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Sore Throat

Sore Throat. Richard Usatine, MD. 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

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Sore Throat

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  1. Sore Throat Richard Usatine, MD

  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

  3. Infectious Causes of Pharyngitis

  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

  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

  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)

  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

  8. Case 1

  9. What is the differential diagnosis in order of likelihood? • Strep • Viral

  10. Sensitivity and Specificity

  11. Positive Predictive Value (PPV) • Changes based on the prevalence in the population • True positives/all positives • Higher prevalence increases the PPV

  12. How well does PE predict strep throat?

  13. How well does history predict strep throat?

  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

  15. Clinical Prediction Rule for Strep Throat

  16. Probability of Strep throat based on points (pretest probability)

  17. How many points does our patient have?

  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

  19. How to swab for rapid strep test or culture.

  20. 3 categories • low probability of GABHS - no test, no treat • intermediate probability - test • high probability - treat, no test

  21. Rapid Strep Test Done • Result for patient in case one: • positive

  22. 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

  23. What symptomatic treatment could you offer the patient? • Acetaminophen • gargling with warm salt water • throat lozenges • fluids, warm or cold, can be soothing

  24. 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

  25. Case 2 mild erythema with cobblestone appearance of posterior pharynx, left tonsillar exudate present

  26. How many points does our patient have?

  27. Rapid Strep Test Done • Result is negative • Symptomatic treatment

  28. 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

  29. Case 3

  30. Scarlet fever • How do we treat this? • What does this have to do with rabbits?

  31. 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

  32. Case 4

  33. How many points does our patient have?

  34. What do you do? • No test • No treat – no antibiotics • Treat symptoms

  35. 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

  36. Case 5

  37. Peritonsillar Abscess

  38. Peritonsillar Abscess

  39. 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

  40. Case 6

  41. Differential Diagnosis • Mononucleosis • Strep Throat • Viral • Consider a CBC and a monospot. • EBV VCA-IgM is more sensitive but more expensive.

  42. 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

  43. Case 7 deep erythema, palatal petechiae and no exudate, tonsillar swelling present

  44. How many points does our patient have?

  45. www.med.sc.edu:85/ fox/strep-thr.jpg

  46. Strep Throat

  47. Candida in aman with AIDS

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