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Diagnosis and Treatment of Respiratory Illness in Children and Adults Second Edition/January 2008 Pharyngitis Algorithm

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Diagnosis and Treatment of Respiratory Illness in Children and Adults Second Edition/January 2008 Pharyngitis Algorithm Health Care Guideline: ICS I Diagnosis and Treatment of Respiratory Illness in I NSTITUTE FOR C LINICAL Children and Adults S YSTEMS I MPROVEMENT Second Edition January 2008 The information contained in this ICSI Health Care Guideline is intended primarily for health profes- sionals and the following expert audiences: • physicians, nurses, and other health care professional and provider organizations; • health plans, health systems, health care organizations, hospitals and integrated health care delivery systems; • health care teaching institutions; • health care information technology departments; • medical specialty and professional societies; • researchers; • federal, state and local government health care policy makers and specialists; and • employee benefit managers. This ICSI Health Care Guideline should not be construed as medical advice or medical opinion related to any specific facts or circumstances. If you are not one of the expert audiences listed above you are urged to consult a health care professional regarding your own situation and any specific medical questions you may have. In addition, you should seek assistance from a health care professional in interpreting this ICSI Health Care Guideline and applying it in your individual case. This ICSI Health Care Guideline is designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a protocol for all patients with a particular condition. An ICSI Health Care Guideline rarely will establish the only approach to a problem. Copies of this ICSI Health Care Guideline may be distributed by any organization to the organization's employees but, except as provided below, may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally constituted medical group, the ICSI Health Care Guideline may be used by the medical group in any of the following ways: • copies may be provided to anyone involved in the medical group's process for developing and implementing clinical guidelines; • the ICSI Health Care Guideline may be adopted or adapted for use within the medical group only, provided that ICSI receives appropriate attribution on all written or electronic documents; and • copies may be provided to patients and the clinicians who manage their care, if the ICSI Health Care Guideline is incorporated into the medical group's clinical guideline program. All other copyright rights in this ICSI Health Care Guideline are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adaptations or revisions or modifications made to this ICSI Health Care Guideline. Health Care Guideline: Diagnosis and Treatment of Respiratory Illness in ICS I Children and Adults I NSTITUTE FOR C LINICAL 1 S YSTEMS I MPROVEMENT A = Annotation Patient reports some combination of symptoms: • Sore throat Second Edition • Rhinorrhea January 2008 • Cough • Fever • Laryngitis • Headache A 2 3 yes Does patient have See immediately emergent symptoms? A A no 6 4 Symptoms of pharyngitis: 5 • Sudden onset of sore throat yes Schedule visit or • Exudative tonsilitis Are comorbid consult with provider • Tender anterior cervical conditions present? for need to be seen adenopathy • History of fever A • Headache no • Abdominal pain • No rhinorrhea, cough, 6 hoarseness 7 See pharyngitis yes Are symptoms algorithm box #15 suggestive of 8 pharyngitis? Symptoms of rhinitis: • Pruritis of the eyes, nose, A palate, ears no • Watery rhinorrhea 8 • Sneezing • Seasonal changes 9 • Family history of allergies See rhinitis algorithm yes Are symptoms • Sensitivity to specific box #30 suggestive of allergens, especially dust, rhinitis? animal dander, pollen and mold A • Atopy no • Nasal congestion • Postnasal drip 10 1 1 See sinusitis yes Are symptoms 1 0 algorithm box #44 suggestive of sinusitis? Symptoms of sinusitis: Upper respiratory symptoms A present greater than 7 days. no Two or more of the following factors present at a point of 12 greater than 7 days after onset: 1 3 • Cough • Documented past history of • Patient education yes • Home care call-back Are symptoms sinusitis instructions suggestive of VURI? • Ear pressure/fullness A • Facial pain, particularly if A aggravated by postural no changes or by valsalva maneuver 14 • Fatigue • Fever Evaluation by • Hyposmia/anosmia provider • Known anatomical nasal blockage • Nasal congestion • Nasal drainage • Poor response to decongestive • Postnasal drip • Tenderness over sinus area • Tooth pain www.icsi.org Copyright © 2008 by Institute for Clinical Systems Improvement 1 Diagnosis and Treatment of Respiratory Illness in Children and Adults Second Edition/January 2008 Pharyngitis Algorithm 15 A = Annotation Patient has symptoms suggestive of pharyngitis A 16 History/physical Treatment: Penicillin is the drug A of choice. 