What history and assessments should be done for a 44-year-old female with a 6-day acute upper respiratory infection (URI) presenting with a sore throat, who has not improved with over-the-counter (OTC) medications including guaifenesin (Mucolytic), Cepacol (Cepacol contains acetaminophen and benzocaine), and Sudafed (Pseudoephedrine)?

History and Assessment for 6-Day URI with Persistent Sore Throat

This patient requires immediate assessment for Group A Streptococcal pharyngitis and evaluation for suppurative complications, as symptoms persisting beyond 5-7 days without improvement on OTC therapy warrant consideration of bacterial infection or complications. 1, 2

Critical History Elements to Obtain

Symptom Progression and Red Flags

• Fever pattern: Document if fever is present, its duration, and whether it exceeds 101.5°F, as persistent fever beyond 3 days suggests bacterial infection requiring antibiotic therapy 1, 2
• Worsening symptoms: Ask specifically about increasing throat pain, difficulty swallowing, or inability to maintain oral hydration, which may indicate suppurative complications 2
• Voice changes: Inquire about hoarseness or dysphonia, as symptoms persisting beyond 7-10 days require different evaluation 1
• Respiratory symptoms: Assess for stridor, respiratory distress, or difficulty breathing, which would necessitate urgent escalation of care 1

Specific Symptom Characteristics

• Throat pain quality: Determine if pain is unilateral (suggests peritonsillar abscess) versus bilateral 2
• Associated symptoms: Document presence of rhinitis, cough, ear pain, or neck swelling 1
• Systemic symptoms: Ask about fatigue, body aches, and whether symptoms are improving, stable, or worsening 1

Risk Factors and Comorbidities

• Tobacco use: Critical to document, as smoking increases risk of complications and warrants expedited evaluation 1
• Occupational voice use: Active duty status means she is a professional voice user, which warrants earlier and more aggressive evaluation 1
• Recent procedures: Rule out recent intubation, head/neck/chest surgery 1
• Chronic conditions: Assess for diabetes, immunosuppression, or other conditions that increase infection risk 1

Physical Examination Components

Head and Neck Examination

• Oropharyngeal inspection: Look for tonsillar erythema, edema, exudate (suggests streptococcal pharyngitis), or asymmetric tonsillar enlargement (suggests abscess) 1
• Neck palpation: Examine for cervical lymphadenopathy, neck masses, or fluctuance suggesting abscess formation 1, 2
• Uvula position: Deviation suggests peritonsillar abscess 2
• Voice assessment: Listen for muffled "hot potato" voice, which indicates peritonsillar involvement 1

Vital Signs Assessment

• Temperature: Document if ≥101.5°F or <35°C, both indicating potential bacterial infection or severity 1
• Respiratory rate: Rate ≥30 breaths/min suggests severe infection requiring hospitalization 1
• Blood pressure: <90/60 mmHg indicates hemodynamic compromise 1
• Heart rate: ≥125 beats/min suggests systemic involvement 1

Additional Examination

• Respiratory examination: Assess for signs of lower respiratory tract involvement, as URI can progress to pneumonia 1
• Ear examination: Check for acute otitis media as a suppurative complication 2
• Swallowing observation: Watch patient swallow to assess for dysphagia or odynophagia 1

Diagnostic Testing Required

Microbiologic Testing

• Throat culture: Obtain posterior pharyngeal swab for culture before initiating antibiotics, looking for at least 10 colonies of Group A β-hemolytic streptococci 1
• Rapid antigen detection test: Can be performed immediately, though sensitivity varies (60-95%), and negative results should be confirmed with culture 1

Decision Points for Escalation

Criteria Requiring Antibiotic Therapy

• Confirmed Group A Streptococcus: Positive culture or rapid test warrants immediate antibiotic initiation 1
• Clinical criteria: Fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough suggest bacterial pharyngitis 1

Criteria Requiring Urgent Referral or Hospitalization

• Suppurative complications: Peritonsillar abscess, cervical lymphadenitis, or acute otitis media 2
• Airway compromise: Stridor, respiratory distress, or inability to swallow secretions 1, 2
• Hemodynamic instability: Hypotension, tachycardia, or signs of sepsis 1
• Failure to improve after 48 hours of appropriate antibiotic therapy 2

Common Pitfalls to Avoid

• Do not assume viral etiology simply because initial OTC therapy was tried—6 days without improvement warrants bacterial evaluation 1, 2
• Do not overlook atypical pathogens: If streptococcal testing is negative but symptoms persist, consider Mycoplasma or Chlamydophila requiring macrolide coverage 2
• Do not delay throat culture while waiting for symptom resolution—bacterial confirmation is essential at this stage 1
• Do not miss unilateral findings that suggest abscess formation requiring surgical drainage rather than antibiotics alone 2

Antibiotic Selection if Indicated

If Group A Streptococcus is confirmed or highly suspected:

• First-line: Penicillin or amoxicillin for 10 days 1
• Penicillin allergy (non-anaphylactic): First-generation cephalosporin (cephalexin or cefadroxil) 2
• Penicillin allergy (anaphylactic): Azithromycin 500 mg daily for 5 days or clarithromycin 500 mg twice daily for 10 days 1, 2
• If no improvement after 48 hours: Switch to macrolide to cover atypical pathogens 2