# Clinical Cases: Common Acute Complaints ## Case 1: Sore Throat - Is It Strep? ### Patient Demographics - **Age:** 19 years old - **Sex:** Female - **Occupation:** College student ### Chief Complaint "My throat has been killing me for 2 days. I think I need antibiotics." ### History of Present Illness Ms. Aisha Johnson is a 19-year-old college student presenting with severe sore throat for 2 days. She reports difficulty swallowing, subjective fever (felt "hot" last night), and fatigue. She denies cough, congestion, or runny nose. Her roommate had a similar illness last week and was treated with antibiotics. She has midterm exams this week and wants to "get better quickly." ### Review of Systems - **Positive:** Sore throat, fever, fatigue, decreased appetite, mild headache - **Negative:** No cough, no nasal congestion, no rhinorrhea, no rash, no joint pain, no abdominal pain ### Past Medical History - No chronic conditions - No prior history of strep throat - No allergies to medications ### Physical Examination - **Vital Signs:** Temp 101.2F (38.4C), HR 88, BP 110/70, RR 16 - **General:** Uncomfortable-appearing, but not toxic - **HEENT:** - Oropharynx: Bilateral tonsillar enlargement with white-yellow exudates - No palatal petechiae - Uvula midline, not edematous - **Neck:** Tender, enlarged bilateral anterior cervical lymphadenopathy - **Lungs:** Clear to auscultation - **Skin:** No rash ### Clinical Image ![Streptococcal pharyngitis with tonsillar exudates](case_01_image.jpg) *Image: Culture-positive streptococcal pharyngitis showing enlarged tonsils with white exudates, characteristic of Group A streptococcal infection.* **Image Source:** Wikimedia Commons **Attribution:** James Heilman, MD, CC BY-SA 3.0 **URL:** https://commons.wikimedia.org/wiki/File:Strep_throat2010.JPG ### Modified Centor Score Assessment | Criteria | Present? | Points | |----------|----------|--------| | Tonsillar exudates | Yes | +1 | | Tender anterior cervical lymphadenopathy | Yes | +1 | | Fever (history or measured > 38C) | Yes | +1 | | Absence of cough | Yes | +1 | | Age 15-44 years | Yes | 0 | | **Total Score** | | **4** | **Interpretation:** Score of 4 indicates high probability of Group A Streptococcal pharyngitis (approximately 50-60% pre-test probability). Testing is still recommended before treatment. ### Diagnostic Testing - **Rapid Strep Test:** Positive ### Assessment 1. **Group A Streptococcal pharyngitis** - Confirmed by positive rapid strep test ### Management Plan **Antibiotic Therapy:** - Amoxicillin 500 mg PO twice daily for 10 days - Alternative if penicillin-allergic (non-anaphylactic): Cephalexin 500 mg twice daily for 10 days - Alternative if severe penicillin allergy: Azithromycin 500 mg day 1, then 250 mg days 2-5 **Supportive Care:** - Acetaminophen or ibuprofen for pain and fever - Salt water gargles - Throat lozenges - Adequate hydration - Rest **Patient Education:** - Symptoms should improve within 1-2 days of starting antibiotics - Complete the full 10-day course to prevent rheumatic fever - Contagious until 24 hours after starting antibiotics; avoid close contact - Return if worsening symptoms, difficulty swallowing liquids, or drooling **Return Precautions:** - Difficulty breathing or swallowing - Inability to swallow saliva (drooling) - Severe neck swelling or stiffness - Symptoms not improving after 48-72 hours of antibiotics ### Follow-Up - No routine follow-up needed if symptoms resolve - Return if symptoms persist or worsen ### Teaching Points 1. **Modified Centor Score:** Useful for estimating strep probability and guiding testing decisions. Even with a score of 4, testing is preferred before treatment due to significant false-negative clinical prediction. 2. **Antibiotic stewardship:** Antibiotics for pharyngitis are only indicated for confirmed or highly suspected GAS infection. Most pharyngitis is viral. 3. **Treatment goals:** Primary goal of treating strep throat is preventing rheumatic fever, which requires completing the full antibiotic course. 