The Journal of Family Practice

While the lesions appeared verrucous and cauliflower-like, this seemed an unusual place for condyloma. So the FP performed a shave biopsy out of concern that this could be a benign tumor. The results came back as human papillomavirus (HPV)-related condyloma.

In addition to the growths that were seen under the pannus, there was also intertrigo in that area. Intertrigo is a nonspecific term for a rash in an intertriginous area. Erythema seen between skin folds is the tip-off to intertrigo. The most common causes of intertrigo are fungal infections and irritation that come from sweating and the rubbing together of skin. Another cause of an erythematous rash in an intertriginous area is inverse psoriasis.

The FP performed a potassium hydroxide (KOH) preparation by scraping the erythematous area with a microscope slide and looking at the specimen under the microscope. The KOH was negative and the diagnosis was determined to be nonspecific intertrigo related to obesity. The FP told the patient to try to keep the area dry and to try some over-the-counter 1% hydrocortisone cream for the inflammation and irritation.

Pannus condylomas are uncommon—but not rare—in this age of increasing obesity. While they are secondary to HPV, they are not necessarily sexually transmitted HPV types. Based on the patient’s sexual history, the FP did not recommend screening for sexually transmitted infections.

On the initial visit, the FP counseled the patient about the importance of weight loss for good health and hygiene. The patient chose cryotherapy for treatment of the growths. While the patient held the pannus up, the FP sprayed the condyloma with liquid nitrogen using a cryo-gun. The patient chose to have a second freeze-thaw cycle and was scheduled for a follow-up visit in 3 to 4 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Genital warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

While the lesions appeared verrucous and cauliflower-like, this seemed an unusual place for condyloma. So the FP performed a shave biopsy out of concern that this could be a benign tumor. The results came back as human papillomavirus (HPV)-related condyloma.

In addition to the growths that were seen under the pannus, there was also intertrigo in that area. Intertrigo is a nonspecific term for a rash in an intertriginous area. Erythema seen between skin folds is the tip-off to intertrigo. The most common causes of intertrigo are fungal infections and irritation that come from sweating and the rubbing together of skin. Another cause of an erythematous rash in an intertriginous area is inverse psoriasis.

The FP performed a potassium hydroxide (KOH) preparation by scraping the erythematous area with a microscope slide and looking at the specimen under the microscope. The KOH was negative and the diagnosis was determined to be nonspecific intertrigo related to obesity. The FP told the patient to try to keep the area dry and to try some over-the-counter 1% hydrocortisone cream for the inflammation and irritation.

Pannus condylomas are uncommon—but not rare—in this age of increasing obesity. While they are secondary to HPV, they are not necessarily sexually transmitted HPV types. Based on the patient’s sexual history, the FP did not recommend screening for sexually transmitted infections.

On the initial visit, the FP counseled the patient about the importance of weight loss for good health and hygiene. The patient chose cryotherapy for treatment of the growths. While the patient held the pannus up, the FP sprayed the condyloma with liquid nitrogen using a cryo-gun. The patient chose to have a second freeze-thaw cycle and was scheduled for a follow-up visit in 3 to 4 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Genital warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

While the lesions appeared verrucous and cauliflower-like, this seemed an unusual place for condyloma. So the FP performed a shave biopsy out of concern that this could be a benign tumor. The results came back as human papillomavirus (HPV)-related condyloma.

In addition to the growths that were seen under the pannus, there was also intertrigo in that area. Intertrigo is a nonspecific term for a rash in an intertriginous area. Erythema seen between skin folds is the tip-off to intertrigo. The most common causes of intertrigo are fungal infections and irritation that come from sweating and the rubbing together of skin. Another cause of an erythematous rash in an intertriginous area is inverse psoriasis.

The FP performed a potassium hydroxide (KOH) preparation by scraping the erythematous area with a microscope slide and looking at the specimen under the microscope. The KOH was negative and the diagnosis was determined to be nonspecific intertrigo related to obesity. The FP told the patient to try to keep the area dry and to try some over-the-counter 1% hydrocortisone cream for the inflammation and irritation.

Pannus condylomas are uncommon—but not rare—in this age of increasing obesity. While they are secondary to HPV, they are not necessarily sexually transmitted HPV types. Based on the patient’s sexual history, the FP did not recommend screening for sexually transmitted infections.

