Check out this Telemedicine Case Study and test your skills as a clinician.

1. A Telemedicine
Case Study
Bring out your inner diagnostician
THE PULSE OF TELEHEALTH | MeMD

2. HISTORY OF PRESENT ILLNESS
2
 A 59 year old Female presents to your virtual clinic with sore throat and a picture
attached showing mild bilateral tonsillar exudate.
 There is no significant past medical/surgical/familial/social history besides an
appendectomy at age 26 and occasional alcohol use.
 The patient states that they had sinus symptoms for about a week and then began
having a sore throat 3 days ago and were seen at an Urgent Care last night with a
negative rapid strep test result.
 The patient says that they feel fine they just want some relief from their sore throat
and are frustrated that they were sent home without anything to help with their
symptoms.

3. DIFFERENTIAL DIAGNOSIS
3
 After considering the patient’s presentation
and negative rapid strep test, you
conclude the likely diagnosis to be viral
pharyngitis. You reassure the patient that
their sore throat will resolve in the next
couple of days and recommend salt water
gargles and to follow up with their primary
care provider if their symptoms do not
resolve in the next 2-3 days.
 The patient understands and is grateful for
the reassurance and will begin salt water
gargles to help with symptoms.

4. FOLLOW-UP CONSULTATION
4
 Two weeks later, you receive a call
from the same patient. They state that
their sore throat resolved a couple
days after your last contact, but that
they saw some blood in their urine this
morning and feel like their ankles are
swollen. You ask the patient if the
Urgent Care had done a culture lab
test, but they are unsure and have not
heard anything from them.

5. DIFFERENTIAL DIAGNOSIS
5
 You check the literature and see that Rapid Strep Test has a
sensitivity of 80-90%. You refer the patient to present at a
nearby Emergency Department and explain your concern for
Post-Streptococcal Glomerulonephritis (PSGN). You inform the
patient that they need to explain to the provider they see
that they were referred for this specific reason as PSGN can
be a serious condition. The patient agrees to go to the
nearest emergency department, her husband will drive her
there immediately.

6. 2 4 H O U R F O L L O W - U P
6
 24 hours later, a follow up
call reveals that the patient
presented to the ED and
the diagnosis of PSGN was
confirmed. The patient is
staying in the hospital for
monitoring and supportive
management, and is
expected to recover
completely.

7. T A K E H O M E P O I N T S
7
 It is important to remember the possibility of a post-streptococcal syndrome for telemedicine patients
with a history of a resolved sore throat in the recent past, especially those who were not treated with
an antibiotic, as in this case. These syndromes include glomerulonephritis, rheumatic fever, and
polyarthritis.
 These syndromes are more common in younger patients, especially children.
 The rare cases of post-streptococcal syndromes are NOT an indication for blanket treatment of all sore
throats/pharyngitis with antibiotics without a positive rapid strep test or strep culture.
 Telemedicine practice is moving toward closer cooperation between telemedicine providers and
primary care providers with regard to pharyngitis and the need for lab confirmation of strep infection
(as opposed to the much more common case of viral pharyngitis) before antibiotics are initiated.
 As in this case the onset of a post-streptococcal syndrome is typically several weeks after the initial
(untreated) strep pharyngitis so there is plenty of time to properly test these acute pharyngitis patients
before antibiotics are prescribed.