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Et tu Brute (db)?

Bohdan A. Oryshkevich, MD, MPH

The vast majority of mistakes in pharyngitis come from the fact that the vital signs are not taken, no one looks at the HEENT and no one feels the tonsils.

I have seen a variety of conditions missed because someone did not take a pulse. The patient was actually complaining of pounding of the neck: he had atrial flutter not strep.

Or the patient had a peri-tonsillar abscess which was missed because the tc was negative? No one looked at the throat.

The recent case here with a young girl with strep toxic shock syndrome was a case in point. Despite an extensive literature search I could find no report of an active pharyngitis leading to strep toxic shock syndrome. It may be a similar bacterium but it is not necessarily the same disease. This patient did appear to have localized pain. Localized pain is a feature of strep toxic syndrome. But we have no information about what the doctors saw or did except for the fact that she apparently had a throat culture twice. That is not a screen for toxic shock syndrome.

In reality, what every doctor needs to do is know the basics. A seemingly straightforward strep throat with an exceedingly high temperature may occur in atrial septal defect. One does not need to do anything fancy just listen to the heart the next time the patient comes and when the pulse is slower. Know the differential and think of it every time.

I think that too often doctors ignore the chief complaint or jump to the conclusions. I found that the nursing assistants in my clinic could not even get the chief complaint right so one had to start all over and often get them to take the temperature properly as in that case of strep throat and ASD and a temperature of 105 that I had some years ago. She had a very fast pulse and a low temperature. The pulse gave me a clue to her temperature. A double check on my nursing assistant.

Bohdan A. Oryshkevich, MD, MPH