A 32-year-old woman comes to the office due to 3 days of sore throat and cough productive of white sputum. She has also had malaise, nausea, and headache but no shortness of breath. No close contacts have had similar symptoms. The patient has a history of hypertension and acne; she takes lisinopril and uses benzoyl peroxide cream. She does not use tobacco, alcohol, or illicit drugs. The patient is monogamous with her husband. Family history is significant for chronic kidney disease in her father. She is allergic to penicillin, which causes a rash. Temperature is 38.6 C (101.5 F), blood pressure is 122/70 mm Hg, pulse is 83/min, and respirations are 14/min. Oropharyngeal examination reveals pharyngeal erythema, palatal petechiae, and bilateral white, patchy tonsillar exudates. There are 2 tender, 1.5-cm lymph nodes in the anterior cervical chain. The lungs are clear to auscultation. The abdomen is soft and nontender. No other lymphadenopathy, organomegaly, or rashes are present. The remainder of the physical examination is normal. Which of the following is the most appropriate course of action in management of this patient?

Question

A 32-year-old woman comes to the office due to 3 days of sore throat and cough productive of white sputum.  She has also had malaise, nausea, and headache but no shortness of breath.  No close contacts have had similar symptoms.  The patient has a history of hypertension and acne; she takes lisinopril and uses benzoyl peroxide cream.  She does not use tobacco, alcohol, or illicit drugs.  The patient is monogamous with her husband.  Family history is significant for chronic kidney disease in her father.  She is allergic to penicillin, which causes a rash.  Temperature is 38.6 C (101.5 F), blood pressure is 122/70 mm Hg, pulse is 83/min, and respirations are 14/min.  Oropharyngeal examination reveals pharyngeal erythema, palatal petechiae, and bilateral white, patchy tonsillar exudates.  There are 2 tender, 1.5-cm lymph nodes in the anterior cervical chain.  The lungs are clear to auscultation.  The abdomen is soft and nontender.  No other lymphadenopathy, organomegaly, or rashes are present.  The remainder of the physical examination is normal.  Which of the following is the most appropriate course of action in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with sore throat, pharyngeal erythema, and tonsillar exudates has acute pharyngitis. Most cases of acute pharyngitis are due to viral pathogens, but 5%-15% of individuals have group A Streptococcus (GAS) infections. In adults, the Centor criteria score can help distinguish whether a patient is likely to have GAS. This clinical predictive tool assigns 1 point for each of the following manifestations: Tonsillar exudate Tender anterior cervical adenopathy Fever Absence of cough Patients with a Centor score <3 have a low probability of a GAS infection; they do not require testing or antimicrobial treatment and can be managed symptomatically (Choice D). Patients with a Centor score of 3 (as in this patient) or 4 are more likely to have GAS and require a streptococcal rapid antigen detection test (RADT) to confirm the microbiologic diagnosis (recommended prior to antibiotic initiation). The Centor criteria are most useful for identifying patients who do not need to be tested or treated for GAS pharyngitis. Different guidelines may use different cutoffs, but the presence of 3 criteria generally warrants testing. (Choices B and C) Patients who have a positive streptococcal RADT should be treated with antibiotics. Ten days of oral penicillin V or amoxicillin is the standard of care. Patients with a nonanaphylactic allergy to penicillin can receive 10 days of a first-generation cephalosporin (eg, cephalexin); 5 days of azithromycin can also be used. This patient with a Centor score of 3 should receive a streptococcal RADT before antibiotic therapy is considered. (Choice E) Throat culture is the most sensitive test for the detection of GAS. However, throat culture results require 24-48 hours for test results. In adults, a streptococcal RADT alone is considered sufficient to diagnose or exclude GAS. Educational objective: The Centor criteria score is widely used to predict the likelihood of streptococcal pharyngitis. The criteria are tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough. Streptococcal rapid antigen detection testing is recommended for patients who have >3 Centor criteria. Patients with <3 criteria are likely to have viral pharyngitis and do not require testing or antimicrobial treatment.

A 32-Year-Old Woman Comes to the Office Due to 3