On the initial visit, the FP counseled the patient about the importance of weight loss for good health and hygiene. The patient chose cryotherapy for treatment of the growths. While the patient held the pannus up, the FP sprayed the condyloma with liquid nitrogen using a cryo-gun. The patient chose to have a second freeze-thaw cycle and was scheduled for a follow-up visit in 3 to 4 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Genital warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

At first, the FP considered the diagnosis of seborrheic keratosis, as the lesions were verrucous and pigmented. But after asking to see the patient’s genital area, the FP made the diagnosis of condyloma acuminata.

This is a good example of how seeing the whole picture beyond what the patient shows you can lead to a more accurate diagnosis. Verrucous lesions on the penis are usually condyloma acuminata, but it is important to know that condyloma can spread up the abdomen and onto the upper thighs, as was seen in this case. The lesions can also be hyperpigmented in people of color. If any doubts remain, a shave biopsy of one of the abdominal lesions would prove the diagnosis of condyloma by demonstrating human papillomavirus (HPV) changes histologically.

In this case, the FP discussed the risk of other sexually transmitted infections with the patient. Syphilis and human immunodeficiency virus tests were ordered, and both turned out to be negative.

The patient chose cryotherapy as a treatment option and the lesions were frozen with liquid nitrogen using a standard cryo-gun and a 1 mm halo, creating an appropriate freeze ball for each lesion. The patient tolerated the procedure well and was willing to have a second freeze thaw cycle for a more rapid treatment response. The FP suggested a follow-up visit in 3 to 4 weeks for a second round of cryotherapy. The patient indicated that he would be willing to try topical imiquimod after the next visit if the cryotherapy didn’t fully work.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Genital warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

At first, the FP considered the diagnosis of seborrheic keratosis, as the lesions were verrucous and pigmented. But after asking to see the patient’s genital area, the FP made the diagnosis of condyloma acuminata.

This is a good example of how seeing the whole picture beyond what the patient shows you can lead to a more accurate diagnosis. Verrucous lesions on the penis are usually condyloma acuminata, but it is important to know that condyloma can spread up the abdomen and onto the upper thighs, as was seen in this case. The lesions can also be hyperpigmented in people of color. If any doubts remain, a shave biopsy of one of the abdominal lesions would prove the diagnosis of condyloma by demonstrating human papillomavirus (HPV) changes histologically.

In this case, the FP discussed the risk of other sexually transmitted infections with the patient. Syphilis and human immunodeficiency virus tests were ordered, and both turned out to be negative.

The patient chose cryotherapy as a treatment option and the lesions were frozen with liquid nitrogen using a standard cryo-gun and a 1 mm halo, creating an appropriate freeze ball for each lesion. The patient tolerated the procedure well and was willing to have a second freeze thaw cycle for a more rapid treatment response. The FP suggested a follow-up visit in 3 to 4 weeks for a second round of cryotherapy. The patient indicated that he would be willing to try topical imiquimod after the next visit if the cryotherapy didn’t fully work.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Genital warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

At first, the FP considered the diagnosis of seborrheic keratosis, as the lesions were verrucous and pigmented. But after asking to see the patient’s genital area, the FP made the diagnosis of condyloma acuminata.

This is a good example of how seeing the whole picture beyond what the patient shows you can lead to a more accurate diagnosis. Verrucous lesions on the penis are usually condyloma acuminata, but it is important to know that condyloma can spread up the abdomen and onto the upper thighs, as was seen in this case. The lesions can also be hyperpigmented in people of color. If any doubts remain, a shave biopsy of one of the abdominal lesions would prove the diagnosis of condyloma by demonstrating human papillomavirus (HPV) changes histologically.

In this case, the FP discussed the risk of other sexually transmitted infections with the patient. Syphilis and human immunodeficiency virus tests were ordered, and both turned out to be negative.

The patient chose cryotherapy as a treatment option and the lesions were frozen with liquid nitrogen using a standard cryo-gun and a 1 mm halo, creating an appropriate freeze ball for each lesion. The patient tolerated the procedure well and was willing to have a second freeze thaw cycle for a more rapid treatment response. The FP suggested a follow-up visit in 3 to 4 weeks for a second round of cryotherapy. The patient indicated that he would be willing to try topical imiquimod after the next visit if the cryotherapy didn’t fully work.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Genital warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed this patient with condyloma acuminata, also known as genital warts. The warts were well-keratinized since the patient was circumcised and the warts were not under foreskin. Genital warts found in the moist area under the foreskin of uncircumcised men tend to look more cauliflower-like.

