A 37-year-old man comes to the physician for acute onset of a sore throat that has gotten progressively worse during the day. He is also experiencing some mild myalgias. For the past 2 days, he has had subjective fevers and a nonproductive cough. He does not have chills or fatigue. The patient has not been exposed to a similar illness and has no HIV risk factors. He has no significant past medical history, takes no medications, and has no known allergies.
His temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 16/min. Oropharyngeal examination shows slightly enlarged tonsils with grayish-white exudates. There are a few palpable, bilateral, small, and slightly tender anterior cervical nodes. Auscultation of the heart and lungs is normal. The abdomen is soft, and there is no hepatosplenomegaly.
What is the best next step in management of this patient?

Question

A 37-year-old man comes to the physician for acute onset of a sore throat that has gotten progressively worse during the day.  He is also experiencing some mild myalgias.  For the past 2 days, he has had subjective fevers and a nonproductive cough.  He does not have chills or fatigue.  The patient has not been exposed to a similar illness and has no HIV risk factors.  He has no significant past medical history, takes no medications, and has no known allergies.
His temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 16/min.  Oropharyngeal examination shows slightly enlarged tonsils with grayish-white exudates.  There are a few palpable, bilateral, small, and slightly tender anterior cervical nodes.  Auscultation of the heart and lungs is normal.  The abdomen is soft, and there is no hepatosplenomegaly.
What is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_985a_af02_853d_a3b1c3eca2c1_MD0002_00 This patient has acute pharyngitis and fulfills 3 of 4 Centor criteria (he does not fulfill the criterion of "absence of cough" given that he has a nonproductive cough). The most appropriate next step is to obtain a rapid antigen test to exclude group A streptococcal (GAS) pharyngitis as untreated patients are at risk for developing complications (eg, rheumatic fever, acute glomerulonephritis, peritonsillar abscess). The Centor criteria (tonsillar exudates, tender anterior cervical lymphadenopathy, fever by history, and absence of cough) help determine the likelihood of GAS pharyngitis and guide further workup and treatment. Patients with 0-1 criteria do not require further work up or treatment (high negative predictive value). Patients with >2 criteria should be evaluated with a rapid streptococcal antigen test (RSAT), which has high specificity. Some clinicians will treat GAS pharyngitis empirically if all 4 criteria are met. Guidelines may use different cutoffs, but the presence of 3 criteria (as in this patient) generally warrants testing. (Choice A) Antibiotics are indicated in patients with a positive RSAT or those who fulfill 4 Centor criteria. Oral penicillin V and amoxicillin are common first-line agents due to their modest cost, narrow spectrum, and tolerability. First-generation cephalosporins (eg, cephalexin) are an alternate therapy if treatment fails. Macrolides (eg, erythromycin) are used for penicillin-allergic patients. (Choice B) Nonsteroidal anti-inflammatory drugs are appropriate for symptomatic relief of pain associated with nonspecific pharyngitis, but this patient should first be evaluated with an RSAT. (Choice C) Infectious mononucleosis (IM) can present in a similar fashion, but it is more common in patients age 15-24. Other signs and symptoms that are commonly seen with IM but are absent in this patient include fatigue (90%-100%), posterior lymphadenopathy (100%), and splenomegaly (60%). (Choice E) Although throat culture has high sensitivity and specificity in identifying GAS infection, the delay in obtaining results often limits its use in the acute setting. Throat culture can be considered in patients who have a negative RSAT result yet in whom the suspicion for GAS infection is still high (eg, 4 positive Centor criteria with negative RSAT). Educational objective: The Centor criteria (tonsillar exudates, tender anterior cervical lymphadenopathy, fever by history, and absence of cough) are widely used to determine the likelihood of group A streptococcal pharyngitis. Patients with >2 criteria should have a rapid streptococcal antigen test and receive therapy with oral penicillin or amoxicillin if test results are positive. __________ References: Principles of appropriate antibiotic use for acute pharyngitis in adults: background. (http://www.ncbi.nlm.nih.gov/pubmed/11255530) Executive Summary: Clinical practice guideline for the diagnosis and management of group a streptococcal pharyngitis: 2012 Update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/23091044)

A 37-Year-Old Man Comes to the Physician for Acute Onset