Clinical Problem Solving 12

Clinical Problem Solving 12 PowerPoint PPT Presentation


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Clinical Problem Solving 12

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1. Clinical Problem Solving 12/16/08 Moderator: Stuart Cohen MD Discussant: Carlos Estrada MD

2. Case #1 21 y/o Caucasian Male presents to clinic with 8 day h/o fever and malaise 2 days PTA developed sore throat Denies myalgias, cough, shortness of breath No nausea, vomiting or diarrhea Denies nasal congestion, rhinorrhea Denies headache, stiff neck, visual changes

3. Case #1 No rash, joint pain No dysuria, frequency or urgency No sick contacts No recent travel outside of country or hikes in the woods

4. Case #1 PMH: None MEDS: None Fam Hx: non-contributory Soc Hx: Senior at University of Alabama Tuscaloosa No tobacco or drug use Social alcohol consumption Not sexually active

5. Case #1 PE: 120/60, 70, 12, 100.2 HEENT Erythematous posterior pharynx with cobblestoning, large tonsils with exudate Bilateral anterior cervical and posterior cervical adenopathy (tender) CV: RRR with no M/R/G Lungs: Clear bilaterally, ABD: soft, non-tender, non-distended, No hepatosplenomegaly EXT: No C/C/E Neuro: Non-focal

6. Case #1 Data Rapid Strep: Positive WBC 13.3, HCT 39, Plts 244 18% segs, 50% lymphs, 18% Monos, 8% Atypical lymphs Monospot: Positive EBV VCA IgM: Positive Throat Culture: No growth

7. Mono/Strep both? True co-infection with GAS and EBV is rare but reported in the literature GAS colonization in patients with EBV is more likely (some reports suggest up to 30%)

8. Centor Criteria Tonsillar exudates Tender anterior cervical adenopathy Fever by history Absence of cough 0 or 1 positive ? NPV of 80% 3 or 4 positive ? PPV of 50-60%

9. Diagnostic testing for GAS Rapid Streptococcal Antigen Test (RAST) Sensitivity 80-90% Specificity 90- 95% Throat Culture Sensitivity 90% Specificity 95%

10. Rationale for antibiotics To prevent Rheumatic Fever To prevent peritonsillar abscess To prevent transmission To relieve symptoms For patients with severe pharyngitis, symptoms resolve 2.5 days earlier with antibiotics

11. Antibiotics in patients with EBV Macular-papular pruritic rash which is frequently prolonged Offending Antibiotics Amoxicillin Penacillin Azithromycin Levofloxacin Cephalexin Not reported with Clindamycin Mechanism of rash unknown Rash does not presage true drug allergy

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