4. **Test before treat:** Rapid strep testing is recommended even with high clinical suspicion to avoid unnecessary antibiotics for viral pharyngitis. --- ## Case 2: The Persistent Cough - Acute Bronchitis ### Patient Demographics - **Age:** 42 years old - **Sex:** Male - **Occupation:** High school teacher ### Chief Complaint "I've had this cough for almost 2 weeks and it won't go away. I need something stronger." ### History of Present Illness Mr. Robert Chen is a 42-year-old man presenting with cough for 12 days. The illness started with nasal congestion, sore throat, and low-grade fever. Those symptoms resolved after 4-5 days, but the cough persists. The cough is sometimes productive of clear-to-yellow mucus, worse at night, and occasionally triggers gagging. He reports fatigue and chest discomfort from coughing. He has tried over-the-counter cough suppressants with minimal relief. He states, "My neighbor had the same thing and got a Z-pack and felt better. Can I have one?" ### Review of Systems - **Positive:** Cough (productive), chest soreness from coughing, fatigue - **Negative:** No fever currently, no shortness of breath at rest, no wheezing, no hemoptysis, no night sweats, no weight loss ### Past Medical History - No chronic conditions - No asthma or COPD - Non-smoker (never) - No allergies ### Physical Examination - **Vital Signs:** Temp 98.4F, HR 76, BP 124/78, RR 14, SpO2 98% on room air - **General:** Well-appearing, occasional coughing during exam - **HEENT:** Oropharynx clear, no exudates, no postnasal drip visible - **Neck:** No lymphadenopathy - **Lungs:** Clear to auscultation bilaterally, no wheezes, no crackles, no rhonchi - **Cardiovascular:** Regular rate and rhythm ### Clinical Assessment **Does this patient need a chest X-ray?** | Red Flag for Pneumonia | Present? | |------------------------|----------| | Fever > 100.4F (38C) sustained | No | | Tachypnea (RR > 20) | No | | Tachycardia (HR > 100) | No | | Abnormal lung exam (focal crackles, egophony) | No | | Hypoxia (SpO2 < 95%) | No | | Elderly or immunocompromised | No | **Conclusion:** No red flags for pneumonia; chest X-ray not indicated. ### Assessment 1. **Acute bronchitis** - Viral illness with expected prolonged cough ### Management Plan **Antibiotics: NOT INDICATED** **Patient Education (Key Conversation Points):** "I understand the cough is frustrating and affecting your daily life. Let me explain what's happening: This is acute bronchitis - a viral infection that has inflamed your airways. The cough is your body's way of clearing the irritation. Here's the important part: antibiotics don't help because this is caused by a virus, not bacteria. Multiple studies involving thousands of patients show that antibiotics don't make the cough go away faster but do cause side effects like diarrhea and allergic reactions, and contribute to antibiotic resistance. The cough typically lasts 2-3 weeks total, sometimes longer. I know that sounds discouraging when you're at 12 days, but you should notice gradual improvement." **Symptomatic Treatment:** - Honey (1-2 teaspoons) for cough, especially before bed - Dextromethorphan (OTC cough suppressant) for nighttime symptom relief - Ibuprofen or acetaminophen for chest discomfort - Adequate hydration - Humidifier at night **Return Precautions:** - New or worsening fever - Shortness of breath - Cough lasting > 3 weeks without improvement - Hemoptysis (coughing blood) - Worsening symptoms after initial improvement ("double sickening") ### Follow-Up - No routine follow-up needed if symptoms resolve - Return in 1-2 weeks if cough not improving ### Teaching Points 1. **Antibiotic stewardship:** Acute bronchitis is one of the most common conditions for inappropriate antibiotic prescribing. Clear communication about why antibiotics won't help is essential. 2. **Setting expectations:** Educating patients that cough from bronchitis typically lasts 2-3 weeks helps prevent return visits and antibiotic requests. 3. **Distinguishing bronchitis from pneumonia:** Clinical assessment without red flags allows confident diagnosis of bronchitis without chest X-ray. 4. **Symptomatic treatment:** Offering alternative treatments (honey, OTC medications) demonstrates concern for patient comfort while appropriately withholding antibiotics. --- ## Case 3: Acute Low Back Pain ### Patient Demographics - **Age:** 35 years old - **Sex:** Male - **Occupation:** Warehouse worker ### Chief Complaint "I threw out my back lifting at work 3 days ago. I can barely move." ### History of Present Illness Mr. Marcus Williams is a 35-year-old warehouse worker presenting with acute low back pain for 3 days. He was lifting a heavy box at work when he felt sudden pain in his lower back. The pain is constant, rated 7/10, located in the lower lumbar region, and worsens with movement, bending, and prolonged