Nursing Program Aquifer

Internal Medicine 15: 50- year-old male with cough and nasal congestion

Author/Editor:Author/Editor: Jennifer Bierman, MD

INTRODUCTION HISTORY

You speak with Dr. Griffin about Mr. Taleb.You speak with Dr. Griffin about Mr. Taleb.

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It is September and you are working with Dr. Erin Griffin in her outpatient general medicine clinic. She asks you to see Mr. Fadil Taleb, a 50-year-old male with respiratory symptoms. Dr. Griffin tells you he is relatively new to the practice and has been seen only once in the past for a general physical.

HISTORY HISTORY

You begin to take a history from Mr. Taleb.You begin to take a history from Mr. Taleb.

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You enter the room and introduce yourself. You then begin taking a history.

“What brings you to the oGce today”What brings you to the oGce today?”

“I have been sick for the past three or four days. It started with my throat being scratchy and lots of sneezing. Now my nose is all stopped up, and I’m blowing it constantly. I’m also coughing a lot.”

“Have you had a fever?””Have you had a fever?”

“I felt warm the first day but now I just have the chills occasionally. I am also really tired.”

The best options are indicated below. Your selections are indicated by the shaded boxes.

“Is anyone else you know ill?””Is anyone else you know ill?”

“My kids were sick at the end of last week. One of them is still coughing but the others seem better. My kids are in school right now, and during the school year it seems like one of them picks up something at school almost every other week. I ride the bus to and from work, and there are always people coughing there.”

“Do you smoke?””Do you smoke?”

“Yeah, doc, I know it’s not good for my health, but I do smoke. Usually it’s about a half pack per day, but since I have been sick, I have been smoking only one or two cigarettes a day.”

Question What risk factors does the patient have for an upper respiratory infection (URI)? Select all that apply.

A. Exposure to sick contacts, especially children in the

home

B. Cigarette smoking

C. Season

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Answer Comment > The correct answers are A, B, C> The correct answers are A, B, C

Risk Factors for Upper Respiratory Infection Adults with children in their homesAdults with children in their homes have more frequent URIs (colds). American adults average two to four colds per year while children average six to eight. Crowded conditions predispose

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patients to infection; thus, the incidence of colds is higher in those who spend time in schools.

Studies have shown that cigarette smokecigarette smoke causes structural changes in the respiratory tract and diminishes the immune response to both bacterial and viral respiratory infections. Also, smokers have more severe symptoms when they have an URI.

There is a seasonal incidence of viral URIseasonal incidence of viral URI correlating with colder months in temperate areas. They begin in early fall and continue through the spring. Humidity probably plays a role with virus survival.

Nursing Program Aquifer Internal Medicine – References

Archavi L, Benowitz NL. Cigarette Smoking and Infection. Arch Intern Med. 2004;164:2206-2216.

Gwaltney JM. “The Common Cold.” Principles and Practices of Infectious Diseases. 6th ed. St. Louis, MO: Churchill Livingston; 2005.

ROS AND CHART REVIEW HISTORY

You continue your history with Mr. Taleb.You continue your history with Mr. Taleb.

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“Tell me more about your cough. Do you bring anything up?”

“No, it’s a dry cough, but it wakes me up at night several times.”

“Do you feel short of breath?”

“No, not really.”

“Does your chest hurt?”

“No. Can’t say that it does.”

“Have you tried any medicine to help?”

“My face has felt full, so I took some Actifed Cold and Allergy tablets, but they didn’t seem to do much. I’ve also taken some Cold-EEZE, vitamin C, and Waltussin DM, but nothing is helping.”

“Have you had problems like this before?”

“I had this same thing last fall and it lasted a couple of weeks. I hate to bother you doctors with this, but I don’t want to get any worse.”

You review Mr. Taleb’s chart and confirm the following:

Past Medical History:Past Medical History:

Hyperlipidemia (6 months ago)

Lab Values:Lab Values: Conventional:Conventional: SI:SI:

Total cholesterol 220 mg/dL 5.70 mmol/L

HDL 41 mg/dL 1.06 mmol/L

LDL 145 mg/dL 3.76 mmol/L

Medications:Medications:

None except over-the-counter medications Actifed Cold and Allergy (phenylephrine and chlorpheniramine) Cold-EEZE (zinc gluconate) Vitamin C Waltussin DM (guaifenesin and dextromethorphan).

AllergiesAllergies:

None

Family History:Family History:

Mother: Alive and well. Father: High cholesterol, HTN. Paternal uncle: Coronary artery disease, hx of MI. Three sisters: Well.

Social History:Social History:

Married and monogamous. Works as a computer specialist for the help desk at the hospital. Three children ages 12, 15, and 18 years old. Has smoked half pack per day for the past 25 years. Quit with each of his wife’s pregnancies, then resumed a year or so later. He rarely drinks alcohol and has never used IV drugs.

Review of Systems:Review of Systems:

No headache, myalgias, hemoptysis, weight loss, or night sweats.

See the associated reference ranges in conventional and SI units.

Nursing Program Aquifer Internal Medicine – SUMMARY STATEMENT CLINICAL REASONING

Question Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.

Guidelines for summary statements.Guidel ines for summary statements.

Your response is recorded in your student case report.

Letter Count: 0/1000

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Answer Comment Mr. Taleb is a 50-year-old male with a history of tobacco use who has a several day history of sore throat, nasal congestion, and non- productive cough which awakens him at night. He denies chest pain, myalgias, hemoptysis, weight loss or dyspnea.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 50-year-old male with a history of tobacco use. 2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

rhinitis sore throat non-productive cough present at night lack of chest pain, myalgias, weight loss, hemoptysis or dyspnea.

