SORE THROAT
Problem solving diagnostic
approach
The most common etiologic agent of acute pharyngitis is
a virus.
The drug of choice for treating group A β-hemolytic streptococcus is
penicillin V.
The most important parts of the diagnostic workup for pharyngitis
are a thorough history and an accurate physical examination.
The heterophil antibody test misses a third of infectious
mononucleosis cases in the first week of the disease.
All patients first seen with pharyngitis should receive appropriate
analgesics, antipyretics, and supportive care.
Clinic Visit
Subjective
Patient Identification and Presenting Problem
Nevien, a 13-year-old girl, complains of a sore throat and fever,
which started abruptly while at a visit to her uncle house yesterday.
She admits to a decreased appetite due to feeling mildly nauseated
without vomiting or diarrhea.
Nevien states that she feels "worn out" with a slight headache.
Her throat is what bothers her the most, even swallowing her own
saliva.
She also admits that her ears ache.
She denies being around anyone who is sick.
Medical History
Allergies
No known drug allergies.
Medical
Nevien is the youngest and the only girl of three children.
Her mother had no complications during the prenatal and delivery
course.
She is up to date with all her immunizations.
She has been in the 60th percentile for weight and height all her life.
She takes no medications.
She has had two episodes of streptococcal pharyngitis in the last 4
years, the last episode being 1.5 years ago.
She did require tympanostomy tubes when she was 2 years old
because of recurrent middle ear infections.
Surgical
Tympanostomy tubes at age 2.
Family History
Both of Nevien's parents are in good health.
Her maternal grandmother died at age 62 of breast cancer.
The rest of her relatives are alive and well.
Social History
Nevien is in 8th grade and is on the honor roll.
She plays volleyball and is a member of a traveling soccer team.
She has never attempted cigarettes or illicit drugs.
Her father smokes outside the house, and he avoids smoking in
the car.
She gets along well with her two older brothers, who are 15 and
17 years old.
Review of Systems
Aside from that mentioned earlier,
she denies abdominal pain,
discolored urine, dizziness,
nasal congestion,
sinus pressure,
or skin rashes.
A dry cough developed since this morning.
Objective
Vital Signs
Height, 147 cms
Weight, 51 kg
Temperature, 38.9 °C
Blood pressure, 98/68
Pulse, 96 (regular) beats per minute
Respiratory rate, 14 respirations per minute
Physical Examination
General
Nevien is a slightly tired-appearing young girl in no
acute distress and appropriately dressed.
Skin
Normal skin turgor and pigmentation.
No rashes are appreciated.
Head, Eyes, Ears,
Nose, and Throat
Normocephalic.
Eyes are anicteric, and the
conjunctivae are clear.
Her tympanic membranes are
without erythema or fluid levels.
Nasal mucosa is slightly swollen,
and the oropharynx shows swollen
and erythematous tonsils with
exudates.
Several petechiae are appreciated
on the upper palate and uvula.
No sinus tenderness is present.
Neck
The thyroid is not palpable.
Bilateral prominent and tender anterior cervical lymph nodes
are palpated.
No posterior cervical, pre- or postauricular lymph nodes are
appreciated.
Chest
Lungs are clear to auscultation bilaterally.
Heart
Regular rate and rhythm. No murmurs are appreciated.
Pulses are +2 throughout.
Abdomen
Flat, normal bowel sounds, soft and nontender. No masses
are appreciated. No hepato- splenomegaly is noted.
Assessment
Working Diagnosis
The working diagnosis is acute pharyngitis.
Differential etiology includes:
group A β-hemolytic streptococcus,
viral not otherwise specified (NOS),
infectious mononucleosis.
Plan
Diagnostic
A rapid streptococcal antigen test is
ordered and returns positive.
No other tests are ordered.
Treatment
Nevien is given penicillin V, 500 mg, to take by mouth every 8 hours
for 10 days, because she refused the intramuscular injection.
Over-the-counter analgesics are recommended for fever and pain.
Analgesic throat spray also is mentioned for her consideration.
She is instructed to drink plenty of fluids and to gargle with warm
salt water for symptomatic relief.
She is given a school absence note and instructed to avoid sharing
utensils and cups with others.
She should take the antibiotic for at least 24 hours before coming
into contact with others.
