PHARYNGITIS

Key: S = standard of care; should be performed except in unusual circumstances and rationale for not completing should be documented on chart.

G = guideline; should be performed in most patients, but many typical patients may have good reasons for not having this performed.

O = optional; may be considered along with other choices for each individual.

History:

Time of onset (S)

Potential life threats

Facial/neck swelling

Difficulty breathing

Trismus (inability to open mouth fully)

Significant voice change

Favoring viral

No fever, cough present, conjunctivitis

Favoring bacterial/Group A В hemolytic Streptococcus

Fever (T>100˚ For 38˚ C), sudden onset sore throat, painful swallowing, Headache, vomiting, abdominal pain

Age (streptococcus more common 5-15 year olds)

Past Medical History:

1) Immunosupression: (chronic steroids, DM, Cancer/Chemotherapy, Alcoholism, HIV, sickle cell, transplant, IVDA, ESRD, liver disease)

2) Recurrent Streptococcal Infections

3) Rheumatic Fever

4) Known Valvular heart Disease

Physical Exam:

- Throat exam (S)

- (Stridor, drooling, respiratory difficulty, neck/facial swelling, trismus, peritonsilar abscess, elevated tongue, exudate, tonsillar hypertrophy, uvula (deviation? swelling?)

Testing: Throat culture (O)

1) If signs/symptoms of bacterial infection treat empirically, no culture required unless recurrent or not responding to appropriate antibiotic therapy

2) If no sign/symptoms suggestive of bacterial infection then standard throat culture. However, if clear viral syndrome culture can be omitted

Treatment:

1) Antibiotics for Adults Suspected Group A В hemolytic Streptococcus:

Drug of Choice: PCN VK 250mg TID of QID or 500mg BID for 10 days

Or LA Benzathine PCN G 1.2 million units IM

(for patients with questionable compliance)

Alternatives: Erythromycins, Cephalosporins

Note: Recurrent episodes or unresponsive to appropriate antibiotics should be treated with Augmentin or Clindamycin

2) Intravenous Access/Fluids if seriously ill, or suspected dehydration (O)

3) Decadron 10mg IV if severe exudative pharyngitis (O)

4) Analgesics (O)

Discharge Instructions: (S)

1) Return if unable to new fever swallow, drooling or trouble breathing

2) Follow up with private MD in 48 hours if not improved

3) Call number on Culture card as directed and start antibiotics if results are positive

4) Plenty of liquids

5) Analgesics as directed, anesthetic throat lozenges

Triage Criteria: All patients to Walk-In EXCEPT: unstable vital signs, stridor, drooling, respiratory difficulty, neck/facial swelling, trismus, peritonsilar abscess, elevated tongue, any other evidence of airway compromise

These guidelines are intended to be tools to facilitate clinical decision making. They are not the standard of care for each patient. No guideline can anticipate every situation, and the physician should deviate from the guidelines when clinical judgement so indicates.