The best options are indicated below. Your selections are indicated by the shaded boxes.

Nursing Program Aquifer Internal Medicine – DIFFERENTIAL DIAGNOSIS 1 CLINICAL REASONING

Question Based on Mr. Taleb’s history, which of the following are the top threethree diagnoses on your differential? Select all that apply.

A. Allergic rhinitis

B. Acute bacterial sinusitis

C. Acute bronchitis

D. Asthma

E. Bacterial pneumonia

F. Influenza

G. Strep pharyngitis

H. Tuberculosis

I. Viral upper respiratory infection

J. Infectious mononucleosis

K. Pertussis

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Answer Comment > The correct answers are A, C, I> The correct answers are A, C, I

Most Likely / Important DiagnosesMost Likely / Important Diagnoses

The following are the most likely / important diagnoses at this point:

allergic rhinitis (A)allergic rhinitis (A) acute bronchitis (C)acute bronchitis (C) viral upper respiratory infection (URI) (I)viral upper respiratory infection (URI) (I)

DiUerential of Acute Respiratory Symptoms in Middle- Aged Male with Tobacco History The following diagnoses are less likely:The following diagnoses are less likely:

Acute bacterial sinusitisAcute bacterial sinusitis

Occurs when an initial viral nasopharyngeal infection spreads to become a secondary bacterial infection of the paranasal sinuses.

Viral rhinosinusitis is diagnosed when symptoms or signs of acute rhinosinusitis (nasal congestion, facial pain/pressure, purulent nasal discharge) are present less than 10 days, and the symptoms are not worsening.

Acute bacterial rhinosinusitis (ABRS) should be diagnosed when symptoms or signs of acute rhinosinusitis fail to improve within 10 days or when symptoms or signs worsen within 10 days after an initial improvement (double worsening).

AsthmaAsthma

Often presents with a chronic, nocturnal cough — or cough, dyspnea, and/or wheezing associated with exertion.

Symptoms do not include rhinorrhea, sore throat, sneezing, and chills — these are suggestive of an infectious etiology rather than asthma.

Bacterial pneumoniaBacterial pneumonia

Characterized by persistent fever, cough with purulent sputum, dyspnea, and often pleuritic chest pain.

Require symptoms present long enough to suggest a secondary bacterial infection such as pneumonia.

InfluenzaInfluenza

Characterized by upper and lower respiratory tract symptoms accompanied by systemic symptoms. High fever of 102 to 104 F and chills are very common, along with severe myalgias and headache.

Stuffy and runny nose can be present in influenza, but are more

characteristic of the common cold. Onset is so abrupt that patients can often identify the precise

time their symptoms began. Outbreaks typically occur during winter months.

Streptococcal pharyngitisStreptococcal pharyngitis

Typically presents with abrupt onset of sore throat, painful swallowing, and fever. Cough, nasal congestion, and rhinorrhea coryza are uncharacteristic.

TuberculosisTuberculosis

Chronic illness with weight loss, night sweats, or hemoptysis. Inquiry about travel to developing countries, exposure to TB, and

HIV risk factors would be indicated if TB was a serious consideration.

Infectious mononucleosisInfectious mononucleosis

Characterized by sore throat, fatigue, and lymphadenopathy. Cough is not a typical feature.

Pertussis (whooping cough)Pertussis (whooping cough)

Had been uncommon in the U.S. due to near universal vaccination. However, in the past few years the incidence has increased, and outbreaks in schools have occurred in many states. This is likely due to decreasing use of vaccination, waning immunity in those previously vaccinated, or just better testing and reporting.

The Centers for Disease Control (CDC) recommends that all adults receive a one-time booster, which is accomplished with a Tdap vaccine. Adolescents are also receiving an additional booster.

Pertussis has three phases:

1. catarrhal – seven to ten days of symptoms indistinguishable from a URI, with rhinorrhea, malaise, low-grade fever, and mild cough 2. paroxysmal – one to six weeks of paroxysms of rapid coughing associated with a high-pitched whoop that is frequent and often worse at night; this whoop is not common in adults 3. convalescent – one to three weeks of lessening cough

The catarrhal phase is unlikely without a known exposure.

Nursing Program Aquifer Internal Medicine – References

Fauci A, Braunwald E, Kasper D, et al. Harrison’s Principles of Internal Medicine, Part Eight. Disorders of the Respiratory System. New York, NY: McGraw-Hill Inc.; 2008.

Rosenfeld RM, Piccirillo JF, Chandrasehkar, SS, et al. Clinical Practice Guideline: Adult Sinusitis. Otolaryngol Head Neck Surg. April 2015; 152(S2):s1-s39

DIFFERENTIAL DIAGNOSIS 2 CLINICAL REASONING At this point, URIURI, allergic rhinitisallergic rhinitis, and acute bronchitisacute bronchitis seem to be the most likely diagnoses. You are anxious to gather more information from Mr. Taleb.

DiUerential of Acute Respiratory Symptoms in Middle-Aged Male with Smoking History

Viral URIViral URI Sore throatSore throat is often the first symptom. SneezingSneezing and stuffy nosestuffy nose are classic symptoms, particularly in its first stage.

AllergicAllergic rhinitisrhinitis

The cardinal symptom is the seasonal occurrenceseasonal occurrence of sneezing, watery rhinorrhea, nasalof sneezing, watery rhinorrhea, nasal congestion, and itchy, watery eyescongestion, and itchy, watery eyes. Causes symptoms that last for weekslast for weeks during exposure to environmental allergens; thus, a short duration of symptoms would argue against this diagnosis. Fever is not common, and if present argues against this diagnosis.

