Tuesday, March 28, 2023
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Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine
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Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine
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Ms. Carr, a junior member of the medical center's administrative staff, presents to the urgent care center with a 3-day history of sore throat, cough, congestion, and sneezing. She says she feels feverish and that she thinks her glands are swollen, but she does not know her temperature. She is 27 years old, has no significant medical history, and no known drug allergies. She does not work with young children and has no children of her own. On examination, her temperature is 37.8°C, her pulse is 80 beats/min, and her respiratory rate is 12 breaths/min. She has no rash. Her pharynx is erythematous, and there is a single 2-mm patch of exudate on her right tonsil. Her ears are normal. She has shotty posterior cervical adenopathy (not present anteriorly), and her lungs are clear. The office where she is being seen does not have rapid streptococcal (strep) testing available.
Ms. Carr is supposed to board an airplane in less than 24 hours for 3 days of fundraising in another city. Seeing her today is Dr. Trainer. “Good news, Ms. Carr,” says Dr. Trainer. “Looks like you most likely just have a viral upper respiratory infection.” Dr. Trainer expresses concern about her ears during air travel and advises that if she must fly, she should still try to get plenty of rest; drink lots of fluids; take acetaminophen, aspirin, or a nonsteroidal antiinflammatory drug for discomfort; and use an over-the-counter nasal decongestant as required for symptoms of congestion and prophylactically before her flight. Ms. Carr responds, “I must fly. But I’m worried about strep throat. My last doctor always gave me antibiotics when I had a sore throat." Dr. Trainer explains that it is very unlikely that she has strep throat by clinically validated criteria and that antibiotics are ineffective to treat a viral infection. She is nonetheless insistent on leaving with a prescription for antibiotics, asking, "Aren't you concerned about my ears like you said? And I'm going to be out of town in back-to-back meetings. How will I get antibiotics if I get sicker?"