Genital warts are caused by human papillomavirus infection, which encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from 3 weeks to 8 months.

Anogenital warts are the most common viral sexually transmitted disease (STD) in the United States. There are approximately one million new cases of genital warts per year in the United States. Most infections are transient and clear up within 2 years, but some infections persist and recur, causing a great deal of distress for patients.

The diagnosis is usually clinical. Genital warts are typically asymptomatic and present as flesh-colored, exophytic lesions on the genitalia, including the penis, vulva, vagina, scrotum, perineum, and perianal skin. External warts can appear as small bumps, or they may be flat, verrucous, or pedunculated.

The FP discussed the patient’s history of unsafe sex and recommended that he receive screening for other STDs. The patient did not believe he had human immunodeficiency virus (HIV), but was willing to be tested for it and for syphilis. He denied any urethral discharge or burning on urination, but wanted to be screened for gonorrhea and chlamydia, as well. The FP ordered blood tests for syphilis and HIV and a urine screen for gonorrhea and chlamydia which were all negative.

After discussing treatment options, the patient opted to pursue cryotherapy. The FP sprayed the condyloma with liquid nitrogen using a freeze/thaw/freeze cycle and offered the patient a prescription for imiquimod cream. However, the patient preferred to return for additional cryotherapy. A follow-up appointment was set for 3 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed this patient with condyloma acuminata, also known as genital warts. The warts were well-keratinized since the patient was circumcised and the warts were not under foreskin. Genital warts found in the moist area under the foreskin of uncircumcised men tend to look more cauliflower-like.

Genital warts are caused by human papillomavirus infection, which encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from 3 weeks to 8 months.

Anogenital warts are the most common viral sexually transmitted disease (STD) in the United States. There are approximately one million new cases of genital warts per year in the United States. Most infections are transient and clear up within 2 years, but some infections persist and recur, causing a great deal of distress for patients.

The diagnosis is usually clinical. Genital warts are typically asymptomatic and present as flesh-colored, exophytic lesions on the genitalia, including the penis, vulva, vagina, scrotum, perineum, and perianal skin. External warts can appear as small bumps, or they may be flat, verrucous, or pedunculated.

The FP discussed the patient’s history of unsafe sex and recommended that he receive screening for other STDs. The patient did not believe he had human immunodeficiency virus (HIV), but was willing to be tested for it and for syphilis. He denied any urethral discharge or burning on urination, but wanted to be screened for gonorrhea and chlamydia, as well. The FP ordered blood tests for syphilis and HIV and a urine screen for gonorrhea and chlamydia which were all negative.

After discussing treatment options, the patient opted to pursue cryotherapy. The FP sprayed the condyloma with liquid nitrogen using a freeze/thaw/freeze cycle and offered the patient a prescription for imiquimod cream. However, the patient preferred to return for additional cryotherapy. A follow-up appointment was set for 3 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed this patient with condyloma acuminata, also known as genital warts. The warts were well-keratinized since the patient was circumcised and the warts were not under foreskin. Genital warts found in the moist area under the foreskin of uncircumcised men tend to look more cauliflower-like.

Genital warts are caused by human papillomavirus infection, which encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from 3 weeks to 8 months.

Anogenital warts are the most common viral sexually transmitted disease (STD) in the United States. There are approximately one million new cases of genital warts per year in the United States. Most infections are transient and clear up within 2 years, but some infections persist and recur, causing a great deal of distress for patients.

The diagnosis is usually clinical. Genital warts are typically asymptomatic and present as flesh-colored, exophytic lesions on the genitalia, including the penis, vulva, vagina, scrotum, perineum, and perianal skin. External warts can appear as small bumps, or they may be flat, verrucous, or pedunculated.

The FP discussed the patient’s history of unsafe sex and recommended that he receive screening for other STDs. The patient did not believe he had human immunodeficiency virus (HIV), but was willing to be tested for it and for syphilis. He denied any urethral discharge or burning on urination, but wanted to be screened for gonorrhea and chlamydia, as well. The FP ordered blood tests for syphilis and HIV and a urine screen for gonorrhea and chlamydia which were all negative.