A self-limited inflammation of the large airways in the lung which is characterized by coughcough. It leads to excessive tracheobronchial mucus production

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AcuteAcute bronchitisbronchitis

sufficient to cause purulent sputumpurulent sputum in half of patients. The cause is usually viral, but it can leadbut it can lead to a secondary bacterial infection.to a secondary bacterial infection. Symptoms during the first few days are hard to distinguish from those of a URI. However, the cough of acute bronchitis persists for more than fivepersists for more than five daysdays.

PHYSICAL EXAM PHYSICAL EXAM

You listen to Mr. Taleb’s breath sounds.You listen to Mr. Taleb’s breath sounds.

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You proceed with the physical examination. During your examination, you note the following:

Vital signs:Vital signs:

Temperature:Temperature: 37.2 C (98.9 F) Pulse:Pulse: 76 beats/minute Respiratory rate:Respiratory rate: 14 breaths/minute Blood pressure:Blood pressure: 125/76 mmHg Weight:Weight: 91 kg (200 lbs)

Height:Height: 178 cm (70 in) Body Mass Index:Body Mass Index: 28.7 kg/m2

General:General: Well developed, well nourished male. No acute distress.

Eyes:Eyes: Clear conjunctiva, no discharge, anicteric sclera.

Ears:Ears: Canals are clear. TMs are clear. No redness or bulging.

Nose:Nose: No maxillary or frontal sinus tenderness on palpation. No dullness on transillumination.

Throat:Throat: Slightly reddened posterior pharynx but no exudates or tonsillar enlargement. There is no cobblestoning.

Neck:Neck: No cervical or supraclavicular lymphadenopathy.

Chest:Chest: Good excursion. No dullness to percussion. Rhonchi throughout all lung fields. There are no wheezes or crackles.

CV:CV: RRR normal S1 and S2. No murmurs, rubs, or gallops.

Skin:Skin: Yellow nicotine stains on right ring and middle finger.

Acute Respiratory Physical Exam Findings CobblestoningCobblestoning

Postnasal drip is manifested by symptoms of the sensation of dripping down the back of the throat and frequent throat clearing. On examination you may see a reddened pharynx, discharge, and sometimes a “cobblestone road” appearance of the posterior pharynx. This is due to swollen lymphoid tissue.

RhonchiRhonchi

Low-pitched, continuous sounds often described as similar to a snoring sound. Generated by narrowing of larger airways due to mucus from bronchitis or narrowing from asthma or COPD.

WheezesWheezes

High-pitched whistling sound during breathing when air flows through a

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The best option is indicated below. Your selections are indicated by the shaded boxes.

narrowed airway, most commonly heard in asthmatics and patients with acute bronchospasm.

CracklesCrackles

Synonymous with rales. A discontinuous sound heard more often during inhalation caused by airway opening. The sounds are often divided into dry or moist, with the dryness being caused by disease processes such as fibrosis and the moistness or wetness being secondary to heart failure or pneumonia.

Question Based on your clinical suspicion, which one physical exam maneuver would be most helpful to further evaluate the current findings? Choose the single best answer.

A. Feel for vibrations along the posterior chest while

patient is saying ninety-nine.

B. Auscultate while patient is saying eeeee.

C. Ask the patient to cough and repeat the auscultation.

D. Listen at bases while patient in the lateral decubitus

position.

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Answer Comment > The correct answer is C> The correct answer is C

Feeling for vibrations along the posterior chest while the patient is saying “ninety-nine” is an example of testing for tactile fremitustactile fremitus. Tactile fremitus is increased over areas of consolidation (as in lobar pneumonia) and decreased over a pneumothorax. Increased fremitus in a consolidated lung occurs because sound waves travel faster through liquid (the consolidation) than through air. Decreased fremitus occurs in the setting of a pneumothorax because the air is a barrier to the sound waves.

Auscultating while the patient says “eeee” (like the letter E) is an example of egophonyegophony. If lung consolidation is present, the high- frequency noises are preferentially transmitted across the abnormal lung tissue, causing the observer to hear an “aaaa” (like the letter A) through the chest. This is also known as “e to a changes.”

Listening to the bases while the patient is in a lateral decubitus position could potentially identify pleural effusions, but this procedure has low sensitivity and specificity and is not a common physical exam maneuver.

PHYSICAL EXAM QUESTION TEACHING

” DEEP DIVEDEEP DIVE

The best option is indicated below. Your selections are indicated by the shaded boxes.

You perform a nasal exam on Mr. Taleb.You perform a nasal exam on Mr. Taleb.

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Dr. Griffin joins you to review what you have covered with Mr. Taleb up to this point. She asks what you found on the nasal examination. You confess you didn’t look up his nose, but will now.

You examine Mr. Taleb’s nose and find clear discharge with slight erythema of the nasal mucosa.

Question Which findings on a nasal examination are most consistent with bacterial sinusitis? Choose the single best answer.

A. Mucosal edema, erythema, and purulent nasal

discharge.

B. Mild mucosal edema that is shiny or glassy-appearing,

and clear nasal discharge.

C. Mild mucosal edema that is pale or bluish in color. Clear

nasal discharge.

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Answer Comment > The correct answer is A> The correct answer is A

Nasal Examination Findings and Associated Conditions

Purulent discharge in addition to mucosal edema and erythema

Bacterial sinusitis

Mucosa is either normal or mildly edematous and shiny or glassy-appearing, clear nasal discharge

Viral URI

Mild mucosal edema that is boggy and pale or bluish in color as well as clear nasal discharge

Allergic rhinitis

Remember that not all that is green is bacterial. When a patient describes yellow-green discharge, this may be caused by either a virus or bacteria.

