encephalopathy
- Hepatorenal syndrome
- Splenomegaly / hypersplenism
Summary Table:
| Q | Answer | Key Concept |
|---|---|---|
| 30 | B | GAS pharyngitis peaks at age 5-15; cough rules out GAS |
| 31 | D | Epiglottitis = airway emergency; never examine throat, never delay |
| 40 | B | Portal hypertension is the central complication of cirrhosis |
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