After discussing treatment options, the patient opted to pursue cryotherapy. The FP sprayed the condyloma with liquid nitrogen using a freeze/thaw/freeze cycle and offered the patient a prescription for imiquimod cream. However, the patient preferred to return for additional cryotherapy. A follow-up appointment was set for 3 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

I recently saw a 73-year-old Hispanic woman in the emergency department who said (through her daughter, who was translating) that she was experiencing mild headache, shortness of breath, and throat swelling. She had previously sought care for these complaints, but her condition had not improved. Her past medical and surgical history was otherwise unremarkable.

On examination, her voice was hoarse and she had bilateral 1+ pitting edema of her lower extremities. Her vital signs were stable, her lungs were clear, her throat appeared normal, and she didn’t have any skin rashes. However, her lab results included a white blood cell count of 2100/mcL, platelet count of 73,000/mcL, and an absolute neutrophil count of 1000/mm³. Her b-type natriuretic peptide, cardiac marker, and thyroid-stimulating hormone levels were normal.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not. That is, until we learned about a drug the patient had obtained in Mexico.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not.

I gathered a more detailed history and learned that the patient had been living in the United States for years, but she occasionally returned to Mexico for visits and routine medical care. During one of these trips, she’d obtained metamizole—a drug banned in the United States—and was taking it for her headaches.

A Web search revealed rare adverse effects of agranulocytosis, neutropenia, and anaphylaxis from metamizole. It is highly probable that the metamizole caused my patient’s symptoms and abnormal labs findings. I advised her of my suspicions and recommended that she stop taking the medication. A hospitalist then took over her care.

The key takeaway from this case is to account for all medications when gathering a patient’s history, including those that may be obtained outside of the United States.

Nick Ly, DO
Lillington, NC

I recently saw a 73-year-old Hispanic woman in the emergency department who said (through her daughter, who was translating) that she was experiencing mild headache, shortness of breath, and throat swelling. She had previously sought care for these complaints, but her condition had not improved. Her past medical and surgical history was otherwise unremarkable.

On examination, her voice was hoarse and she had bilateral 1+ pitting edema of her lower extremities. Her vital signs were stable, her lungs were clear, her throat appeared normal, and she didn’t have any skin rashes. However, her lab results included a white blood cell count of 2100/mcL, platelet count of 73,000/mcL, and an absolute neutrophil count of 1000/mm³. Her b-type natriuretic peptide, cardiac marker, and thyroid-stimulating hormone levels were normal.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not. That is, until we learned about a drug the patient had obtained in Mexico.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not.

I gathered a more detailed history and learned that the patient had been living in the United States for years, but she occasionally returned to Mexico for visits and routine medical care. During one of these trips, she’d obtained metamizole—a drug banned in the United States—and was taking it for her headaches.

A Web search revealed rare adverse effects of agranulocytosis, neutropenia, and anaphylaxis from metamizole. It is highly probable that the metamizole caused my patient’s symptoms and abnormal labs findings. I advised her of my suspicions and recommended that she stop taking the medication. A hospitalist then took over her care.

The key takeaway from this case is to account for all medications when gathering a patient’s history, including those that may be obtained outside of the United States.

Nick Ly, DO
Lillington, NC

I recently saw a 73-year-old Hispanic woman in the emergency department who said (through her daughter, who was translating) that she was experiencing mild headache, shortness of breath, and throat swelling. She had previously sought care for these complaints, but her condition had not improved. Her past medical and surgical history was otherwise unremarkable.

On examination, her voice was hoarse and she had bilateral 1+ pitting edema of her lower extremities. Her vital signs were stable, her lungs were clear, her throat appeared normal, and she didn’t have any skin rashes. However, her lab results included a white blood cell count of 2100/mcL, platelet count of 73,000/mcL, and an absolute neutrophil count of 1000/mm³. Her b-type natriuretic peptide, cardiac marker, and thyroid-stimulating hormone levels were normal.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not. That is, until we learned about a drug the patient had obtained in Mexico.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not.

I gathered a more detailed history and learned that the patient had been living in the United States for years, but she occasionally returned to Mexico for visits and routine medical care. During one of these trips, she’d obtained metamizole—a drug banned in the United States—and was taking it for her headaches.

A Web search revealed rare adverse effects of agranulocytosis, neutropenia, and anaphylaxis from metamizole. It is highly probable that the metamizole caused my patient’s symptoms and abnormal labs findings. I advised her of my suspicions and recommended that she stop taking the medication. A hospitalist then took over her care.

The key takeaway from this case is to account for all medications when gathering a patient’s history, including those that may be obtained outside of the United States.