RESPIRATORY PATHOGENS TEACHING

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Dr. Griffin asks you about treatment.Dr. Griffin asks you about treatment.

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You tell Dr. Griffin, “I think Mr. Taleb has a viral upper respiratory infection. He does not have a fever, productive cough, or signs of consolidation – ruling out pneumonia. His throat is not very red, and there are no exudates, so I don’t think it is strep throat. Since he does not have purulent nasal discharge, sinus tenderness or tooth pain, sinus infection is unlikely. His rhonchi support the possibility of early viral bronchitis, but it is too early in his illness to say for sure. Given the constellation of nasal congestion, scratchy throat, and cough with a benign physical, I think a viral URI is the most likely diagnosis.”

Dr. Griffin says, “I agree with you that Mr. Taleb is suffering from the common cold. How do you think we should treat him?”

At this point, Mr. Taleb interjects, “A Z-Pack has worked for me in the past.”

Question Before answering, you need to consider possible pathogens. What are the most common pathogens for the common cold? Select all that apply.

A. Streptococcus pneumoniae

B. Influenza

C. Rhinovirus

D. Corona viruses

E. Mycoplasma pneumoniae

F. RSV

G. Metapneumovirus

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Answer Comment > The correct answers are B, C, D, F, G> The correct answers are B, C, D, F, G

Rhinovirus 30-50%

Corona viruses 10-15%

Parainfluenza virus 5%

Respiratory syncytial virus (RSV) 5%

Influenza virus 25-30%

Adenoviruses 5-10%

Others: enteroviruses, human metapneumovirus

< 1%

References

Gwaltney JM. “The Common Cold.” Principles and Practices of Infectious Diseases. 6th ed. (St. Louis, MO: Churchill Livingston, 2005).

TREATING THE URI THERAPEUTICS With some help from Dr. Griffin, you explain to Mr. Taleb that you believe he has a common cold. You go on to explain that colds are caused by viruses and not bacteria and that antibiotics treat bacterial infections only. You end by telling him that viral infections are self-limited, and treatment is supportive. You discuss how to prevent spreading the cold and and inform Mr. Taleb when he can expect to feel better. You then ask if he has any questions.

“Are you sure it is not the Zu? Should I get a Zu shot?””Are you sure it is not the Zu? Should I get a Zu shot?”

“My last doctor always gave me antibiotics. Are you sure I don’t”My last doctor always gave me antibiotics. Are you sure I don’t need them?”need them?”

You give Mr. Taleb a patient handout about colds and antibioticspatient handout about colds and antibiotics that he

The best options are indicated below. Your selections are indicated by the shaded boxes.

can look over at home.

URI Prevention and Duration PreventionPrevention

Respiratory viruses are spread from person to person by droplets from coughing or sneezing. Prevent spreading the cold by frequent hand-washing and using a tissue to block sneezes or coughs.

DurationDuration

Most commonly cold symptoms last seven to ten days, however 25% can last up to two weeks. In smokers, the symptoms can be more severe and can last longer.

Question What are the best initial options to treat acute bacterial sinusitis? Select all that apply.

A. Cefuroxime

B. Amoxicillin

C. Azithromycin

D. Trimethoprim-sulfamethoxazole

E. Amoxicillin-clavulanic acid

F. Doxycycline

G. No antibiotics

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Answer Comment

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> The correct answers are E, F, G> The correct answers are E, F, G

Treatment of Acute Bacterial Sinusitis Although Streptococcus pneumoniae and Haemophilus influenzae are the most common organisms in bacterial sinusitis and can be treated with antibiotics, avoiding antibiotics is indeed an option. Many cases resolve on their own and a recent study showed that antibiotics may not shorten the duration of acute bacterial sinusitis.

If antibiotics are prescribed, amoxicillin clavulanate is first line given increased resistance of H. Influenzae and S. Pneumoniae to amoxicillin alone. Doxycycline or respiratory quinolones (levofloxacin and moxifloxacin) are suggested for patients who are penicillin allergic.

For a discussion on treatment of acute bacterial sinusitis, see the Infectious Disease Society of America guideline (.pdf).

Trimethroprim-sulfamethoxazole is no longer recommended given high rates of H. Influenzae resistance to trimethoprim- sulfamethoxazole.

Streptococcus pneumoniae has increasing resistance to macrolides, such as azithromycin or erythromycin, so their use should be minimized.

​Treatment of Chronic Bacterial Sinusitis Chronic sinusitis is defined as symptoms lasting longer than 12 weeks. Chronic sinusitis is often polymicrobial, with anaerobes in addition to aerobes. Thus, broader-spectrum antibiotics, such as cefuroxime, quinolones or amoxicillin-clavulanic acid, should be employed with the duration of therapy for three to six weeks.

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The best option is indicated below. Your selections are indicated by the shaded boxes.

E. CBC with differential

F. Monospot or heterophile antibody

G. None

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Answer Comment > The correct answer is G> The correct answer is G

With Mr. Taleb’s clinical picture, no further studies areWith Mr. Taleb’s clinical picture, no further studies are necessary at this time (G).necessary at this time (G).

Diagnostic Workup of Viral URI None of the following are appropriate in the diagnosticNone of the following are appropriate in the diagnostic workup of viral URI.workup of viral URI.

