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Slide 1 - Sore Throat Richard Usatine, MD
Slide 2 - What are causes of sore throats? Infectious - viral, bacterial, mycoplasma, chlamydiae, candida Allergic - allergic rhinitis Acid Reflux - GERD Trauma – e.g., swallowing a chicken bone Chemical irritants or burns Epiglottitis Thyroiditis Retropharyngeal abscess
Slide 3 - Infectious Causes of Pharyngitis
Slide 4 - Strep throat versus viral pharyngitis ask about: fever, pain on swallowing physical exam: throat - exudate, palatal petechiae, injection, swelling neck - tender anterior cervical adenopathy children - strawberry tongue, sand paper rash
Slide 5 - Why do we want to diagnose and treat GABHS? to prevent rheumatic fever: less than 200 cases of acute rheumatic fever per year in the US to prevent suppurative complications (e.g., peritonsillar abscess) to speed up recovery and shorten duration: treatment with antibiotics (only if started early in the clinical course) speeds symptomatic recovery of patients with culture-proven GABHS by about a half day to reduce spread to others
Slide 6 - Downside of using antibiotics Promotes antibiotic resistance Adverse reactions such as allergy and anaphylaxis Costly compared to health education Patients do not need antibiotics to feel satisfied with the doctor-patient encounter (Hamm)
Slide 7 - Case 1 A 25 year old man comes to your office with the complaint of a bad sore throat for 2 days. He has felt chills and fever today but has not measured his temperature. He has some pain on swallowing. He has a slight runny nose and denies cough and other symptoms. He was previously healthy. T= 38.5 PE: ears - TM's normal nose – clear neck - no cervical adenopathy lungs – clear
Slide 8 - Case 1
Slide 9 - What is the differential diagnosis in order of likelihood? Strep Viral
Slide 10 - Sensitivity and Specificity
Slide 11 - Positive Predictive Value (PPV) Changes based on the prevalence in the population True positives/all positives Higher prevalence increases the PPV
Slide 12 - How well does PE predict strep throat?
Slide 13 - How well does history predict strep throat?
Slide 14 - History and Physical No individual item has sufficient predictive value on its own Need to combine items to get greater predictive value Purpose of a clinical decision rule
Slide 15 - Clinical Prediction Rule for Strep Throat
Slide 16 - Probability of Strep throat based on points (pretest probability)
Slide 17 - How many points does our patient have?
Slide 18 - What are the tests? Rapid strep test Done in minutes in the office Throat culture Gold standard – how can you get false negatives or positives? ASO titer – not useful for practicing medicine
Slide 19 - How to swab for rapid strep test or culture.
Slide 20 - ppt slide no 20 content not found
Slide 21 - 3 categories low probability of GABHS - no test, no treat intermediate probability - test high probability - treat, no test
Slide 22 - Rapid Strep Test Done Result for patient in case one: positive
Slide 23 - Antibiotic treatment PenVK 500 mg tid x 10 #30 Studies indicate increased failure rates of preventing acute rheumatic fever of 2 times with treatment of 7 days and 3 times with treatment of 5 days. Erythromycin or Azithromycin for patients allergic to penicillin
Slide 24 - What symptomatic treatment could you offer the patient? Acetaminophen gargling with warm salt water throat lozenges fluids, warm or cold, can be soothing
Slide 25 - Case 2 A 30 year old man comes to your office with a scratchy throat and a headache for one day. His nose is slightly stuffy and he has a non-productive cough. He denies allergies and fever. He smokes 1 ppd. VS : T= 37.1 PE: ears - TM's normal nose – clear mucus and boggy mucosa face - no sinus tenderness neck - tender adenopathy
Slide 26 - Case 2 mild erythema with cobblestone appearance of posterior pharynx, left tonsillar exudate present
Slide 27 - How many points does our patient have?