Nick Ly, DO
Lillington, NC

As a scribe and accepted future medical student, I was quite interested in the article, “Medical scribes: How do their notes stack up?” by Misra-Hebert, et al (J Fam Pract. 2016;65:155-159) and the editorial, “Working with scribes—the good, the surprising” (J Fam Pract. 2016;65:154,176) in the March issue. I was struck, however, that both pieces implied that only medical assistants (MAs) are scribes.

I am familiar with practices where MAs assume a “documentation support” function in addition to their traditional role, and I currently work in a practice with professional scribes. Professional scribes are often recent college graduates who are working before beginning their studies to become a physician or physician assistant.

In my experience, MAs want to do the work they were hired and trained to do and are not enthusiastic about extensive charting. However, professional scribes apply to the position expecting to do this very task, with the goals of learning from the doctor-patient interaction, deepening their medical knowledge, and becoming comfortable in a clinical setting.

Although I am glad to see that MAs improve documentation quality per the original research mentioned above, it would be beneficial to compare the outcomes of professional scribes to those of cross-trained MAs or to traditional providers who do their own note-writing.

D. Brendan Johnson, BA
Minneapolis, Minn

As a scribe and accepted future medical student, I was quite interested in the article, “Medical scribes: How do their notes stack up?” by Misra-Hebert, et al (J Fam Pract. 2016;65:155-159) and the editorial, “Working with scribes—the good, the surprising” (J Fam Pract. 2016;65:154,176) in the March issue. I was struck, however, that both pieces implied that only medical assistants (MAs) are scribes.

I am familiar with practices where MAs assume a “documentation support” function in addition to their traditional role, and I currently work in a practice with professional scribes. Professional scribes are often recent college graduates who are working before beginning their studies to become a physician or physician assistant.

In my experience, MAs want to do the work they were hired and trained to do and are not enthusiastic about extensive charting. However, professional scribes apply to the position expecting to do this very task, with the goals of learning from the doctor-patient interaction, deepening their medical knowledge, and becoming comfortable in a clinical setting.

Although I am glad to see that MAs improve documentation quality per the original research mentioned above, it would be beneficial to compare the outcomes of professional scribes to those of cross-trained MAs or to traditional providers who do their own note-writing.

D. Brendan Johnson, BA
Minneapolis, Minn

As a scribe and accepted future medical student, I was quite interested in the article, “Medical scribes: How do their notes stack up?” by Misra-Hebert, et al (J Fam Pract. 2016;65:155-159) and the editorial, “Working with scribes—the good, the surprising” (J Fam Pract. 2016;65:154,176) in the March issue. I was struck, however, that both pieces implied that only medical assistants (MAs) are scribes.

I am familiar with practices where MAs assume a “documentation support” function in addition to their traditional role, and I currently work in a practice with professional scribes. Professional scribes are often recent college graduates who are working before beginning their studies to become a physician or physician assistant.

In my experience, MAs want to do the work they were hired and trained to do and are not enthusiastic about extensive charting. However, professional scribes apply to the position expecting to do this very task, with the goals of learning from the doctor-patient interaction, deepening their medical knowledge, and becoming comfortable in a clinical setting.

Although I am glad to see that MAs improve documentation quality per the original research mentioned above, it would be beneficial to compare the outcomes of professional scribes to those of cross-trained MAs or to traditional providers who do their own note-writing.

D. Brendan Johnson, BA
Minneapolis, Minn

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

THE CASE

A 35-year-old woman sought care for a fever and sore throat that she’d had for 4 days. She denied symptoms of cough, rhinorrhea, or sputum production.

The patient’s medical history included severe recurrent streptococcal pharyngitis as a child and teenager. At the age of 17, she developed a fever of 105° F with associated delirium, dysphagia, nausea, and vomiting, and missed several days of school. She also lost 82 pounds, developed oral thrush, and continued to feel fatigued for approximately a year. After her primary care physician noted a heart murmur on physical exam, she was sent for echocardiography and diagnosed with rheumatic fever secondary to streptococcal pharyngitis.

Eighteen years (and numerous streptococcal infections) later, the patient was at our facility and we were ordering a rapid antigen detection test (RADT) for her current illness. The throat specimen was positive for group A ß-hemolytic streptococcus (GAS). The patient’s 8-year-old daughter also had a sore throat, fever, and positive RADT; her symptoms resolved with oral amoxicillin for 10 days. The patient’s husband was also treated successfully with oral amoxicillin/clavulanate for 10 days for similar symptoms. The patient herself, however, was unsuccessfully treated with oral amoxicillin 500 mg twice daily for 7 days.