Chest x-ray

A chest x-ray is necessary to diagnose pneumonia and would be a reasonable test to perform if the lung exam showed rales or signs of consolidation, or for an ill- appearing patient with fever, tachypnea, or hypoxemia. It is also indicated for patients with chronic cough, i.e., a cough that has lasted longer than six to eight weeks. A chest x-ray is not routinely obtained in smokers. The U.S. Preventive Services Task Force (USPSTF) and The American Lung Association both recommend lung cancer screening with low dose CT scans (not chest x-rays) for current or former smokers 55 years or older with a 30 pack- year smoking history. Learn more about lung cancer screening here:

1. NCBI article about lung cancer mortality with low dose CT screening

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2. American Lung Association: Guidance on CT lung cancer

Rapid strep test

Rapid strep test is used clinically to detect Group A Streptococcus, which causes almost all bacterial pharyngitis. The newest rapid antigen detection tests have good sensitivity (80-90%) and specificity (95%). However, most pharyngitis is viral, with rhinoviruses being the most common. The classic clinical picture of strep throat is fever, sore throat, and absence of nasal congestion or cough along with pharyngeal erythema and exudates and tender cervical adenopathy. A rapid strep test is not necessary in the absence of these symtpoms.

Throat culture

Throat culture is the gold standard for strep throat, but a result can take two to three days. Should not be performed without the typical findings for streptococcal pharyngitis.

Sinus CT

Radiological studies do not differentiate bacterial sinusitis from viral sinusitis. More than 80% of viral rhinosinusitis can have abnormalities on CT or plain films. Thus, a sinus CT is not a helpful test.

CBC with differential

Results are typically normal in patients with viral URIs, including sinusitis. Although the white blood cell count can be elevated in patients with influenza, pneumonia, and bacterial pharyngitis, it will not differentiate between them. Results of a CBC won’t be available immediately and won’t change management. This test will only increase the cost of care, not the quality.

Monospot or heterophile antibody test

Monospot or heterophile antibody test is done if infectious mononucleosis (IM) is considered. IM is rare in older adults, more common in teens and young adults. The typical symptoms include fever, sore throat, and fatigue. Cervical lymphadenopathy is usually prominent on physical examination.

VIRAL VS. BACTERIAL PHARYNGITIS TESTING You explain to Mr. Taleb why he does not need an x-ray or a throat swab.

Most pharyngitis is viral, with rhinoviruses being the most common etiology. Only 5-15% of cases of pharyngitis are bacterial, with Group A streptococcus causing almost all bacterial pharyngitis.

Although streptococcal pharyngitis is usually self-limited, treatment with antibiotics is indicated to prevent acute rheumatic fever, reduce person-to- person transmission, and decrease the incidence of local complications, such as peritonsillar and retropharyngeal abscesses.

Post-streptococcal glomerulonephritis is an uncommon complication of strep throat; there is no evidence that antibiotic treatment prevents it.

Decision Tools for Evaluation/Treatment of Strep Throat Predictive rules have been developed that can be helpful in determining which patients should undergo a rapid strep test. The most commonly used of these rules, the Modified Centor Criteria, has a good negative predictive value, but a relatively poor positive predictive value. Thus it is useful in figuring out which patients likely do not have strep pharyngitis and therefore do not need further testing. This test should not be used to make a diagnosis

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of strep pharyngitis in the absence of testing for strep.

Criteria: Modified CentorCriteria: Modified Centor (also called McIsaac Score)

Give one point for each positive response:

Tonsillar exudate or erythema Anterior cervical adenopathy Cough absent Fever present:

Age 3 to 14 years: +1 point Age 15 to 45 years: 0 points Age over 45 years: -1 point

Standard practice has been to collect a rapid strep test in all children with a Modified Centor score of 2 or more. Recently, the American College of Physicians made a new recommendation for adults saying that rapid strep testing should be reserved only for patients with a Modified Centor score of 3 or more. This reflects the lower prevalence of strep among adults with sore throat, compared to children.

Approach: ClinicalApproach: Clinical suspicion basedsuspicion based on Modifiedon Modified Centor scoringCentor scoring

Children Adults

Score of 3-5 Perform Rapid Antigen Test

Perform Rapid Antigen Test

Score of 2 Perform Rapid Antigen Test

Symptomatic treatment without testing

… Rapid antigen test Positive

Treat with antibiotics

Treat with antibiotics

… Rapid antigen test Negative

Perform confirmatory strep culture, and treat if positive

Symptomatic treatment without further testing (unless high risk such as immunocompromised)

The best options are indicated below. Your selections are indicated by

Score of 0 or 1 Symptomatic treatment without testing

Symptomatic treatment without testing

Antimicrobial therapy should be used only when Group A strep is highly likely. Penicillin is the treatment of choice; erythromycin is an alternative when patients are allergic to penicillin.

SYMPTOMATIC TREATMENT THERAPEUTICS

Mr. Taleb asks you what he can do to feel better.Mr. Taleb asks you what he can do to feel better.

!

the shaded boxes.

A. Decongestants

B. Antihistamine combination therapy (with decongestant

and/or analgesic)

C. Antihistamines monotherapy

D. Mucolytics

E. Cough suppressants

F. Nonsteroidal anti-inflammatories

G. Vitamin C

H. Zinc

I. Echinacea

J. Ipratropium bromide nasal spray 0.06%

K. Oseltamivir

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Answer Comment > The correct answers are B, F, J> The correct answers are B, F, J

Upper Respiratory Infection Interventions Interventions That Decrease the Frequency or Duration ofInterventions That Decrease the Frequency or Duration of Symptoms of URISymptoms of URI

Non-selectiveNon-selective antihistaminesantihistamines

Two moderate quality meta-analyses of antihistamines monotherapy showed no clinically significant reduction in severity or duration of overall symptoms or nasal obstruction and an increase in adverse events, primarily sedation with first- generation anti-histamines.