17 Collect specimen for rapid strep test and Commonly prescribed backup culture antibiotics not reliably A antistreptococcal: 1. Sulfa medications 18 (Septra, Bactrim, 1 9 Gantrisin) positive 2. Nitrofurantion Rapid stress test Treatment and (Macrodantin) result? education 3. Tetracycline A negative 20 21 23 24 Symptoms yes Complete improved within treatment Education for Consider strep 48-72 hours? home remedies culture A A A A no 22 2 5 Consider re-evaluation Strep culture positive • Broad spectrum culture result? • Mono testing, if appropriate • Empirical antibiotic therapy A A negative 2 6 Educate on non-GABS pharyngitis symptoms A 27 28 Symptoms yes Continue with home improved? care A A no 2 9 Consider re-evaluation • Broad spectrum culture • Mono testing, if appropriate A www.icsi.org Institute for Clinical Systems Improvement 2 Diagnosis and Treatment of Respiratory Illness in Children and Adults Second Edition/January 2008 Rhinitis Algorithm 30 A = Annotation Patient presents with symptoms of rhinitis A 3 1 History/physical A 32 3 7 38 Signs and symptoms no Signs and symptoms yes Consider referral to suggest allergic suggest structural specialist etiology? etiology? A A yes no 33 3 9 Initiate symptomatic treatment Non-allergic • Allergen avoidance rhinitis • Medication therapy A A 4 0 34 35 Initiate symptomatic yes • Patient education Symptoms • Follow-up as treatment improved? appropriate A A A 4 1 no 4 2 3 6 Symptoms no Consider referral to Consider: specialist • Further diagnostic testing improved? • Referral to a specialty A A provider yes A 43 • Continue treatment • Follow-up • Patient education www.icsi.org Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Second Edition/January 2008 Sinusitis Algorithm 44 A = Annotation Patient has symptoms suggestive of sinusitis A 4 5 Schedule visit within 24-48 hours A 4 6 History/physical A 47 Does patient have sinusitis? no yes 48 49 Home self-care Treatment A A 50 51 Treatment no Education failure? A yes 5 2 Consider alternative diagnosis or referral to ear, nose and throat provider www.icsi.org Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Second Edition/January 2008 Table of Contents Work Group Leader Algorithms and Annotations ....................................................................................... 1-51 Leonard Snellman, MD Algorithm (Main) ...............................................................................................................1 Pediatrics, HealthPartners Algorithm (Pharyngitis) .....................................................................................................2 Medical Group Algorithm (Rhinitis) ...........................................................................................................3 Work Group Members Algorithm (Sinusitis) ..........................................................................................................4 Allergy Foreword David Graft, MD Park Nicollet Health Scope and Target Population ......................................................................................... 6 Services Clinical Highlights and Recommendations .................................................................. 6 ENT Priority Aims ................................................................................................................. 6 William Avery, DO Related ICSI Scientific Documents .............................................................................. 7 Sanford Health Disclosure of Potential Conflict of Interest ................................................................... 7 Family Practice Introduction to ICSI Document Development .............................................................. 7 Jeffrey Jenkins, MD Description of Evidence Grading.................................................................................. 8 Sanford Health Introduction .........................................................................................................................9 Heather Krueger, MD Annotations ................................................................................................................... 9-50 Quello Clinic Annotations (Main) .................................................................................................. 9-20 Carolyn Sparks, MD University of Minnesota Annotations (Pharyngitis) .....................................................................................
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