SOAPin' without a Scope

If you read my last blog post, you should have been able to feel how excited I was to hear my first murmur (if not, just take my word for it). Man, was I pumped. I was going to get in the clinic and hear tons of 'em: murmurs, gallops, rubs. I was going to hear them all. I was ready to diagnose an aortic stenosis or perhaps an atrial septal defect. Throw me an EKG, doc; I see ST-elevation in the inferior leads (II, III, and aVF)! On Sunday night, my three roommates knew I was in the zone.  I literally looked like I was ready to catch some kid right then and there. And after HemeOnc and Cardio, I had the blood and CV system down cold. Dammit I was ready. Except for one tiny, itty bitty detail... I forgot to bring my stethoscope.

Yes, 2.5 hours away, sitting on top of my EMS bag and uniform, lay my trusty scope. Literally the ONLY thing I had to bring to Community Week was that item. I didn't need my white coat; I didn't need a tie. John Younce even forgot his keys to the apartment we were staying in! The only thing I had to remember was that stethoscope, and I dropped the ball. I actually remembered at 10 pm Sunday night, just as my head hit the pillow. Needless to say I was extremely embarrassed when I had to ask my preceptor if I could borrow one for the week. Fortunately, I was working at a doctor's office; there were tons of them lying around. But I was a carpenter without a saw, a surgeon without a scalpel, a catcher without a mitt, a shoemaker without a.... well you get the idea. A med student needs a stethoscope!

Disappointment #2: I didn't hear ONE murmur. Not one. I told my preceptor if he heard one to come grab me if I was in another room. But he didn't hear one, and neither did I in three days. Not even a S3, which can be normal in kids. Instead, I found a lot of mucus, and a boat-load of cerumen (that's the medical term for "earwax"). Not that my time wasn't valuable; I learn more in that clinic than I do in the classroom. Very high yield (and I can potty train your kid by 21 months if you need me too), but damn you I wanted a bloody murmur! Afterwards, I called Clodagh on the drive home, and she was batting like .700 for murmurs. Everyone had one! Holosystolic, midsystolic, crescendo, decrescendo. Ahhh, the luck of the Irish...

But as promised, here is my first SOAP note on a real patient. Doctors get ready to cringe, professors enjoy a nice laugh. Please note that identifying information has been subtly changed for patient privacy.


Medical Student Progress Note
Robert Swendiman, MS2
10/7/2010, 11:15am

S – Jane Doe is an 5 year old female complaining of fever and a “broken brain” over the last 2 days. She is autistic and has a significant hx for recurrent strep throat.

O – Medications: ibuprofen (for fever); Allergies: NKDA; Vitals: mild tachycardia with all other vitals WNL; PE: Jane is found sitting comfortably on exam table. HEENT: tonsilar hypertrophy and irritation with purulent exudate, mild discomfort while swallowing, tympanic membrane of left ear slightly opaque and irritation noted. Lungs: bilateral breath sounds CTA. CV and Neuro: nl. No other significant findings. Labs: positive rapid strep test.

A/P – Jane, 5 y/o F with fever and a “broken brain” over the last two days, presents with tonsilar hypertrophy and exudate on her soft palate and mild left auricular tympanic membrane opaqueness/irritation. She tested positive for strep in clinic.
1. Fever/Tachycardia – significant PMHx for strep throat and positive rapid antigen test, symptoms most likely due to Streptococcus pyogenes infection, otitis media also considered, patient given antibiotic and mother counseled about continuing Motrin regiment for fever
2. Tonsilar Hypertrophy/Exudate and Difficulty Swallowing – (see above)
3. Inflamed Left Tympanic membrane – Streptococcal infection may have spread to left ear, superinfection considered and antibiotic chosen to cover both strep throat and otitis media
4. “Broken Memory” – PMHx of autism, patient counseled that she will feel better after recovering from infection since both symptoms presented at the same time

Discussion – Which antibiotics are most effective for treating Group A Streptococcus?

In children with tonsilar pharyngitis and an associated bacterial infection, Group A Streptococcus (GAS) is the most common microbial culprit. Since the 1950s, penicillin has been the gold standard for treating this infection, but recently this antimicrobial agent has proven less effective (over 20% of patients are not cured with standard therapy), and treatment choices have changed. Some research demonstrates that over time, other antimicrobials such as cephalosporins and some macrolides may be more effective than penicillin.

Debate continues concerning the choice of antibiotics and the duration of treatment. Untreated strep throat can lead to pernicious sequelae such as rheumatic fever, and numerous studies have been done comparing the clinical effectiveness of different treatment plans. For example, when comparing a short 5 day course of cefuroxime axetil versus a standard 10 day oral penicillin regimen, both therapies were proven to be equally effective and in curing the infection and subsequent prevention of post-infection sequelae. Since Streptococcus pyogenes has never been linked to penicillin resistance, this 10 day therapy still remains the most common treatment. Other treatments are used based on recurrence and physician preference.

References:
1. Pichichero ME. Group A streptococcal tonsillopharyngitis: cost-effective diagnosis and treatment. Ann Emerg Med. 1995;25(3):390-403.
2. Adam D, Scholz H, Helmerking M. Comparison of short-course (5 day) cefuroxime axetil with a standard 10 day oral penicillin V regimen in the treatment of tonsillopharyngitis. J Antimicrob Chemother. 2000;45 Suppl:23-30.
3. Colletti T, Robinson P. Strep throat: guidelines for diagnosis and treatment. JAAPA. 2005;18(9):38-44.

Robert A. Swendiman, MS2
Pager/Cell – 301.275.9566