A 2015 Cochrane systematic review showed

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NSAIDsNSAIDs

that NSAIDs may improve most pain-related symptoms caused by the common cold, but there is no evidence that they improve the cough, congestion, or rhinorrhea associated with the common cold.

IpratropiumIpratropium bromidebromide

One meta-analysis showed that use of ipratropium bromide sprays three to four times daily may decrease the symptoms of rhinorrhea and sneezing, but not nasal congestion.

AntihistamineAntihistamine combinationcombination therapy (withtherapy (with decongestantdecongestant and/orand/or analgesic)analgesic)

Low-moderate quality meta-analysis revealed the best evidence for antihistamine-decongestant combination (NNT = 5 for global symptoms); other combinations had small to moderate effects in adults and older children.

Interventions That Have Not Demonstrated Decrease inInterventions That Have Not Demonstrated Decrease in Frequency or Duration of Symptoms of URIFrequency or Duration of Symptoms of URI

Despite the paucity of data, millions of dollars are spent on over- the-counter (OTC) cold products each year.

Topical decongestants

Topical decongestants are not recommended for more than three days given the risk of rhinitis medicamentosa (nasal congestion caused by over-use of topical decongestants). Oral decongestants are often prescribed. There are no studies proving their efficacy, although some studies show a small decrease in nasal congestion and rhinorrhea.

Mucolytics Mucolytics, such as guaifenesin, have not been proven to improve symptoms.

Cough suppressants

Cough suppressants, such as codeine and dextromethorphan, are frequently prescribed for cough suppression, though evidence of

efficacy from clinical trials is lacking.

Vitamin C Studies have been mixed regarding the use of large doses of vitamin C to either prevent or treat the common cold.

Zinc Echinacea

Although often touted in the lay press, several controlled studies have shown that neither zinc nor echinacea show benefit in the treatment of cold symptoms.

Oseltamivir (Tamiflu)

Oseltamivir (Tamiflu) is an oral agent used for the prevention and treatment of influenza. If given with the first 48 hours it can decrease the duration of illness by two to three days. It can also be used to prevent influenza in a patient with a known exposure. However, vaccination is the best way to preventvaccination is the best way to prevent influenzainfluenza. Anyone who wants to reduce their chances of getting the flu can be vaccinated, but people who are at high risk of having serious flu complications or people who live with or care for those at high risk for complications are given priority when vaccine supplies are limited. Read more about who should receive a flu vaccine at: http://www.cdc.gov/FLU/protect/keyfacts.htm

FIVE A’S AND FIVE R’S MANAGEMENT

” DEEP DIVEDEEP DIVE

DIAGNOSES

MENUMENU

Dr. Griffin reviews the five A’s and five R’s of smoking cessation.Dr. Griffin reviews the five A’s and five R’s of smoking cessation.

!

You and Dr. Griffin step out of the room so Mr. Taleb can dress. Dr. Griffin says, “I want to go over some information with you that is good to review before discussing tobacco use with patients: the five A’s and five R’s for smoking cessation.”

Tobacco Cessation Counseling 5 A’s – Help Tobacco Users Willing to Quit5 A’s – Help Tobacco Users Willing to Quit

AASK: at every visit. The initial step is to identify if the patient uses tobacco. AADVISE: all tobacco users to quit. Emphasize the 5 R’s (relevance, risk,

rewards, roadblocks, and repetition). AASSESS: willingness to quit. “Do you feel ready to stop?”- If no, go to the 5

R’s. If yes, proceed to ASSIST. AASSIST: in setting up a quit date and offer pharmacologic as well as

behavioral support. AARRANGE: a follow-up visit. Congratulate success or review circumstance

that led to relapse.

5 R’s – Enhance Motivation for Patients Unwilling to Quit5 R’s – Enhance Motivation for Patients Unwilling to Quit

RRELEVANCE: Tailor advice and discussion to each patient.

TEACHING POINTTEACHING POINT

FINDINGS

NOTES

BOOKMARKS

RRISKS: Discuss the risks of continued smoking, such as short- and long- term personal health risks or harm to family.

RREWARDS: Discuss the benefits of quitting – live longer, save money, and smell better while setting an example for your children.

RROADBLOCKS: Identify barriers to quitting – weight gain, withdrawal symptoms, fear of failure, and depression.

RREPETITION: Reinforce the motivational message at every visit.

TOBACCO CESSATION COUNSELING CARE DISCUSSION You and Dr. Griffin return to the exam room.

“Mr. Taleb, we recommend ibuprofen and an antihistamine called chlorpheniramine to help with your symptoms. You can get them without a prescription. If you don’t get better within the next week, or if you develop a fever, give us a call.”

“Sure thing. I’m glad you took the time to explain why I don’t need antibiotics.”

“Before you go, I want to remind you that the most important thing you can do for your health is to stop smoking, and I strongly encourage you to quit. I know it is hard, but I also know that you can do it! … Are you willing to give it a try?”

“Thanks, Doc. I understand what you are saying about my overall health. I am not sure I am ready to quit, but I’ll think about it. My kids are giving me a hard time about smoking, too.”

“OK, but keep in mind that there are a lot of benects to quitting – you’ll feel better, save money, and live longer. Besides that, your children will have a healthier place to live.”

“Well, you might have a point there.”

