THE USMLE TIMES - #104
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Welcome to issue #104 of The USMLE Times! Welcome to all new members—and welcome back to those returning!
I’m Paul Ciurysek, MD, founder of The USMLE Guys, and this is The USMLE Times. This daily newsletter aims to provide super high-yield USMLE concepts commonly tested on exam day. All content is FREE! If you’d like to work with me and my team, please see the options at the bottom of today’s newsletter. If you’d like to support my efforts, please share the newsletter with a friend.
Here’s what’s on tap for issue #104 of the USMLE Times:
Question of the Week (Digestive Pathology)
This week’s video training (How To Build Step 1 Momentum)
Question deep-dive & breakdown
Let’s dive in!
A 55-year-old male presents to the emergency department with a 4-day history of fever, chest pain, and difficulty swallowing. He reports having undergone a dental procedure 10 days ago. His vital signs are as follows: Heart rate 110/minute, respiratory rate 20/minute, blood pressure 100/70 mmHg, temperature 102.2°F (39°C), and oxygen saturation 95% on room air. Laboratory results reveal elevated white blood cell count and C-reactive protein. A computed tomography scan of the chest is performed, which reveals diffuse soft tissue inflammation and fluid collection in the mediastinal space. Which of the following is the most likely cause of this patient's symptoms?
A) Esophageal perforation due to forceful vomiting
B) Pneumomediastinum secondary to barotrauma
C) Aortic dissection with mediastinal hematoma
D) Descending necrotizing mediastinitis
E) Spontaneous bacterial peritonitis with retroperitoneal extension
The answer & question breakdown is at the bottom of the post 👇🏼
🔗 LINKS TO RECENT POSTS
USMLE Times Issue #103 - READ HERE
USMLE Practice Question #100 - TRY IT HERE
USMLE Practice Question #99 - TRY IT HERE
This week’s recommended video 👇🏼
ANSWER + QUESTION BREAKDOWN
The mental model used to answer this question comes from our detailed test-taking skills masterclass (check it out if you want to elevate your USMLE test-taking skills) Here’s how to think through this question:
Step 1. Read the vignette and get the actual question: “Which of the following is the most likely cause of this patient's symptoms?”
Step 2. Determine if this is a 1st order, 2nd order, or 3rd order question. This is 2nd order: 1st. Figure out what’s happening; 2nd: Identify the most likely cause of the findings.
Step 3. Based on your thoughts from step 2 above, ask yourself: “What’s the most likely underlying cause for these findings?”
Step 4. Look at the answer choices and select the one that matches your thoughts from step 3 above.
** Aim to take this mental model into all of your USMLE practice questions **
GENERAL ANALYSIS
This vignette describes a 55-year-old male who presents with fever, chest pain, and difficulty swallowing following a dental procedure 10 days ago. His vital signs indicate fever (102.2°F), tachycardia (heart rate 110/min), and mildly low blood pressure (100/70 mmHg), suggesting a systemic inflammatory or infectious process. The CT scan of the chest reveals diffuse soft tissue inflammation and fluid collection in the mediastinal space, which is highly concerning for mediastinitis. The question asks for the most likely cause of his symptoms.
Key Clues To Consider:
Recent dental procedure
Fever, chest pain, dysphagia
CT findings of soft tissue inflammation and fluid collection in the mediastinum
ANSWER CHOICES:
CHOICE A: Esophageal perforation due to forceful vomiting
Explanation: Esophageal perforation (e.g., Boerhaave syndrome) can lead to mediastinitis when esophageal contents leak into the mediastinum. This condition typically follows episodes of severe vomiting and presents with chest pain, subcutaneous emphysema, and signs of sepsis. There is no history of vomiting or trauma to suggest esophageal perforation in this patient. Additionally, the recent dental procedure and the absence of pneumomediastinum on imaging make this diagnosis less likely.
CHOICE B: Pneumomediastinum secondary to barotrauma
Explanation: Pneumomediastinum refers to air in the mediastinal space, often due to barotrauma from mechanical ventilation, severe coughing, or trauma. The patient’s symptoms and imaging findings suggest an infectious process rather than air leakage into the mediastinum. Pneumomediastinum typically presents with subcutaneous emphysema and does not involve fluid collections or diffuse soft tissue inflammation—as seen on this patient's CT scan.
CHOICE C: Aortic dissection with mediastinal hematoma
Explanation: Aortic dissection can cause chest pain radiating to the back and may result in a mediastinal hematoma visible on imaging. It is a life-threatening condition that requires immediate intervention. The patient’s presentation is more consistent with an infectious process rather than a vascular emergency like aortic dissection. Additionally, there is no mention of tearing chest pain or pulse deficits that would suggest dissection.
CHOICE D: Descending necrotizing mediastinitis
Explanation: Descending necrotizing mediastinitis (DNM) is a rare but life-threatening infection that spreads from odontogenic or pharyngeal infections into the mediastinum. It often follows dental procedures or infections in the head and neck region. The infection can rapidly progress through fascial planes into the mediastinum, causing severe inflammation, abscess formation, and sepsis. This patient’s history of a recent dental procedure, along with fever, chest pain, dysphagia, and CT findings of diffuse soft tissue inflammation and fluid collection in the mediastinal space, are classic for DNM.
CHOICE E: Spontaneous bacterial peritonitis with retroperitoneal extension
Explanation: Spontaneous bacterial peritonitis (SBP) occurs in patients with cirrhosis and ascites when bacteria infect the peritoneal fluid. It can lead to systemic sepsis but does not typically extend into the retroperitoneum or mediastinum. This patient has no history of liver disease or ascites, making SBP unlikely. Additionally, SBP does not explain his recent dental procedure or CT findings of mediastinal involvement.
THE VERDICT…
Descending necrotizing mediastinitis (DNM) is a severe infection that spreads from odontogenic or pharyngeal infections into the mediastinum through fascial planes. It often follows dental procedures or infections in the head and neck region and is associated with high mortality if not diagnosed early.
This patient’s recent dental procedure (a common precipitant), fever, chest pain, dysphagia, elevated inflammatory markers (WBC count and CRP), and CT findings of soft tissue inflammation and fluid collection all point towards DNM as the most likely diagnosis.DNM requires prompt surgical drainage and broad-spectrum antibiotics due to its fulminant course
Correct answer: D) Descending necrotizing mediastinitis
That’s it for issue #104 of The USMLE Times!
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