What is the next best plan for an elderly female patient with a sore throat, vomiting, fever, and a sluggish onset of symptoms over 2 days?

Immediate Assessment for Life-Threatening Complications

This elderly patient with 2 days of fever, sore throat, and vomiting requires urgent evaluation to rule out dangerous complications including peritonsillar abscess, retropharyngeal abscess, epiglottitis, and systemic sepsis before considering routine pharyngitis management. 1, 2

Critical Red Flag Assessment

Immediately assess for the following life-threatening conditions:

• Peritonsillar abscess: Look for unilateral tonsillar swelling, uvular deviation, trismus (difficulty opening mouth), "hot potato voice," and severe dysphagia 1
• Retropharyngeal abscess: Evaluate for neck stiffness, posterior pharyngeal wall swelling, neck tenderness or swelling, drooling, and difficulty swallowing 1
• Epiglottitis: Assess for drooling, stridor, patient sitting forward, and respiratory distress—airway management is paramount if suspected 1, 2
• Sepsis indicators: Check for altered mental status, hypotension, tachycardia, and signs of systemic toxicity 3

Why This Patient Is High-Risk

• Elderly patients may present atypically with serious infections, and fever in this population generally indicates serious bacterial infection 3
• Vomiting combined with fever and sore throat raises concern for systemic illness beyond simple pharyngitis 4
• "Sluggish onset" may indicate progressive deterioration requiring urgent intervention 2

Immediate Diagnostic Workup

Perform the following without delay:

• Complete blood count with differential to assess for leukocytosis or left shift indicating bacterial infection 5
• Blood cultures if patient appears systemically ill or has high fever 4
• Lateral neck radiograph or CT scan if any concern for deep space infection or airway compromise 1, 2
• Direct visualization of the oropharynx and posterior pharynx for abscess, asymmetry, or obstruction 1

Initial Management Priorities

Airway Management First

• Maintain high index of suspicion for airway compromise and have equipment ready for emergency airway management 1, 2
• Consider early otolaryngology consultation if any concern for abscess or deep space infection 1

Symptomatic Treatment During Evaluation

• Provide immediate analgesic therapy with acetaminophen or ibuprofen for pain and fever control 1, 6
• Use caution with NSAIDs in elderly patients due to cardiovascular, renal, and gastrointestinal risks 1
• Ensure adequate hydration, especially given vomiting 5

What NOT to Do

• Do not prescribe antibiotics empirically without identifying the underlying cause—antibiotics provide minimal benefit even for confirmed strep throat and are not indicated for viral pharyngitis 1, 7
• Do not assume this is simple pharyngitis given the patient's age, systemic symptoms, and vomiting 1, 3

If Life-Threatening Complications Are Ruled Out

Only after excluding dangerous conditions, consider routine pharyngitis evaluation:

• Rapid antigen detection test or throat culture for Group A Streptococcus if bacterial pharyngitis is suspected 7
• Most sore throats resolve spontaneously within 3-4 days for fever and within one week for throat pain, even without antibiotics 8, 7
• Antibiotics shorten symptom duration by only 1-2 days with number needed to treat of 6 after 3 days 8, 7

Common Pitfalls to Avoid

• Underestimating severity in elderly patients: Infections in this population may present with atypical symptoms including altered mental status, falls, or functional decline rather than classic fever 3
• Delaying imaging when indicated: Any concern for deep space infection or airway compromise warrants immediate imaging 1, 2
• Missing systemic complications: Streptococcal pharyngitis can rarely lead to serious complications including subdural empyema, requiring high vigilance 4