Slide 28 - Rapid Strep Test Done Result is negative Symptomatic treatment
Slide 29 - Case 3 A 6 year old girl is brought to your office with low grade fever, sore throat, and poor appetite for 3 days. Father states that she does not have cough or runny nose. No vomiting or diarrhea. She is allergic to Penicillin. PE : T = 38.2 P 110 ears - TM's normal nose - clear throat - tonsils - beefy red and almost touching in midline. Uvula in midline, no exudate, no petechiae neck - enlarged tender anterior cervical nodes lungs – clear skin - sandpaper rash prominent around axilla
Slide 30 - Case 3
Slide 31 - Scarlet fever How do we treat this? What does this have to do with rabbits?
Slide 32 - Case 4 A 19 year old woman comes to your office with 2 days of sore throat, cough, and runny nose. Patient feels feverish but has not taken her temperature. She has no other symptoms and no history of other medical problems. The patient very much wants penicillin. T = 37.4 P 80 ears - TM's normal nose - boggy red mucosa with clear mucus neck - shotty nodes lungs - clear
Slide 33 - Case 4
Slide 34 - How many points does our patient have?
Slide 35 - What do you do? No test No treat – no antibiotics Treat symptoms
Slide 36 - Case 5 A 25 year old woman comes to your office with a severe sore throat for 4 days and has difficulty swallowing. She now feels very hot and has been off work for 2 days. Her neck also hurts. She denies cough and rhinitis. No known allergies. Patient appears to be in moderate distress but she is able to breath comfortably. T = 39.5 ears - normal nose - clear throat - it is difficult for the patient to open her mouth because of pain neck - bilateral anterior cervical adenopathy with right worse than left
Slide 37 - Case 5
Slide 38 - ppt slide no 38 content not found
Slide 39 - Peritonsillar Abscess
Slide 40 - Peritonsillar Abscess
Slide 41 - Case 6 A 16 year old girl is brought to your office by her mom for a fever and sore throat. She complains that it hurts to swallow and she has swollen glands. A friend was diagnosed with "mono" 3 weeks ago. Patient has no known history of mono. Patient denies cough and runny nose. Her temperature last night was 103 degrees F (oral). T = 39 100/65 P 100 neck - bilateral enlarged tender anterior cervical nodes and smaller posterior cervical adenopathy lymph nodes – axillary adenopathy lungs - clear abd - no splenomegaly
Slide 42 - Case 6
Slide 43 - Differential Diagnosis Mononucleosis Strep Throat Viral Consider a CBC and a monospot. EBV VCA-IgM is more sensitive but more expensive.
Slide 44 - Case 7 A 41 year old man comes to your office with a painful throat and a headache for one day. No cough. T = 38.1 BP 150/90 P 70 ears - TM's normal nose - clear neck - right anterior cervical node is tender and enlarged lungs - clear
Slide 45 - Case 7 deep erythema, palatal petechiae and no exudate, tonsillar swelling present
Slide 46 - How many points does our patient have?
Slide 47 - www.med.sc.edu:85/ fox/strep-thr.jpg
Slide 48 - ppt slide no 48 content not found
Slide 49 - Strep Throat
Slide 50 - Candida in a man with AIDS
Slide 51 - Viral
Slide 52 - Herpangina
Slide 53 - Coxsackie A16 Virus www.netwave.or.jp/~jibika/ herpangina.jpg
Slide 54 - ppt slide no 54 content not found
Slide 55 - Summary Use of clinical prediction rule to diagnose sore throat (useful in other diseases) Clinical prediction rule helps to establish pretest probability and put patient in one of three categories No test, no treat Test and treat based on result No test, just treat Use antibiotics for sore throat when probability of strep throat is above your treatment threshold
Slide 56 - Photographs by: Richard Usatine, MD for slides 4, 12 and 14 Hospital Practice Web sites icarus.med.utoronto.ca/carr/manual/pta.html Atlas of Infectious Diseases
Slide 57 - Useful web sites: MedRules has the pharyngitis prediction rule: http://www.palmgear.com/index.cfm?fuseaction=software.showsoftware&prodid=10959 Or get it at Ectopic Brain, a great site for other PDA software: http://pbrain.hypermart.net/