She was then given oral amoxicillin/clavulanate 875 mg twice daily for 14 days, but received no relief. Even after receiving clindamycin 600 mg twice daily for 10 days, she had minimal relief and remained positive for GAS on repeat RADT. It was at this point that tonsillectomy was considered as a possible treatment modality for her refractory GAS pharyngitis.

The patient consented to the procedure and underwent a tonsillectomy. She has remained asymptomatic for 2 years and there have been no reported outbreaks of GAS infection in her household.

DISCUSSION

Streptococcal pharyngitis is an infection of the oropharynx and/or nasopharynx that is caused by Streptococcus pyogenes (also known as GAS). It is one of the most frequent illnesses encountered by primary care physicians, and primarily occurs in children ages 5 to 15 years.^1,2 The signs and symptoms of GAS pharyngitis include an abrupt onset of a sore throat, tonsillar exudate, tender cervical adenopathy, and fever. (The classic presentation of GAS pharyngitis in a different patient can be seen in the FIGURE.)

Throat cultures are the gold standard for the diagnosis of GAS pharyngitis, but results take 24 to 48 hours, which can delay appropriate treatment. Therefore, the use of the RADT is often preferred clinically.¹ RADT is not recommended for children and adults who show clinical symptoms that are highly suggestive of a viral illness, such as cough, rhinorrhea, hoarseness, or oral ulcers. A negative RADT in children and adolescents necessitates a throat culture to confirm the diagnosis.²

The antibiotics of choice are either penicillin 50 mg/kg/d in 4 divided doses or amoxicillin 40 mg/kg/d in 3 divided doses (maximum for both is 2000 mg/d) for 10 days. Options for patients with penicillin allergies include clindamycin or clarithromycin for 10 days or azithromycin for 5 days.²

The Infectious Diseases Society of America (IDSA) does not recommend routine testing or empiric treatment of asymptomatic carriers. However, it does recommend treatment of GAS carriers in certain situations, such as when: ²

• the carrier has acute rheumatic fever
• there is a family or personal history of acute rheumatic fever
• there is a post-streptococcal glomerulonephritis outbreak
• a family has excessive anxiety about GAS infections
• a tonsillectomy is being considered.

When—and for whom—is tonsillectomy beneficial?

Tonsillectomy is a treatment option for patients with recurrent episodes of GAS pharyngitis. Indications include patients with 7 GAS infections in a year, 5 episodes in 2 years, or 3 episodes in 3 years.^3,4 In select patient populations, tonsillectomy has been shown to decrease missed work days and medical expenses caused by recurrent pharyngitis.^5,6

Alho et al demonstrated that adults with recurrent episodes of GAS pharyngitis benefit from tonsillectomy in terms of fewer repeat infections and more days without throat pain.⁷ A randomized controlled trial conducted by Koskenkorva et al found that the overall rates of pharyngitis, throat pain, rhinitis, and cough were significantly lower in adults who received a tonsillectomy vs those who did not.⁵ Still, whether tonsillectomy is worthwhile in adults is debatable; Burton et al found no evidence that tonsillectomy is effective for chronic or recurrent acute tonsillitis in adults.⁸

Our patient has not missed work or visited her primary care physician because of a GAS infection since her tonsillectomy.

Overall meta-analysis results indicate that tonsillectomy results in a 43% reduction in the incidence of pharyngitis in children between the ages of 4 and 16.^8,9 One study found that children without tonsillectomy were 3.1 times more likely to develop subsequent GAS pharyngitis than children who underwent tonsillectomy.⁹ Another study found that children who received tonsillectomy demonstrated a decrease in sore throat episodes by 1.2 episodes per year and a decrease in school absenteeism by 2.8 days per year.⁶ Tonsillectomy does carry a risk of intraoperative and postoperative bleeding in children and adults, which may make it a less desirable option for some patients.⁶

THE TAKEAWAY

Recurrent GAS pharyngitis poses a significant challenge for clinicians. When episodes recur, it may be prudent to treat asymptomatic carriers in the patient’s household. Tonsillectomy should be considered in refractory cases since recurrent GAS pharyngitis directly impacts the wellness and productivity of patients. Our patient certainly benefited from the surgery: She has not missed any work days or had to visit her primary care physician because of a GAS infection since her tonsillectomy.

