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A Study in Telemedicine

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1. A Telemedicine Case Study Bring out your inner diagnostician THE PULSE OF TELEHEALTH | MeMD 2. HISTORY OF PRESENT ILLNESS 2  A 59 year old Female presents to your…
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  • 1. A Telemedicine Case Study Bring out your inner diagnostician THE PULSE OF TELEHEALTH | MeMD
  • 2. HISTORY OF PRESENT ILLNESS 2  A 59 year old Female presents to your virtual clinic with sore throat and a picture attached showing mild bilateral tonsillar exudate.  There is no significant past medical/surgical/familial/social history besides an appendectomy at age 26 and occasional alcohol use.  The patient states that they had sinus symptoms for about a week and then began having a sore throat 3 days ago and were seen at an Urgent Care last night with a negative rapid strep test result.  The patient says that they feel fine they just want some relief from their sore throat and are frustrated that they were sent home without anything to help with their symptoms.
  • 3. DIFFERENTIAL DIAGNOSIS 3  After considering the patient’s presentation and negative rapid strep test, you conclude the likely diagnosis to be viral pharyngitis. You reassure the patient that their sore throat will resolve in the next couple of days and recommend salt water gargles and to follow up with their primary care provider if their symptoms do not resolve in the next 2-3 days.  The patient understands and is grateful for the reassurance and will begin salt water gargles to help with symptoms.
  • 4. FOLLOW-UP CONSULTATION 4  Two weeks later, you receive a call from the same patient. They state that their sore throat resolved a couple days after your last contact, but that they saw some blood in their urine this morning and feel like their ankles are swollen. You ask the patient if the Urgent Care had done a culture lab test, but they are unsure and have not heard anything from them.
  • 5. DIFFERENTIAL DIAGNOSIS 5  You check the literature and see that Rapid Strep Test has a sensitivity of 80-90%. You refer the patient to present at a nearby Emergency Department and explain your concern for Post-Streptococcal Glomerulonephritis (PSGN). You inform the patient that they need to explain to the provider they see that they were referred for this specific reason as PSGN can be a serious condition. The patient agrees to go to the nearest emergency department, her husband will drive her there immediately.
  • 6. 2 4 H O U R F O L L O W - U P 6  24 hours later, a follow up call reveals that the patient presented to the ED and the diagnosis of PSGN was confirmed. The patient is staying in the hospital for monitoring and supportive management, and is expected to recover completely.
  • 7. T A K E H O M E P O I N T S 7  It is important to remember the possibility of a post-streptococcal syndrome for telemedicine patients with a history of a resolved sore throat in the recent past, especially those who were not treated with an antibiotic, as in this case. These syndromes include glomerulonephritis, rheumatic fever, and polyarthritis.  These syndromes are more common in younger patients, especially children.  The rare cases of post-streptococcal syndromes are NOT an indication for blanket treatment of all sore throats/pharyngitis with antibiotics without a positive rapid strep test or strep culture.  Telemedicine practice is moving toward closer cooperation between telemedicine providers and primary care providers with regard to pharyngitis and the need for lab confirmation of strep infection (as opposed to the much more common case of viral pharyngitis) before antibiotics are initiated.  As in this case the onset of a post-streptococcal syndrome is typically several weeks after the initial (untreated) strep pharyngitis so there is plenty of time to properly test these acute pharyngitis patients before antibiotics are prescribed.
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    Aug 11, 2017
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