What is the possible diagnosis and next steps for a 45-year-old female patient presenting with a 3-day history of sore throat, initially mild but worsening to severe throat pain, accompanied by transient headache, mild hoarseness, odynophagia, and an erythematous oropharynx without tonsillar swelling or exudates?

Acute Viral Pharyngitis (Most Likely Diagnosis)

This patient most likely has acute viral pharyngitis, and antibiotics should NOT be prescribed. The presence of hoarseness, yellow-green sputum production, and absence of tonsillar exudates or lymphadenopathy strongly suggest a viral etiology rather than Group A Streptococcus (GAS) pharyngitis. 1, 2

Clinical Reasoning Against Bacterial Pharyngitis

The patient's presentation has multiple features that argue strongly against GAS pharyngitis:

• Hoarseness is a viral indicator – This symptom is highly suggestive of viral origin and uncommon in bacterial pharyngitis 1, 2
• Absence of tonsillar exudates – While not required for GAS, the erythematous oropharynx WITHOUT exudates makes bacterial infection less likely 1, 3
• No anterior cervical lymphadenopathy – Tender enlarged anterior cervical nodes are a key finding in strep throat, and their absence reduces the likelihood 1, 3
• Gradual symptom progression over 3 days – GAS typically presents with sudden-onset severe sore throat, whereas this patient had gradual worsening 1, 4
• Productive cough with colored sputum – The feeling of phlegm and yellow-green expectoration suggests viral upper respiratory infection rather than isolated pharyngitis 1, 2

Modified Centor Score Assessment

Apply the Modified Centor criteria to determine need for testing 1, 2:

• Fever by history: Unclear from presentation (0 or 1 point)
• Tonsillar exudates: Absent (0 points)
• Tender anterior cervical adenopathy: Absent (0 points)
• Absence of cough: Patient HAS cough/phlegm (0 points)

Total Score: 0-1 points – Testing for GAS is NOT indicated with scores <3 1, 2

Recommended Management Plan

Do NOT perform testing or prescribe antibiotics

• No rapid antigen detection test (RADT) or throat culture needed – Clinical features strongly suggest viral etiology, and testing should not be performed when viral features predominate 1, 2
• Antibiotics are contraindicated – They provide no benefit for viral pharyngitis and increase adverse events including nausea, vomiting, headache, and drowsiness 1

Symptomatic Treatment Only

Recommend the following supportive measures 1:

• Analgesics/antipyretics: Continue paracetamol (acetaminophen) or ibuprofen for pain and fever relief
• Salt water gargles: Patient already using this effectively – encourage continuation
• Cough suppressants: Dextromethorphan or codeine if cough becomes bothersome
• First-generation antihistamines: Diphenhydramine for symptom relief if needed
• Hydration and rest: Standard supportive care

Expected Clinical Course

• Duration: Symptoms typically resolve in 5-7 days, may persist up to 10 days 2
• Reassurance: Explain this is a self-limited viral illness that will resolve without antibiotics

Red Flags Requiring Urgent Re-evaluation

Instruct the patient to return immediately if any of the following develop 1:

• Difficulty swallowing or breathing
• Drooling
• Neck tenderness or swelling (concern for peritonsillar abscess, parapharyngeal abscess, or Lemierre syndrome)
• Severe worsening of symptoms
• Inability to maintain hydration
• Symptoms persisting beyond 10-14 days (requires re-evaluation for alternative diagnoses)

Common Pitfall to Avoid

Do not prescribe antibiotics "just in case" or due to patient pressure. 1 The absence of classic streptococcal features (sudden onset, exudates, lymphadenopathy, absence of cough) combined with viral indicators (hoarseness, productive cough) makes GAS pharyngitis highly unlikely. Unnecessary antibiotic use contributes to resistance, adverse effects, and increased healthcare costs without clinical benefit. 1