What is the likely diagnosis and management for a 28-year-old male with fever, sore throat, nausea, and body pain, currently taking diclofenac (nonsteroidal anti-inflammatory drug) and paracetamol (acetaminophen)?

Likely Diagnosis and Management

This 28-year-old male most likely has acute viral pharyngitis, and his current regimen of paracetamol and diclofenac is appropriate for symptomatic relief; continue both analgesics as needed, but do NOT add antibiotics unless he meets 3-4 Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough). 1

Clinical Assessment

Apply Centor Scoring System

The Centor criteria help identify patients with higher likelihood of Group A streptococcal infection 1:

• Fever (present = 1 point)
• Tonsillar exudates (assess on exam)
• Tender anterior cervical lymphadenopathy (assess on exam)
• Absence of cough (assess clinically)

The Centor system is validated in adults like this patient, though less useful in children. 1

Diagnostic Algorithm Based on Centor Score

For 0-2 Centor criteria (low likelihood of streptococcal infection):

• No rapid antigen testing needed 1
• No throat culture needed 1
• No antibiotics indicated 1
• Continue symptomatic treatment only 1

For 3-4 Centor criteria (high likelihood of streptococcal infection):

• Consider rapid antigen test (RAT) 1
• If RAT is negative, throat culture is NOT necessary 1
• Discuss modest antibiotic benefits versus risks (side effects, resistance, microbiota disruption, costs) 1
• If antibiotics indicated: Penicillin V twice or three times daily for 10 days 1

Current Medication Assessment

Analgesic Regimen is Appropriate

Both ibuprofen (diclofenac is an NSAID like ibuprofen) and paracetamol are recommended first-line treatments for acute sore throat symptoms. 1, 2

• Ibuprofen shows slightly better efficacy than paracetamol for pain relief, particularly after 2 hours 2
• Both medications are safe for short-term use with low risk of adverse effects 1, 2
• The combination of an NSAID (diclofenac) plus paracetamol provides multimodal analgesia 1

Important Safety Consideration

If this patient develops a vesicular rash suggesting chickenpox (varicella), IMMEDIATELY STOP diclofenac and all NSAIDs due to increased risk of severe bacterial skin infections; continue only paracetamol. 3

What NOT to Do

Do Not Prescribe Antibiotics for Mild Presentations

Antibiotics should NOT be used in patients with 0-2 Centor criteria to relieve symptoms. 1

• Antibiotics do not prevent rheumatic fever or glomerulonephritis in low-risk patients 1
• Prevention of suppurative complications (quinsy, otitis media, lymphadenitis, mastoiditis, sinusitis) is NOT a specific indication for antibiotics 1

Do Not Use These Treatments

• Zinc gluconate: Not recommended for sore throat 1, 2
• Herbal treatments or acupuncture: Inconsistent evidence 1, 2
• Routine corticosteroids: Not recommended unless severe presentation (3-4 Centor criteria) AND used with antibiotics 1, 2
• Biomarkers (CRP, procalcitonin): Not necessary for routine assessment 1

Management Plan

Symptomatic Treatment (Current Approach is Correct)

• Continue paracetamol 500-1000 mg every 4-6 hours as needed 1, 2
• Continue diclofenac (or substitute ibuprofen 400-600 mg every 6-8 hours) as needed 1, 2
• Adequate hydration and rest 4
• Warm salt water gargles may provide additional symptomatic relief 1

When to Reassess for Antibiotics

Only if patient has 3-4 Centor criteria should you consider antibiotics, and even then, discuss the modest benefits versus risks with the patient. 1

Expected Course

Most viral pharyngitis resolves within 3-7 days with symptomatic treatment alone 1, 4

Common Pitfalls to Avoid

• Do not reflexively prescribe antibiotics for sore throat without proper clinical scoring 1
• Do not use aspirin if patient is younger (risk of Reye syndrome in children, though this patient is 28 years old) 1
• Do not stop NSAIDs prematurely - they are effective and appropriate for this indication 1, 2
• Do not order throat cultures routinely - only if high clinical suspicion and RAT performed 1