Case 30: Sore throat

Opening scenario

Alex Soto, a 19-year-old male, comes to the urgent care clinic because of a sore throat.

Vital signs

• Temperature: 102°F (38.9°C)
• Blood pressure: 122/74 mm Hg
• Heart rate: 70/min
• Respirations: 15/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Speak with a hoarse voice.
• When the examinee feels for lymph nodes in your neck, say that it hurts.
• When the examinee presses on your abdomen, say that it hurts a little bit all over.
• You are not aware of the meanings of medical terms (e.g., laryngoscopy) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: When the examinee mentions that she/he would like to run some tests, say: “Can you not just give me some antibiotics? I really want to get out of here.”

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• I have a really sore throat.
• Location
• It is mostly the back of my throat.
• Intensity (on a scale from 0–10)
• I would say at least a 7, maybe an 8.
• Quality
• It is almost a burning pain.
• Onset
• It started last night.
• Precipitating events
• None.
• Progression/constant/intermittent
• I think it is getting worse.
• Previous episodes
• Maybe as a child. But nothing recently.
• Radiation
• No.
• Alleviating factors
• Cold drinks really help.
• Aggravating factors
• It hurts more when I swallow.
• Associated symptoms
• I also woke up with a really hoarse voice this morning.
  • Previous episodes of hoarse voice
  • No.
  • Problems swallowing food
  • Yes, it really hurts to eat or swallow so I have not really had anything to eat since yesterday.
    • Able to swallow liquids
    • No, I have no problem getting liquids down – but it is really painful.

Review of systems specific to sore throat

• Headache
• No.
• Nausea/vomiting
• Yes, my throat is so swollen that I really feel a bit nauseous when I talk. But I have not thrown up.
• Fever/chills
• I think so. I definitely had chills yesterday in the evening. Did the nurse not take my temperature when I got here?
• Fatigue
• Yes, I was tired all day yesterday and today.
• Rash/skin changes
• No.
• Cough
• No.
• Shortness of breath
• No.
• Appetite
• I do not have much of an appetite right now.
• Weight changes
• No.
• Recent infections
• I had a cold 2 weeks ago.
• Runny nose
• No.
• Swollen lymph nodes
• No, not that I have noticed.
• Voice changes
• Well I am really hoarse.
• Halitosis
• Hmm, not sure but I have kind of a gross taste in my mouth and I feel like it smells.
• Abdominal pain
• My whole belly has been hurting a little bit all day today. But it is very mild.

It is important to ask for symptoms of a common cold (rhinitis and/or headache) in patients who present with sore throat, as they are typical for viral tonsillitis but would not be expected in streptococcal pharyngitis.

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• None.
• Medications
• None.
• Hospitalizations
• Never.
• Ill contacts
• My girlfriend says she has also had a sore throat for the past couple of weeks.
• Past surgical history
• None.
• Family history
• My dad has diabetes.
• Work
• I go to college and am majoring in criminal justice, but mostly I am interested in playing football for the college team.
• Home
• I live in a dorm on campus.
• Alcohol
• I drink 1–2 beers on the weekends. During the week I always have football practice, so I do not have time to go out or drink.
• Recreational drugs
• No.
• Tobacco
• Never.
• Exercise
• Football practice almost every day.

Sexual history

• Sexually active
• Yes.
• With whom
• Well, for the past 2 months, my girlfriend. And before that just a few different girls around campus.
• Men or women
• What kind of a question is that? Only women.
• Number of partners over the past year
• Dude, you are asking quite a few questions about this. Maybe 9? 10?
• Protection
• Yes, I always use a condom. The last thing I need is to get one of these girls pregnant.

Obtaining a focused sexual history is important in patients presenting with a sore throat. Unprotected sex is a risk factor for HIV, and an acute HIV infection can present with sore throat (mononucleosis-like syndrome).

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
  • Palpation of the head
  • Inspection of the nose
  • Inspection of the oropharynx
    • Show the examinee this image of your throat:
• Neck examination
  • Inspection of the neck
  • Palpation of the lymph nodes of the head and neck
    • Tenderness to palpation
• Chest examination
  • Auscultation of the lungs
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
    • Mild tenderness to palpation throughout the entire abdomen
  • Palpation of the liver
  • Palpation of the spleen
• Skin examination

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on avoidance of contact sports in suspected mononucleosis.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Soto, I understand that you are not feeling well and that you would like to get back home as quickly as possible. However, at this time I cannot say with certainty whether your symptoms are caused by a bacterial or viral infection. Antibiotics would only be appropriate if bacteria were causing your symptoms, and otherwise they could do more harm than good, or even cause a rash. I would like to run some tests to figure out the exact cause of your symptoms and then discuss the appropriate treatment with you. Does that sound okay?”

Patient note

Differential diagnoses

1. Streptococcal tonsillopharyngitis: This patient's sudden-onset sore throat, tender cervical lymphadenopathy, fever, and lack of cough or other symptoms of cold meet the criteria for microbiologic testing for group A streptococcal (GAS) pharyngitis. Although tonsillar exudates are often found in streptococcal tonsillopharyngitis, they are not always present, and the palatal petechiae seen in this patient are also a typical feature of strep throat. If he is found positive, he should be treated with antibiotics to prevent rheumatic fever and poststreptococcal glomerulonephritis.
2. Infectious mononucleosis (IM): IM can present similarly to bacterial pharyngitis (e.g., sore throat, lymphadenopathy, fever, fatigue) and is common in young adults. It is of particular concern in this case because of the patient's mild abdominal pain, which could indicate splenomegaly, a common finding in IM. Since splenomegaly can lead to life-threatening splenic rupture and this patient is an avid football player, he should be discouraged from playing until his IM has subsided. However, because he does not have generalized lymphadenopathy or the grayish-white deposits on the tonsils typically seen in IM, it is only the second most likely diagnosis.
3. Viral pharyngitis: Viral pharyngitis could also be the cause of this patient's sore throat and erythematous oropharynx. However, his fever and lack of symptoms of cold make this diagnosis less likely than the first two.

Diagnostic studies

• Rapid strep test: throat swab allows for simple and quick detection of group A streptococcal infection (highly specific, sensitivity 70–90%). In cases in which rapid strep testing is negative, throat culture can be used as a follow-up test.
• CBC: Not specific, but can help differentiate viral from bacterial infections. Leukocytosis is generally more common in bacterial pharyngitis, whereas lymphocytosis is more common in viral pharyngitis and infectious mononucleosis.
• Peripheral blood smear: Atypical T lymphocytes can be observed on peripheral smear in infectious mononucleosis.
• Monospot test: confirms diagnosis of infectious mononucleosis if positive (100% specificity). If monospot testing is negative but mononucleosis is suspected, anti-EBV antibodies can be used for diagnosis.

Other differential diagnoses to consider

• Upper respiratory infection (URTI)
• Laryngitis
• See also differential diagnosis of tonsillitis.