What is the recommended treatment for a patient with a non-productive dry cough and sore throat, presenting with erythema (redness) of the throat and swollen cervical lymph nodes, but no fever, myalgias (muscle aches), or shortness of breath?

Management of Acute Pharyngitis with Dry Cough

This patient should receive symptomatic treatment only with NSAIDs (ibuprofen or naproxen) for throat pain and dextromethorphan for cough suppression, without antibiotics or further testing, as the clinical presentation suggests viral pharyngitis. 1, 2

Clinical Assessment and Risk Stratification

The patient's presentation requires evaluation using the modified Centor criteria to determine the likelihood of bacterial (Group A Streptococcus) infection: 1

• Fever by history: Absent (0 points)
• Tonsillar exudates: Not mentioned, presumed absent (0 points)
• Tender anterior cervical adenopathy: Present (1 point)
• Absence of cough: Absent - patient HAS cough (0 points)

Total Centor Score: 1 point 1

With a Centor score <3, this patient has a low probability of Group A streptococcal pharyngitis and does not warrant testing or antibiotic therapy. 1 The presence of a non-productive dry cough strongly suggests a viral etiology, as cough is typically absent in bacterial pharyngitis. 1, 3

Recommended Treatment Approach

For Sore Throat Pain (6/10 severity):

• First-line: Ibuprofen or naproxen for symptomatic relief 1, 3
• These NSAIDs provide effective anti-inflammatory action for the throat erythema and pain with swallowing 4
• Flurbiprofen 8.75 mg lozenges specifically provide relief for swollen and inflamed throat symptoms if available 4
• Phenol-containing throat sprays can provide topical analgesia 5

For Non-Productive Dry Cough:

• First-line: Dextromethorphan 60 mg for maximum cough reflex suppression with prolonged effect 2, 1

  • Standard over-the-counter preparations may contain lower doses; patients should check total dextromethorphan content 2
  • Caution with combination products containing paracetamol to avoid overdose 1, 2

• Alternative options:

  • Simple home remedy of honey and lemon mixture 2, 1
  • Menthol lozenges or inhalation for short-term cough suppression 2, 1
  • First-generation sedating antihistamines if nocturnal cough is problematic 2, 1

What NOT to Prescribe:

• Antibiotics are NOT indicated even with throat erythema and cervical lymphadenopathy, as these findings occur in viral pharyngitis 1, 3
• Codeine or pholcodine have no greater efficacy than dextromethorphan but carry significant adverse effects and are not recommended 1, 2
• Expectorants, mucolytics, and bronchodilators are not recommended for acute non-productive cough 2

Expected Clinical Course and Red Flags

Acute viral pharyngitis is self-limiting with a mean duration of 7 days. 3 The patient should seek medical attention if: 2

• Coughing up blood
• Development of breathlessness
• Prolonged fever and worsening systemic symptoms
• Symptoms persisting beyond 3 weeks
• Development of difficulty swallowing, drooling, neck tenderness, or severe swelling (suggesting peritonsillar abscess or other serious complications) 1

Key Clinical Pitfalls to Avoid

The presence of throat erythema and swollen cervical lymph nodes does NOT indicate bacterial infection requiring antibiotics. 1 These findings are common in viral pharyngitis. The critical error would be prescribing antibiotics based on physical examination findings alone without considering the low Centor score and presence of cough. 1, 3

Antibiotics should not be used to prevent suppurative complications (quinsy, acute otitis media, cervical lymphadenitis) or non-suppurative complications (rheumatic fever, glomerulonephritis) in low-risk patients like this one. 1 Even in confirmed Group A Streptococcus cases with 3-4 Centor criteria, antibiotics provide only modest symptom reduction that must be weighed against side effects, antimicrobial resistance, and costs. 1

Patient Education

• Encourage self-management and adequate hydration 2
• Practice proper cough hygiene (handkerchief use, hand washing) to prevent transmission 2
• If symptoms worsen or red flags develop, return for reassessment 2