Case:

Mr. W is a 30-year-old man who complains of having a sore throat for 3 days. Mr. W’s symptoms started abruptly 3 days ago when sore throat, pain with swallowing, fever, and headaches developed. He denies symptoms of cough, coryza, or rhinorrhea.

Mr. W is otherwise healthy. He has had no recent sick contacts and no recent travel. He is a heterosexual male, married, and monogamous with his wife. He has no history of blood transfusions or illicit drug use.

The physical exam is notable for temperature of 39.2°C, blood pressure is 130/70 mm Hg, pulse is 98 bpm, and respiratory rate is 12 breaths per minute. Sclera and conjunctiva are not injected. Oropharyngeal exam reveals bilateral tonsillar hypertrophy and exudates without ulcers. He has no cervical lymphadenopathy on exam. His abdominal is soft with normal bowel sounds. Skin exam is unremarkable.

Mr. W has 3 points on the modified Centor Score (fever, exudate, and absence of cough). A RADT test is performed.

A RADT test is performed and is positive. Mr. W has no allergies to antibiotics and he is treated with penicillin 500 mg twice daily for 10 days. Two days after starting treatment, he reports improvement in symptoms.

SOAP Note:

S: 30 y/o man complains of sore throat for the past 3 days.  Symptoms began abruptly 3 days ago when he developed a sore throat, pain with swallowing, fever, and headaches.  He denies symptoms of cough, coryza, or rhinorrhea. Patient is otherwise healthy. Denies recent contact with sick and recent travel.  Patient is a heterosexual male, married monogamous with his wife.  He has no history of blood transfusions or illicit drug use.

O: BP 130/70, RR 12, P 98, T 39.2 C

Optic exam: Sclera and conjunctiva not injected

Oropharyngeal exam: Bilateral tonsillar hypertrophy and exudates without ulcers. No cervical lymphadenopathy.

Abdominal Exam: Abdomen is soft with unremarkable bowel sounds.

Skin Exam: Unremarkable

A: Infectious Mononucleosis, Primary HIV Infection- Acute Retroviral Syndrome

Positive RADT test

P: Penicillin 500 mg BID x 10 days

Summary:

Acute onset of sore throat is most often caused by infectious agents, while patients with chronic sore throats with no signs of infection, or those who don’t respond to treatment should be evaluated for noninfectious causes of sore throat. The common viral agents causing respiratory infections are rhinovirus and coronavirus.  Group A beta-hemolytic streptococcus (GABHS) accounts for most incidences of acute bacterial pharyngitis. Less common infections should also be diagnosed as well as nonbacterial pathogens such as HIV, influenza A and B and mononucleosis.  Cough, rhinorrhea and coryza are common symptoms of viral pharyngitis, while patients with bacterial pharyngitis or mononucleosis suffer from fever, tender anterior cervical lymphadenopathy, tonsillar erythema.  Most patients suffering from influenza experience cough and myalgias.  Infectious mononucleosis, another possible diagnosis is most common in patients ages 15 to 24 and patients often experience malaise and marked adenopathy.  Primary HIV infection has similar nonspecific symptoms as pharyngitis and should be considered with high-risk patients. The textbook presentation of GABHS pharyngitis includes abrupt onset of severe throat pain, moderate fever, and headaches.  Edema and erythema is present in posterior pharynx and tonsils as well as gray-white exudates.  Anterior cervical lymph nodes are tender and gastrointestinal symptoms include nausea, vomiting, and abdominal pain. If untreated GABHS can last 8-10, when treated with antibiotics symptoms should improve within 48 hours.  It is important to treat patients with GABHS pharyngitis to prevent further complications such as acute rheumatic fever, acute glomerulonephritis and suppurative sequelae.  GABHS pharyngitis can be diagnosed using a throat culture which has a sensitivity of 90-95% and specificity of 95-99%, but takes 24-72 hours to process.  A faster option is rapid antigen detection test (RADT) which has a sensitivity range of 70-90% and specificity of 90-100%.  Results are available within minutes. Patients should be treated with antibiotics such as penicillin and amoxicillin.  In the event of an allergy, first-generation cephalosporins, clindamycin, clarithromycin or azithromycin can be used.  Severity of symptoms should improve, as well as ability to transmit and possibility of complications.  Patients who have had 4 or more episodes of severe pharyngitis in a year might consider a tonsillectomy.