The School - Aged Child
Case 4.5 Sore Throat
110 The School-Aged Child
Allergies: Samantha has no known allergies to food, medications, or the environment. She is up to date on required immunizations.
OBJECTIVE
General: Alert, quiet, and cooperative; appears well hydrated and well nourished.
Vital s igns: Weight in the offi ce today is 36 kg; temperature is slightly elevated at 38.4 ° Celsius (oral).
Skin: Clear of lesions and warm to touch. There was no cyanosis of her skin, lips, or nails. There was no diaphoresis noted; skin with elastic recoil.
HEENT : Normocephalic; red refl exes are present bilaterally; and pupils are equal, round, and reac- tive to light. There is no ocular discharge noted. External ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, both tympanic membranes are gray, in normal position, with positive light refl exes. Bony landmarks are visible, and there is no fl uid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge and no nasal fl aring. Samantha ’ s mucous membranes are noted to be moist when examin- ing her oropharynx. Both tonsils are erythematous and infl amed. There are exudates present bilater- ally, as well as palatal petechiae.
Neck: Supple and able to move in all directions without resistance; tender anterior cervical nodes present on both sides of the neck; no erythema of the nodes.
Respiratory: Respiratory rate was 28 breaths per minute, and her lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No defor- mities of the thoracic cage noted.
Cardiac: Heart rate was 112 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.
Abdomen: Normoactive bowel sounds were present throughout; soft and nontender; no evidence of hepatosplenomegaly.
Genitourinary: Normal prepubertal female genitalia.
Neuromusculoskeletal: Good tone in all extremities; full range of motion of all extremities; extremi- ties warm and well - perfused. Capillary refi ll is less than 2 seconds. Her spine is straight.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Throat culture ___Rapid strep test ___CBC
___Monospot ___LFTs
What is the most likely differential diagnosis and why?
___Viral pharyngitis (type?) ___Bacterial pharyngitis (type?) ___Fungal pharyngitis (type?) ___Peritonsillar abscess ___ GABHS
Sore Throat 111
What is your plan of treatment, referral, and follow - up care?
Does this patient ’ s psychosocial history affect how you might treat this case?
What if the patient lived in a rural setting?
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: When evaluating a sore throat, several tests may be helpful to determine the cause of the illness and to decide the treatment plan. If group A beta - hemolytic streptococci ( GABHS ) is suspected, a rapid strep test and a throat culture should be performed. Both tests are needed because the rapid test provides a preliminary result, while the culture provides the fi nal result after 48 hours.
The benefi ts of using the rapid strep test along with the culture are avoiding unnecessary antibiotic usage and treating the patient in an appropriate and timely manner. If the Epstein Barr Virus ( EBV ) is suspected, a CBC, monospot, and LFTs should be ordered.
If other viral etiology is suspected, diagnostic testing is not needed. Imaging studies are usually not needed unless a retropharyngeal, parapharyngeal, or peritonsillar abscess is suspected. In that case, a plain lateral neck fi lm may be ordered as an initial screening tool.
What is the most likely differential diagnosis and why?
GABHS:
Several differential diagnoses should be considered when evaluating a sore throat. Viral etiologies cause 40% of cases of sore throats, with enteroviruses, adenoviruses, and EBV being the most common. Bacterial pathogens cause 30% of sore throats, which are usually caused by GABHS, although other pathogens such as Staphylococcus aureus or Haemophilus infl uenzae should also be con- sidered. Pharyngitis caused by the fungus Candida albicans is another differential diagnosis that should be considered, especially for immunosuppressed individuals. Other more urgent diagnoses such as peritonsillar abscess or retropharyngeal abscess need to be ruled out. Given the patient ’ s history of fever of 101 ° F, sore throat, and headache, along with the physical exam fi ndings of ery- thematous tonsils with exudates, palatal petechiae, and cervical adenopathy, the most likely diagnosis is GABHS. In addition to this patient ’ s classic symptoms, many children may also experience nausea or vomiting and/or a scarlatiniform rash.
What is your plan of treatment, referral, and follow - up care?
Penicillin VK is the drug of choice for treating GABHS because it is effective and does not contribute to antibiotic resistance. By using Penicillin VK 20 mg/kg/d in 2 – 3 divided doses for 10 days, not only will the duration of illness be reduced, but the complication of rheumatic fever will be avoided. In pencillin - allergic patients, azithromycin is an appropriate choice. This medication has higher compli- ance rates due to the 12 mg/kg/d (500 mg maximum) once daily dosing for 5 days. Whether the pharyngitis is viral or bacterial in origin, the use of antipyretics for pain and fever is benefi cial, as are other symptomatic treatments such as increasing liquid intake.
Referral to an Ear, Nose, & Throat ( ENT ) specialist is only necessary should complications arise.
Follow - up care is needed if the patient ’ s symptoms worsen or persist for more than 48 hours while on antibiotics.
Does this patient ’ s psychosocial history affect how you might treat this case?
There is nothing in this patient ’ s psychosocial history that would affect how this case is treated.
What if the patient lived in a rural setting?
No changes in diagnosis or treatment are required if the patient lives in a rural setting. However, if the patient has emigrated from or traveled to a high - risk area for diphtheria, other testing and treat- ment should be considered.
112 The School-Aged Child
Are there any demographic characteristics that might affect this case?
There is no racial or ethnic predisposition for the development of GABHS. Regarding age, the major- ity of children who develop GABHS are between 5 – 10 years of age. Socioeconomic status is not known to be associated with GABHS.
Are there any standardized guidelines that you should use to assess or treat this case?
American Heart Association (2009). See reference below.
REFERENCES AND RESOURCES
Baltimore , R. ( 2010 ). Re - evaluation of antibiotic treatment of streptococcal pharyngitis . Current Opinion in Pediatrics , 22 , 77 – 82 .
Choby , B. ( 2009 ). Diagnosis and treatment of streptococcal pharyngitis . American Family Physician , 79 , 383 – 390 . Gerber , M. A. , Baltimore , R. S. , Eaton , C. B. , Gewitz , M. , Rowley , A. H. , Shulman , S. T. , & Taubert , K. A. ( 2009 )
Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. A scientifi c statement from the American Heart Association: Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research . American Heart Association, Circulation 119 , 1541 – 1551 .
Kim , S. ( 2009 ). The evaluation of SD Bioline Strep A rapid antigen test in acute pharyngitis in pediatric clinics . Korean Journal of Laboratory Medicine , 29 , 320 – 323 .