THE CASE

A 35-year-old woman sought care for a fever and sore throat that she’d had for 4 days. She denied symptoms of cough, rhinorrhea, or sputum production.

The patient’s medical history included severe recurrent streptococcal pharyngitis as a child and teenager. At the age of 17, she developed a fever of 105° F with associated delirium, dysphagia, nausea, and vomiting, and missed several days of school. She also lost 82 pounds, developed oral thrush, and continued to feel fatigued for approximately a year. After her primary care physician noted a heart murmur on physical exam, she was sent for echocardiography and diagnosed with rheumatic fever secondary to streptococcal pharyngitis.

Eighteen years (and numerous streptococcal infections) later, the patient was at our facility and we were ordering a rapid antigen detection test (RADT) for her current illness. The throat specimen was positive for group A ß-hemolytic streptococcus (GAS). The patient’s 8-year-old daughter also had a sore throat, fever, and positive RADT; her symptoms resolved with oral amoxicillin for 10 days. The patient’s husband was also treated successfully with oral amoxicillin/clavulanate for 10 days for similar symptoms. The patient herself, however, was unsuccessfully treated with oral amoxicillin 500 mg twice daily for 7 days.

She was then given oral amoxicillin/clavulanate 875 mg twice daily for 14 days, but received no relief. Even after receiving clindamycin 600 mg twice daily for 10 days, she had minimal relief and remained positive for GAS on repeat RADT. It was at this point that tonsillectomy was considered as a possible treatment modality for her refractory GAS pharyngitis.

The patient consented to the procedure and underwent a tonsillectomy. She has remained asymptomatic for 2 years and there have been no reported outbreaks of GAS infection in her household.

DISCUSSION

Streptococcal pharyngitis is an infection of the oropharynx and/or nasopharynx that is caused by Streptococcus pyogenes (also known as GAS). It is one of the most frequent illnesses encountered by primary care physicians, and primarily occurs in children ages 5 to 15 years.^1,2 The signs and symptoms of GAS pharyngitis include an abrupt onset of a sore throat, tonsillar exudate, tender cervical adenopathy, and fever. (The classic presentation of GAS pharyngitis in a different patient can be seen in the FIGURE.)

Throat cultures are the gold standard for the diagnosis of GAS pharyngitis, but results take 24 to 48 hours, which can delay appropriate treatment. Therefore, the use of the RADT is often preferred clinically.¹ RADT is not recommended for children and adults who show clinical symptoms that are highly suggestive of a viral illness, such as cough, rhinorrhea, hoarseness, or oral ulcers. A negative RADT in children and adolescents necessitates a throat culture to confirm the diagnosis.²

The antibiotics of choice are either penicillin 50 mg/kg/d in 4 divided doses or amoxicillin 40 mg/kg/d in 3 divided doses (maximum for both is 2000 mg/d) for 10 days. Options for patients with penicillin allergies include clindamycin or clarithromycin for 10 days or azithromycin for 5 days.²

The Infectious Diseases Society of America (IDSA) does not recommend routine testing or empiric treatment of asymptomatic carriers. However, it does recommend treatment of GAS carriers in certain situations, such as when: ²

• the carrier has acute rheumatic fever
• there is a family or personal history of acute rheumatic fever
• there is a post-streptococcal glomerulonephritis outbreak
• a family has excessive anxiety about GAS infections
• a tonsillectomy is being considered.

When—and for whom—is tonsillectomy beneficial?

Tonsillectomy is a treatment option for patients with recurrent episodes of GAS pharyngitis. Indications include patients with 7 GAS infections in a year, 5 episodes in 2 years, or 3 episodes in 3 years.^3,4 In select patient populations, tonsillectomy has been shown to decrease missed work days and medical expenses caused by recurrent pharyngitis.^5,6

Alho et al demonstrated that adults with recurrent episodes of GAS pharyngitis benefit from tonsillectomy in terms of fewer repeat infections and more days without throat pain.⁷ A randomized controlled trial conducted by Koskenkorva et al found that the overall rates of pharyngitis, throat pain, rhinitis, and cough were significantly lower in adults who received a tonsillectomy vs those who did not.⁵ Still, whether tonsillectomy is worthwhile in adults is debatable; Burton et al found no evidence that tonsillectomy is effective for chronic or recurrent acute tonsillitis in adults.⁸

Our patient has not missed work or visited her primary care physician because of a GAS infection since her tonsillectomy.

