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November 5, 2013 Issue

Clinical Practice Points


Patient Care
Medical Knowledge

Participatory Medicine: A Home Score for Streptococcal Pharyngitis Enabled by Real-Time Biosurveillance. A Cohort Study

This study developed a prediction model that patients with a sore throat could use at home to decide whether they need medical evaluation. Widespread implementation of this new method could reduce unnecessary patient visits to clinicians for management of sore throat.

Use this study to:


Practicing Medicine


Systems Based Practice
Professionalism

Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper

The U.S. health care system is undergoing a shift from individual clinician practice toward team-based care. In this position paper, the ACP presents its position on clinical care teams.

Use this paper to:

  • Ask your residents what is driving the emphasis on health care teams.
  • The ACP outlines several advantages to care teams for both the care of individual patients and public health. Are there potential downsides?
  • Should the physician always be at the “head” of the team? Discuss the argument against this offered by an editorial from the American Association of Nurse Practitioners. Perspectives are also offered by a practicing internist.
  • What do your residents know about “fee-for-service” payments? What incentives and penalties in payment systems are being implemented to encourage the adoption of care team models?

Humanism and Professionalism


Professionalism

Emphasis and Priority

This commentary discusses why many words, particularly racial identifiers, should no longer be used in the opening of a clinical patient presentation.

Use this essay to:

  • Start by presenting a patient who complains of a rash that turns out to be poison ivy. Be sure to use a “racial” identifier (“A 45-year-old black man…”).
  • Ask your residents whether “black” was relevant to the clinical presentation. Why or why not? When might racial, religious, or other identifiers be appropriate? When, if ever, should they be mentioned? In the presentation of the social history? The physical examination?
  • Why might they be useful? Why might they be harmful?
  • Ask your residents if they believe that removal of such language from our introductions will help to “…remedy an inappropriate emphasis on race that has scarred our collective history.”


Medical Knowledge

In the Clinic: Migraine

This concise review is organized around answering key clinical questions that occur when evaluating and treating patients with migraine.

Use this review to:

  • Ask your residents how migraine headache is defined. The International Headache Society’s criteria for diagnosis are provided in the box on page ITC5-3.
  • What does the mnemonic “POUND” stand for, and how is it helpful? Which symptoms and signs should prompt consideration of a more acutely serious cause of headache?
  • Ask your resident to define a medication overuse headache.
  • Download the teaching slides to help you prepare a short talk.
  • Break up your teaching with the multiple-choice questions provided at the end. You can also get CME credit for yourself by logging on and completing the quiz.

mksap16

A 19-year-old man is evaluated for a 2-day history of sore throat, cough, fever, and chills. On physical examination, temperature is 38.9 °C (102.0 °F), blood pressure is 122/82 mm Hg, pulse rate is 88/min, and respiration rate is 14/min. The pharynx is erythematous with tonsillar enlargement and exudates bilaterally. There is no cervical lymphadenopathy.

Which of the following is the most appropriate management?

A. Obtain throat culture and start penicillin therapy
B. Perform rapid antigen detection testing
C. Start penicillin therapy
D. No further testing or treatment indicated

Answer
B. Perform rapid antigen detection testing

Key Point
Use of the four-point Centor criteria is a reasonable way to triage patients with pharyngitis to empiric treatment with antibiotics, symptomatic treatment only, or testing with treatment if the test is positive.

Educational Objective
Manage acute pharyngitis.

This patient should be given a rapid streptococcal antigen test before beginning antibiotic therapy. The patient's primary symptoms (fever, cough, and sore throat) are compatible with either a viral upper respiratory tract infection or streptococcal pharyngitis. The Centor criteria (presence of fever >38.1 °C [100.5 °F], tonsillar exudates, tender cervical lymphadenopathy; absence of cough) predict the likelihood of streptococcal pharyngitis and is a reasonable way to triage patients with pharyngitis to empiric treatment with antibiotics, symptomatic treatment only, or testing with treatment if the test is positive. Patients with all four criteria have a 40% or greater chance of having group A β-hemolytic streptococcal (GABHS) pharyngitis; patients with zero or one criterion have a low (< 3%) probability of GABHS pharyngitis. Patients with two criteria, such as this patient, or three criteria have an intermediate probability of GABHS pharyngitis; for these patients, some guidelines recommend throat culture and others recommend the rapid antigen detection test (RADT) with confirmation of negative results. The advantage of RADT is the immediate availability of the results. RADT has comparable sensitivity and specificity to throat culture. The throat swab for either culture or RADT should be obtained from both tonsils or tonsillar fossae and the posterior pharyngeal wall. In high-risk patients, a negative antigen test should be confirmed by throat culture.

No guidelines recommend antibiotic treatment without further testing. Some recommend treating patients with three or four Centor criteria while test results are pending, although guidelines differ on this point.

Bibliography
Wessels MR. Clinical practice. Streptococcal pharyngitis. N Engl J Med. 2011;364(7):648-655. PMID: 21323542

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.


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