February 17, 2015 Issue
Clinical Practice Points
Fusobacterium necrophorum may cause peritonsillar abscess and life-threatening internal jugular thrombophlebitis. However, it is not known how commonly this bacillus is seen in patients presenting with symptoms of pharyngitis. This study of patients presenting to a student health clinic with pharyngitis found that F. necrophorum was present more often than was group A β-hemolytic streptococcus. Infection with either bacterium increased with increasing Centor scores.
Use this study to:
- Start a teaching session with a multiple-choice question. We’ve provided one below.
- Review with your learners what history and examination findings are important in patients presenting with symptoms of pharyngitis. Use In the Clinic: Pharyngitis to help prepare to answer questions about the differential diagnosis, whether testing is needed, and appropriate treatment.
- Ask your learners if they know what Lemierre disease is. How does it present? How is it treated?
- Review the Centor score criteria. How is the score used?
- Should the results of this research study raise concern about how we approach the therapy of patients with pharyngitis? Read the accompanying editorial that cautions clinicians to be aware of the various organisms that cause pharyngitis, but not to overcomplicate management.
This study randomly assigned adults with the metabolic syndrome to either a simple high-fiber diet or a more complex diet based on the multicomponent American Heart Association (AHA) dietary guidelines. Although participants assigned to the multicomponent advice lost slightly more weight, participants in both groups lost weight, suggesting that simple dietary advice might be a reasonable option for those unable or unwilling to follow more complex dietary advice.
Use this study to:
- Discuss how to approach weight loss counseling and nutritional advice. What are appropriate weight loss goals? With the numerous diets and fads that exist, how should the conversation be focused? Do the results of this article inform your approach?
- Consider using the Summary for Patients to help have a mock conversation with a patient about the study or simplified approach to dietary counseling.
- Have your team members try to adhere to all 13 components of the AHA diet for the next week. You can find them listed in the introduction and in Appendix Table 2. Then, ask everyone how they did. Did this exercise provide some insight (even empathy?) for your patients who are trying to adhere to a diet and lose weight?
- Invite a specialist in bariatric medicine to join your teaching session. How does he or she help a patient choose an approach to dieting?
Prescriptions of opioid medications for chronic pain have increased dramatically, accompanied by increases in opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness. This systematic review found scant and insufficient evidence that long-term opioid therapy for chronic pain improves function, quality of life, or pain outcomes.
Use this article to:
- Review nonnarcotic pain management therapies for chronic pain. Discuss the potential harms of chronic opioid use that are reported in this review.
- Ask your learners how they respond to requests for chronic opioid therapy? Do they find it affects their relationships with their patients? Ask if they worry that some patients may be receiving opioid medications from other providers as well? Do they ask their patients about this?
- This study found the evidence base for the use of chronic opioid therapy for chronic pain to be insufficient. Ask your learner if the absence of evidence precludes them from using a therapy. Should it? In what ways might a systematic review that concludes we lack sufficient evidence in an area be helpful?
This position paper from the American College of Physicians reviews the current and emerging purposes of clinical documentation, the drivers that may influence or distract from these purposes, and the opportunities and challenges that have arisen from electronic health records.
Use this paper to:
- Discuss with your learners how they feel about documentation requirements. Do they feel pressure to document a certain way? Do they understand the drivers behind some of the requirements, in addition to patient care? Will the position paper help clarify the purpose?
- Do your learners think charting requirements help improve patient care? Do they promote notes that provide useful information to fellow providers caring for patients? Ask your learners what characteristics of notes written by others are helpful? Which are not?
- Discuss with your learners in what ways their documentation habits may affect their income when they are out “in the real world” after their training.
- An editorialist encourages us to think of documentation within EHRs as a tool to improve the quality of care. Do your learners agree?
Laugh with the Consult Guys as they discuss a rhythm gone awry after surgery. Freeze the video when Howard and Geno show you the ECG. Do your learners know what’s wrong? Do they know the possible causes? Answer the short multiple-choice questions at the end as a group. Log on yourself and enter your answers to earn CME credit.
Humanism and Professionalism
In his essay, Dr. Buckley tells us of his experience as a physician caring for patients from correctional facilities.
Use this essay to:
- Listen to an audio recording of the essay, read by Dr. Michael LaCombe.
- Ask your learners if they have provided care to incarcerated patients from local correctional facilities. Did they behave differently than normal when talking to these patients? How?
- How much do we know about the lives of these patients? Dr. Buckley notes that discharge from the unit occurred without warning to the patient, so that he never got to say goodbye. How would that make you feel? He notes also that patients seemed more appreciative of the care they were provided. Does that surprise you?
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 a rapid antigen detection testing
C. Start penicillin therapy
D. No further testing or treatment indicated
B. Perform a rapid antigen detection testing
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 result is positive.
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.
Wessels MR. Clinical practice. Streptococcal pharyngitis. N Engl J Med. 2011;364(7):648-655. PMID: 21323542
This question is derived from MKSAP® 16, 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.