Overall meta-analysis results indicate that tonsillectomy results in a 43% reduction in the incidence of pharyngitis in children between the ages of 4 and 16.^8,9 One study found that children without tonsillectomy were 3.1 times more likely to develop subsequent GAS pharyngitis than children who underwent tonsillectomy.⁹ Another study found that children who received tonsillectomy demonstrated a decrease in sore throat episodes by 1.2 episodes per year and a decrease in school absenteeism by 2.8 days per year.⁶ Tonsillectomy does carry a risk of intraoperative and postoperative bleeding in children and adults, which may make it a less desirable option for some patients.⁶

THE TAKEAWAY

Recurrent GAS pharyngitis poses a significant challenge for clinicians. When episodes recur, it may be prudent to treat asymptomatic carriers in the patient’s household. Tonsillectomy should be considered in refractory cases since recurrent GAS pharyngitis directly impacts the wellness and productivity of patients. Our patient certainly benefited from the surgery: She has not missed any work days or had to visit her primary care physician because of a GAS infection since her tonsillectomy.

THE CASE

A 35-year-old woman sought care for a fever and sore throat that she’d had for 4 days. She denied symptoms of cough, rhinorrhea, or sputum production.

The patient’s medical history included severe recurrent streptococcal pharyngitis as a child and teenager. At the age of 17, she developed a fever of 105° F with associated delirium, dysphagia, nausea, and vomiting, and missed several days of school. She also lost 82 pounds, developed oral thrush, and continued to feel fatigued for approximately a year. After her primary care physician noted a heart murmur on physical exam, she was sent for echocardiography and diagnosed with rheumatic fever secondary to streptococcal pharyngitis.

Eighteen years (and numerous streptococcal infections) later, the patient was at our facility and we were ordering a rapid antigen detection test (RADT) for her current illness. The throat specimen was positive for group A ß-hemolytic streptococcus (GAS). The patient’s 8-year-old daughter also had a sore throat, fever, and positive RADT; her symptoms resolved with oral amoxicillin for 10 days. The patient’s husband was also treated successfully with oral amoxicillin/clavulanate for 10 days for similar symptoms. The patient herself, however, was unsuccessfully treated with oral amoxicillin 500 mg twice daily for 7 days.

She was then given oral amoxicillin/clavulanate 875 mg twice daily for 14 days, but received no relief. Even after receiving clindamycin 600 mg twice daily for 10 days, she had minimal relief and remained positive for GAS on repeat RADT. It was at this point that tonsillectomy was considered as a possible treatment modality for her refractory GAS pharyngitis.

The patient consented to the procedure and underwent a tonsillectomy. She has remained asymptomatic for 2 years and there have been no reported outbreaks of GAS infection in her household.

DISCUSSION

Streptococcal pharyngitis is an infection of the oropharynx and/or nasopharynx that is caused by Streptococcus pyogenes (also known as GAS). It is one of the most frequent illnesses encountered by primary care physicians, and primarily occurs in children ages 5 to 15 years.^1,2 The signs and symptoms of GAS pharyngitis include an abrupt onset of a sore throat, tonsillar exudate, tender cervical adenopathy, and fever. (The classic presentation of GAS pharyngitis in a different patient can be seen in the FIGURE.)

Throat cultures are the gold standard for the diagnosis of GAS pharyngitis, but results take 24 to 48 hours, which can delay appropriate treatment. Therefore, the use of the RADT is often preferred clinically.¹ RADT is not recommended for children and adults who show clinical symptoms that are highly suggestive of a viral illness, such as cough, rhinorrhea, hoarseness, or oral ulcers. A negative RADT in children and adolescents necessitates a throat culture to confirm the diagnosis.²

The antibiotics of choice are either penicillin 50 mg/kg/d in 4 divided doses or amoxicillin 40 mg/kg/d in 3 divided doses (maximum for both is 2000 mg/d) for 10 days. Options for patients with penicillin allergies include clindamycin or clarithromycin for 10 days or azithromycin for 5 days.²

The Infectious Diseases Society of America (IDSA) does not recommend routine testing or empiric treatment of asymptomatic carriers. However, it does recommend treatment of GAS carriers in certain situations, such as when: ²