You feel that he is in the contemplative stage, so you educate him about the diseases associated with cigarettes. After a pause, you continue with your questions to Mr. Taleb.

“You’ve quit three times before, and this tells me you can quit forever if you want to. Are there things holding you back?”

“Well, I’m worried that I’ll get cranky and irritable and not stick with it. I’m just not ready.”

“The truth is quitting isn’t easy, but it’s not impossible. There are medications that can help with symptoms like craving and irritability, and we will help you as much as we can. Just so you know, I’m going to talk to you about this every time I see you!”

“Well, okay. Right now, though, I’m going to work on getting rid of this cold! I’ll call you if I run into problems.”

You say goodbye to Mr. Taleb and wish him well.

Five Stages of Change 1. Precontemplation:Precontemplation: During this stage, patients do not even consider changing. Smokers who are “in denial” may not see that the advice applies to them personally. 2. Contemplation:Contemplation: During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain. During this stage, patients assess barriers (e.g., time, expense, hassle, fear, “I know I need to, doc, but…”) as well as the benefits of change. 3. Preparation:Preparation: During the preparation stage, patients prepare to make a specific change. They may experiment with small changes as their determination to change increases, like sampling low-fat foods as a move toward greater dietary modification. 4. Action:Action: The action stage is the one that most physicians are eager to see their patients reach. Any action taken by patients should be praised because it demonstrates the desire for lifestyle change. 5. Maintenance and relapse prevention:Maintenance and relapse prevention: Maintenance and relapse prevention involve incorporating the new behavior “over the long haul.” Discouragement over occasional “slips” may result in the patient giving up. However, most patients find themselves “recycling” through the stages of change several times before the change becomes truly established.

TEACHING POINTTEACHING POINT

Tobacco Dependence Fifteen percent of U.S. adults smoke, which is about 36.5 million people. More than 16 million Americans live with smoking-related disease. One-third of smokers die early from smoking-related illnesses, the most frequent being coronary artery disease (33%), followed by lung cancer (28%), other lung diseases (22%), and other cancers. People who smoke are at increased risk of emphysema and chronic bronchitis as well as cardiovascular, cerebrovascular and peripheral vascular disease.

Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Successful quitters often made multiple attempts before they were finally successful. Regardless of the clinical setting in which you see a patient, you should address their smoking, encourage them to quit, and help facilitate with medications and/or formal counseling.

See the American Cancer Society for more information.

References

Scott McIntosh, University of Rochester Smoking Research Program & The American Academy of Family Physicians National Research Network

TWO WEEKS LATER HISTORY

TEACHING POINTTEACHING POINT

You explain the withdrawal symptoms to Mr. Taleb.You explain the withdrawal symptoms to Mr. Taleb.

!

Two weeks later, Dr. Griffin asks you to go in and see Mr. Taleb again. She is not sure why he is here because the schedule just says “Follow-up”.

“Hi, Mr. Taleb. How are you doing?”

“I’m feeling just fine. You were right; I had a cold and I’m over it now.”

“What seems to be the problem today?”

“Well, I’d like to stop smoking cigarettes. My uncle, who smokes, just had a heart attack, and I don’t want the same thing to happen to me. You mentioned that there are things that can help make quitting easier. Can we talk about them?”

“I’m so pleased you want to stop smoking! Yes, there are several medications that can help with symptoms that occur with nicotine withdrawal. An exercise program and family support can help, too. You told me before that your kids are in favor of you quitting, so it sounds like you will have the family support you need to be successful.”

“Will I gain weight?”

You explain to Mr. Taleb that the symptoms of withdrawal peak on the third day after quitting, which makes this a risky time for relapse. “Weekends may be difficult too, especially if you’re drinking alcohol or doing something associated with smoking. I know you can do this if you keep at it!”

Symptoms of Nicotine Withdrawal Craving cigarettes, insomnia, irritability, anxiety, poor concentration,

depression, and fatigue. Symptoms peak on the third day after quitting.

SMOKING CESSATION THERAPEUTICS

The chemicals in cigarettesThe chemicals in cigarettes

!

Dr. Griffin joins you and is pleasantly surprised that Mr. Taleb is motivated to quit smoking. She reiterates your previous message that quitting is the most important step Mr. Taleb can take in improving his long-term health. She refers Mr. Taleb to a smoking cessation group and then asks you which agent you would prescribe.

Question Which treatments are helpful for smoking cessation? Select all that

TEACHING POINTTEACHING POINT

The best options are indicated below. Your selections are indicated by the shaded boxes.

apply.

A. Bupropion (Wellbutrin, Zyban)

B. Nicotine patch

C. Nicotine inhaler

D. Varenicline (Chantix)

E. Counseling

F. Hypnotherapy

G. Acupuncture/laser therapy

H. Quitting cold turkey

SUBMITSUBMIT

Answer Comment > The correct answers are A, B, C, D, E> The correct answers are A, B, C, D, E

Hypnotherapy (F), acupuncture, and laser therapy (G) have not proven to improve quit rates.

Management of Smoking Cessation Several medications, such as buproprion (Wellbutrin,Several medications, such as buproprion (Wellbutrin, Zyban), nicotine patches or inhalers, and vareniclineZyban), nicotine patches or inhalers, and varenicline (Chantix), are helpful for smoking cessation and generally(Chantix), are helpful for smoking cessation and generally improve quit rates from <10% to 20-30%, compared to self-improve quit rates from <10% to 20-30%, compared to self- quitters (i.e., cold turkey).quitters (i.e., cold turkey). Nicotine replacement used optimally and bupropion have comparable quit rates.