sitting. He has been unable to work since the injury. He denies radiation of pain to the legs, numbness or tingling, weakness in the legs, or difficulty with urination or bowel movements. ### Review of Systems - **Positive:** Lower back pain, muscle spasms, difficulty sleeping due to pain - **Negative:** No leg pain, no numbness or tingling, no weakness, no bowel or bladder dysfunction, no fever, no unexplained weight loss, no history of cancer ### Past Medical History - No chronic conditions - No prior back surgery - Previous episode of back pain 5 years ago (resolved with conservative treatment) - No allergies ### Red Flag Assessment | Red Flag | Present? | |----------|----------| | Saddle anesthesia | No | | Urinary retention or incontinence | No | | Fecal incontinence | No | | Progressive motor weakness | No | | History of cancer | No | | Unexplained weight loss | No | | Fever | No | | IV drug use | No | | Prolonged corticosteroid use | No | | Trauma in osteoporotic patient | No | | Age > 50 with new onset | No | ### Physical Examination - **Vital Signs:** BP 130/82, HR 78, Temp 98.2F - **General:** In obvious discomfort, guarding movement - **Back:** - Tenderness to palpation over bilateral paraspinal muscles L4-S1 - Limited flexion (touches mid-thigh) - No step-off deformity - No midline spinous process tenderness - **Neurological:** - Strength 5/5 bilateral lower extremities (hip flexion, knee extension, ankle dorsiflexion, plantar flexion) - Sensation intact to light touch L4-S1 dermatomes bilaterally - Deep tendon reflexes 2+ bilateral patellar and Achilles - Straight leg raise negative bilaterally - **Gait:** Antalgic but stable ### Assessment 1. **Acute nonspecific low back pain** - Mechanical, without radiculopathy or red flags ### Management Plan **Imaging: NOT INDICATED** - No red flags present - Imaging would not change management - Incidental findings on MRI are common and may lead to unnecessary interventions **Activity Recommendations:** - **Stay active** - This is the most important recommendation - Avoid bed rest (associated with delayed recovery) - Return to normal activities as tolerated - Work modification: light duty for 1-2 weeks, avoiding heavy lifting - Provide work restriction note for employer **Pharmacologic Treatment:** 1. **First-line:** NSAIDs - Ibuprofen 600 mg every 6-8 hours with food (max 2400 mg/day) - OR Naproxen 500 mg twice daily - Use for 1-2 weeks 2. **Muscle relaxant (short-term):** - Cyclobenzaprine 5-10 mg at bedtime for muscle spasms - Limit to 1-2 weeks due to sedation 3. **Avoid opioids** - Not indicated for acute nonspecific low back pain **Non-pharmacologic Treatment:** - Superficial heat (heating pad) for symptom relief - Early mobilization - Gentle stretching as tolerated **Patient Education:** - Prognosis is excellent: 90% of acute back pain improves within 4-6 weeks - Staying active speeds recovery; bed rest delays it - Some discomfort with activity is expected and not harmful - Core strengthening after acute phase resolves can prevent recurrence **Physical Therapy Referral:** - Not indicated initially for acute episode - Consider if not improving by 4-6 weeks ### Return Precautions - New weakness in legs - Numbness in groin or saddle area - Loss of bladder or bowel control - Fever - Significant worsening despite treatment - No improvement after 4-6 weeks ### Follow-Up - Return in 2-4 weeks if not improving - Work status re-evaluation as needed ### Work Restrictions Documentation "Patient may return to light duty with restrictions: no lifting > 10 lbs, no repetitive bending or twisting, frequent position changes every 30-60 minutes. Re-evaluation in 2 weeks." ### Teaching Points 1. **Avoiding unnecessary imaging:** Imaging for acute low back pain without red flags does not improve outcomes and may lead to overtreatment of incidental findings. 2. **Activity over bed rest:** Decades of evidence show that staying active leads to faster recovery than bed rest. 3. **Opioid avoidance:** Acute low back pain should be managed with NSAIDs and muscle relaxants. Opioids are not superior and carry significant risks. 4. **Setting expectations:** Most acute back pain resolves within 4-6 weeks. Patients who understand this are less likely to seek unnecessary interventions. 5. **Yellow flags:** While not present in this case, psychological factors (catastrophizing, fear-avoidance) are important predictors of progression to chronic pain.