Chapter 10-02: Symptoms & Chief Complaints in General Medicine

SORE THROAT

• Physical exam: Inspect the oropharynx (e.g., evaluate for tonsillar inflammation, exudate, soft palate edema, swollen or deviated uvula, oral ulcers); evaluate for lymphadenopathy

• Differential diagnosis:

  • - Viral pharyngitis

    • Epidemiology: More common than bacterial pharyngitis

    • Symptoms: Sore throat. Typically patients with viral pharyngitis are not as sick as patients with bacterial pharnygitis

    • Physical exam: May have tonsillar erythema but usually lack exudate

    • Diagnosis: Rule out bacterial pharyngitis as described below, otherwise it is a clinical diagnosis

    • Treatment: Supportive care, no antibiotics indicated

  • - Strep pharyngitis: Group A strep

    • Symptoms: Fever, odynophagia

    • Physical exam: Tonsillar erythema, edema, and exudate; lymphadenopathy

    • Diagnosis: Centor criteria (1 point each): 1) Fever, 2) Tonsillar exudate, 3) Tender cervical lymphadenopathy, 4) Lack of cough

      • - Score 0–2: Low probability for strep pharyngitis, so do not need to send for a rapid strep test

      • - Score 3–4: Test with rapid strep antigen test and treat; strep culture is unnecessary per the IDSA guidelines

    • Treatment: Penicillin TID-QID for 10 days

  • - Mononucleosis: EBV

    • Symptoms: Fever, extreme fatigue

    • Physical exam: Fever, diffuse lymphadenopathy (symmetric; posterior cervical/auricular > anterior), hepatosplenomegaly, pharyngitis, may have palatal petechiae

    • Diagnosis: CBC with differential (lymphocytosis, atypical lymphocytes), +heterophile antibody (although low sensitivity/specificity), serology, peripheral blood smear (large atypical lymphocytes)

    • Treatment: No antibiotics, supportive care

    • Complications: Splenic rupture (refrain from contact sports for at least the first 3 weeks of illness)

  • - Peritonsillar abscess: Group A strep, Streptococcus anginosus, S. aureus, anaerobes

    • Symptoms: Severe, unilateral throat pain; muffled voice; difficulty opening the mouth; drooling

    • Physical exam: Erythema and edema of the affected tonsil and soft palate, trismus

    • Diagnosis: CT/MRI if concerned for deep neck space infection

    • Treatment: Drainage of abscess, IV antibiotics (ampicillin-sulbactam +/– vancomycin)

    • Complications: Airway obstruction, aspiration, extension into the deep neck tissues

  • - GERD

  • - Post-nasal drip

  • - Acute HIV

SINUSITIS

• Physical exam: Palpate the sinuses (frontal, ethmoid, maxillary); inspect the oropharynx and nasal cavities; perform a cranial nerve exam

• Differential diagnosis:

  • - Viral rhinosinusitis

    • Epidemiology: Most common cause of sinusitis

    • Symptoms: Nasal congestion, sore throat

    • Physical exam: Patients are less sick and lack findings associated with bacterial infection

    • Diagnosis: Clinical diagnosis (no specific labs/imaging required)

    • Treatment: Supportive care, no antibiotics indicated

  • - Acute bacterial rhinosinusitis: S. pneumoniae, H. influenzae

    • Symptoms: Facial pain/pressure/fullness, purulent nasal drainage, nasal congestion, fever

    • Physical exam: Pain with palpation of the facial sinus, nasal turbinate edema, purulent drainage in the nasal cavity/posterior pharynx

    • Diagnosis: Clinical diagnosis (no specific labs/imaging required) based on:

      • - Persistent symptoms >10 days, especially if severe/worsening symptoms >3 days; OR

      • - Initial improvement followed by worsening of symptoms

    • Treatment: Consider observation for patients who are immunocompetent and have good follow-up; amoxicillin-clavulanate BID (typically not amoxicillin due to increasing resistance of S. pneumoniae, H. influenzae) for 5–7 days

    • Complications:

      • - Chronic rhinosinusitis: Symptoms that last >12 weeks. Obtain CT scan and refer to ENT.

      • - Orbital cellulitis: Pain with extraocular movement of ...