Antibiotics and Viral Illnesses: Another Quora Answer


Have you ever had a patient refuse to believe the diagnosis you gave them?

Yes. But it was through his wife, a Registered Nurse who should have known better.

I was working in an Immediate Care and Occupational Medicine clinic in Burlington, Wisconsin one night during an influenza outbreak. A very sick man came in with typical influenza symptoms: fever, chills, body aches, non-productive cough, sore throat, and nasal congestion/clear nasal discharge. On presentation, he was a well-nourished, poorly hydrated, middle aged White male, ill-appearing, in mild distress. Eyes were white, sclera non-injected, extraocular muscles intact. Pupils equally round and reactive to light and accommodation.

Neck was supple with a full range of motion. He had tender bilateral submandibular lymph nodes (no anterior cervical lymphadenopathy which is important). Nasal mucous membranes were injected (red) and hyperemic (congested) bilaterally with a clear discharge. Oral mucous membranes were dry, his pharynx was injected, but without exudate (pus).

He had a cough and auscultation of his lungs revealed bilateral wheezing but no rales, crackles, or rhonchi. There was good air movement despite the wheezes.

Vital Signs: Heart rate regular at 98 beats per minute; temperature 100.5 degrees F; respiratory rate 15/minute; and oxygen saturation 96%.

The rest of the exam was unremarkable.

Based on my findings and the fact that there was a statewide outbreak, I felt he had influenza, a viral illness. He was also dehydrated so we started an IV to give him fluids. I added dexamethasone (a corticosteroid) for two reasons: to decrease or eliminate the wheezing, and help alleviate his body aches. I added IV Toradol for the same reason. It also brought down his temperature, which really wasn't alarmingly high.

He responded well to treatment. While we were rehydrating him, his wife tracked me down and wanted to know why I didn't order a strep test and chest x-ray. I explained again why I thought he had a viral infection. She wouldn't buy it and demanded I order them. Both are relatively cheap so I did, mainly to placate her. Both came back negative: no strep pharyngitis; no pneumonia.

She wouldn't buy that either, explaining to me that the rapid strep assay was “only 90% accurate.” More precisely, I explained that it is both highly specific and sensitive, with a predictive value (at that time) of almost 95%. Besides, there is also a clinical algorithm that has a negative predictive value of almost 85%. Basically, in the presence of a cough, the abscence of tonsillar exudate, and no anterior cervical lymph nodes, it is highly likely NOT strep. I explained that to his wife, too. Then I asked her what she thought he had. No kidding, this was her answer: “acute sinusitis, strep throat, and pneumonia.” So of course he needed antibiotics. In fact, she demanded them.

First of all, treating a viral infection with antibiotics is poor medicine. Secondly, and if you've read some of my previous Answers you should understand, what she thought were the causes of his illness violates Occam's Razor. As it pertains to medicine, it means that the preferred diagnosis is the ONE that most precisely explains most if not all, of the signs, symptoms, and test results.

Despite accomadating her about the RSA and chest x-ray, I refused to treat him with antibiotics. Soooo… she called the clinic administrator and complained. The administrator drove all the way from Janesville, WI to Burlington to “please, please give him an antibiotic.” I explained to her why I felt that was not medically necessary. She then went to the other doc working that night and he was more than happy to prescribe one. For a patient he didn't even see.

Later, I asked him why and he said that he always prescribed an antibiotic for every patient who presents with a sore throat. Why? His reasoning was that he would rather prescribe incorrectly than miss a strep pharyngitis. I call that “CYA Medicine.”

Remember that clinic because it's central to another much more tragic story of mine.

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30.07.2019 19:00
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