Varenicline (Chantix) is the newest smoking-cessation medication. It is a nicotine acetylcholine receptor partial agonist, and in a randomized controlled trial patients had better quit rates than those who used bupropion. For varenicline, the quit rate was 45% at three months compared to 34% for bupropion.The Food and TEACHING POINTTEACHING POINT

Drug Administration (FDA) has put out warnings of neuropsychiatric symptoms that occurred in patients who were taking varenicline. Patients should be monitored for suicidal ideation, increased agitation, vivid dreams, and depressed mood.

Counseling alone doubles quit rates, and counselingCounseling alone doubles quit rates, and counseling combined with medications can improve quit rates to 30-combined with medications can improve quit rates to 30- 40%.40%.

The best options are indicated below. Your selections are indicated by the shaded boxes.

Check for history of seizures, head injuries, or eating disorders.

2. Varenicline can cause nausea, but patients should be advised that this is a common side effect and that if they can tolerate a few days of nausea that it should subside and not be a continued concern.

Question Are there any contraindications to nicotine replacement? Select all that apply.

A. Known CAD or stroke

B. Serious arrhythmia

C. Serious or worsening angina pectoris

D. Accelerated hypertension

E. Pregnancy

F. Recent myocardial infarction

G. Kidney disease

SUBMITSUBMIT

Answer Comment > The correct answers are B, C, D, F> The correct answers are B, C, D, F

Nicotine Replacement Contraindications Worsening cardiovascular disease is a contraindication toWorsening cardiovascular disease is a contraindication to nicotine replacement. nicotine replacement. Serious arrhythmias (such asSerious arrhythmias (such as ventricular tachycardia), worsening angina pectoris,ventricular tachycardia), worsening angina pectoris, accelerated hypertension, and recent MI are allaccelerated hypertension, and recent MI are all contraindications to nicotine replacement.contraindications to nicotine replacement.

TEACHING POINTTEACHING POINT

These are the only limitations to nicotine replacement therapy. Studies of nicotine replacement therapy in pregnant females have not identified negative health outcomes for mothers or their babies, but there is still controversy over whether or not nicotine replacement leads to higher rates of smoking cessation than placebo. Nicotine replacement comes in many forms. The goal is to replace nicotine to eliminate or reduce the physical withdrawal symptoms. Nicotine patches should not be worn while smoking.

Nicotine gumNicotine gum DOSE: Available in 2 or 4 mg pieces (4 mg is equivalent to one cigarette’s nicotine). Used alone, up to 24 pieces a day can be chewed.

USE: Patient should put one piece in mouth and chew slowly until a peppery taste occurs, then park the gum and take a chew every few minutes.

SIDE EFFECTS: Sore jaw and indigestion, especially if chewed too rapidly.

Nicotine inhalerNicotine inhaler DOSE: Between 6 and 16 cartridges daily (each cartridge has 80 inhalations).

USE: Inhale cartridge for each craving. Satisfies hand-to-mouth behavior craving.

Nicotine nasal sprayNicotine nasal spray DOSE: One to two sprays each hour for 6-8 weeks.

ADVANTAGE: Quick delivery that emulates that of a cigarette.

Nicotine lozengesNicotine lozenges DOSE: Available in 2 mg or 4 mg doses, similar to gum.

USE: One lozenge every 1-2 hours. Dissolves like hard candy.

Nicotine patchNicotine patch

DOSE: Comes in 7 mg, 14 mg and 21 mg patches. Patients who smoke a pack per day should start at the 21 mg dose and taper every four weeks. A patient who smokes two packs a day should start with two patches.

USE: Put the patch on the chest, back, or arms. Remove nightly and replace in a different location.

SIDE EFFECTS: Irritation at patch site, which patients should be informed of, with the explanation of that skin is a natural barrier that must be disrupted to allow absorption of the nicotine into their system.

Please note: Please note: Combining the nicotine patch and a self-administeredCombining the nicotine patch and a self-administered agent (nasal spray, lozenge or gum) is the most efficacious form ofagent (nasal spray, lozenge or gum) is the most efficacious form of nicotine replacement.nicotine replacement.

Link to a site that shows examples of nicotine-replacement productsnicotine-replacement products.

References

Coleman T, et al. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev. 2015 Dec 22;(12).

FOLLOW-UP THERAPEUTICS

You call Mr. Taleb to ask how he is doing.You call Mr. Taleb to ask how he is doing.

!

You recommend a nicotine patch at 14 mg/day for four weeks and then 7 mg/day for an additional four weeks. You also recommend that Mr. Taleb use 2 mg nicotine lozenges or gum as needed, but especially during the first week.

You write down the instructions for him to have at home.

Later in the week, you call Mr. Taleb to see how he is doing.

Mr. Taleb tells you, “Thanks for calling. Things are not going so well. My wife lost her job, and I couldn’t afford the medications. But my friend at work said his insurance covered bupropion, and he stopped smoking using it, so I want to try that. My insurance should cover it, too.”

You confer with Dr. Griffin and plan to call the prescription in to the pharmacy. You remind Mr. Taleb that exercise can help mitigate weight gain associated with smoking cessation and counsel him on the use of a pedometer. You arrange a follow-up visit with Mr. Taleb next week.

SUCCESS! HISTORY Several months later, after finishing your rotation with Dr. Griffin, you call her to update her after one of her patients has surgery. During your conversation, she tells you that Mr. Taleb has been successful in his smoking cessation. He finished the bupropion but he uses the nicotrol inhaler as needed when he feels the urge to smoke. He still uses it several times weekly.

“Mr. Taleb said he couldn’t have quit smoking without your help and encouragement.”

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