She is instructed to return to clinic if she does not improve, if a rash
develops, if dark urine is noticed, or if symptoms worsen.
DISCUSSION
Pharyngitis is one of the most common medical conditions
encountered in ambulatory care offices.
It accounts for little more than 1% of all office visits in primary care
offices.
The ultimate decision that must be made by physicians is whether
antibiotics are indicated.
A delicate balance exists between overprescribing antibiotics,
appropriately ordering diagnostic tests, and preventing
complications from untreated pharyngitis.
This is accomplished by a taking a good history, completing an
accurate physical examination, and appropriately ordering
diagnostic tests.
Group A ß hemolytic streptococci
Approximately 15% to 30% of pharyngitis cases in
children are attributable to GABHS, whereas only 5% to
15% of adult cases are caused by the bacterium
The objective in treating GABHS infection is to
improve symptoms,
decrease the spread of disease,
and prevent, although rare, life-threatening
complications, such as rheumatic fever, acute
glomerulonephritis, and peritonsillar abscesses
The most common signs and symptoms of
GABHS infection include:
severe pharyngitis with tonsillar exudates,
anterior cervical lymphadenopathy,
fever,
and palatine petechiae.
If untreated, GABHS pharyngitis can last for about
7 to 10 days and individuals can be infectious for
up to 1 week after the acute phase
Antibiotic Choices for Group A β-Hemolytic Streptococcus
Antibiotic Pediatric Dose Adult Dose Frequency Duration
Penicillin V250 mg 500 mg Three times daily 10 days
Benzathine
Penicillin 600,000 units 1,200,000 units One IM injection
Amoxicillin 13.3 mg/kg/dose 500 mg Three times daily 10 days
Ampicillin 12.5 mg/kg/dose 500 mg Four times daily 10 days
Amoxicillin-
clavulanate
Potassium 20 mg/kg/dose 875 mg Two times daily 10 days
Erythromycin
Ethylsuccinate 10 mg/kg/dose 400 mg Four times daily 10 days
Azithromycin 12 mg/kg/dose 500 mg on day 1 and 250 mg
on days 2-5, Once daily 5 days
Cephalexin 6.25-12.5 mg/kg/dose 250 mg Four times daily 10 days
Group A β-Hemolytic Streptococcus
Sore Throat Score
Give 1 point for each:
The patient is younger than 15 years
Tonsillar swelling or exudates
Tender anterior cervical lymphadenopathy
Temperature >100.4°F
Absence of cough
Subtract 1 point if:
The patient is older than 45 years
Scoring
O to 1 Low risk:
Antibiotic therapy, rapid strep test, and
throat culture are not indicated.
1 to 3 Intermediate risk:
Perform rapid strep test and treat
accordingly.
If rapid strep test is negative, consider throat
culture for children.
4 to 5 High risk:
Empiric antibiotics.
Rapid strep test and/or culture is optional.
Clinical decision rules have been developed to help in accurately
diagnosing GABHS pharyngitis because no single element in the history
or examination is sensitive or specific enough to diagnose or rule out
streptococcal pharyngitis (Gerber, 1998
). Others have supported such an approach (Cooper et al., 2001
).
McIsaac and colleagues (2000
) developed a scored approach by using five criteria: age, tonsillar swelling or exudate, anterior
cervical lymphadenopathy, absence of cough, and fever higher than 100.4°F (Table 17-2). Based on
the score, patients are placed in the low-, intermediate-, or high-risk group. Patients in the low-risk
group should not receive treatment and should have no further testing. Those in the high-risk group
should be given empiric antibiotics, and a throat culture or rapid streptococcal antigen test or both
may be considered. Patients in the intermediate group should have further testing with the rapid
streptococcal antige
n test or throat culture or both. All refractory cases should have a throat culture performed. It is
advocated that children with a negative rapid streptococcal antigen test should have the result
confirmed by a throat culture (Bisno et al., 2002
). A negative rapid streptococcal antigen test does not require confirmation by a throat culture in
adults (Bisno et al., 2002
). The rapid streptococcal antigen test has an approximate sensitivity of 95% and specificity of 97%
(Vincent et al., 2004
). The throat culture has an approximate sensitivity of 97% and specificity of 99%, depending on
the technique and medium used (Vincent et al., 2004
).