A 35-year-old woman comes to the office with a 3-day history of sore throat. A day after the sore throat started, she developed runny nose and cough. The patient has had difficulty sleeping due to the severity of the cough. She has smoked a pack of cigarettes daily for the last 10 years. Temperature is 37.1 C (98.8 F) and blood pressure is 115/65 mm Hg. Oxygen saturation is 98% on room air. The tympanic membranes are clear and intact. The tonsils are red and without exudate. The uvula is midline. There is no cervical lymphadenopathy. The lungs are clear to auscultation, and the abdomen is nontender. Which of the following is the best next step in management of this patient?

Question

A 35-year-old woman comes to the office with a 3-day history of sore throat.  A day after the sore throat started, she developed runny nose and cough.  The patient has had difficulty sleeping due to the severity of the cough.  She has smoked a pack of cigarettes daily for the last 10 years.  Temperature is 37.1 C (98.8 F) and blood pressure is 115/65 mm Hg.  Oxygen saturation is 98% on room air.  The tympanic membranes are clear and intact.  The tonsils are red and without exudate.  The uvula is midline.  There is no cervical lymphadenopathy.  The lungs are clear to auscultation, and the abdomen is nontender.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d226_ae8f_bc81_016ca0a88549_MD0003_00 This patient has acute pharyngitis, characterized by tonsillar and/or oropharyngeal pain and redness. Viral pharyngitis is more common than bacterial pharyngitis and is caused by common cold viruses (eg, adenovirus, rhinovirus, coronavirus), which produce upper respiratory tract symptoms (eg, rhinorrhea, nasal congestion, cough), occasionally accompanied by conjunctival injection (ie, viral conjunctivitis). Viral pharyngitis typically lacks exudates, fever is typically low-grade, and cervical lymphadenopathy is minimal or absent. Symptoms generally self-resolve within a week, and symptomatic treatment (eg, nonsteroidal anti-inflammatory drugs) alone is often sufficient; antibiotics are not indicated (Choice A). In contrast, bacterial pharyngitis, most commonly caused by group A Streptococcus (GAS), typically presents with isolated exudative pharyngitis (ie, absence of cough, rhinorrhea, conjunctivitis), along with fever and anterior cervical lymphadenopathy. Although GAS pharyngitis also self-resolves, it can cause rare but serious complications such as acute rheumatic fever, rheumatic heart disease, and post-streptococcal glomerulonephritis, especially in children. To reduce the risk of these complications, treatment with a penicillin is recommended. Streptococcal rapid antigen detection test (RADT) can diagnose pharyngitis due to GAS but is not needed if clinical suspicion is low. In adults, the Centor criteria are used to determine the need for RADT: Score 0-1: low likelihood of GAS pharyngitis; no testing or antibiotic therapy Score 2-3: intermediate likelihood of GAS; RADT with antibiotic therapy if positive Score 4: high likelihood of GAS; consider empiric antibiotic therapy without testing This patient has a Centor criteria score of 0; neither RADT nor antibiotic therapy is indicated (Choices A and C). (Choice B) Although viral respiratory infections are occasionally complicated by secondary bacterial pneumonia, this patient has no concerning features (eg, fever, crackles on lung examination) for which a chest x-ray is warranted. (Choice E) Throat culture is more sensitive than RADT (90%-95% versus 77%-92%) but is not the first-line test to evaluate for GAS because it takes 24-48 hours (versus 10 minutes for RADT). Given the relatively low incidence of GAS pharyngitis in adults, throat culture is generally reserved to confirm a negative RADT in those in whom GAS infection carries a high risk of complications (eg, history of rheumatic fever, caring for infants). Educational objective: Group A Streptococcus (GAS) pharyngitis is characterized by exudative pharyngitis, fever, tender anterior cervical lymphadenopathy, and absence of cough, features that are less common in viral pharyngitis. Patients at low risk for GAS pharyngitis based on these clinical criteria do not require rapid antigen testing or empiric antibiotic treatment. References: Poststreptococcal illness: recognition and management. (http://www.ncbi.nlm.nih.gov/pubmed/29671499) Common questions about streptococcal pharyngitis. (http://www.ncbi.nlm.nih.gov/pubmed/27386721)

A 35-Year-Old Woman Comes to the Office with a 3-Day