What is the best next step in managing a 50-year-old male farmer with a 4‑day history of sore throat, mild non‑productive cough, chills, no fever, normal tonsils, and an elongated frenulum contacting the tongue base?

Best Next Step: Assess for Suppurative Complications with Immediate Imaging

This 50-year-old farmer with throat pain, chills without documented fever, and 4 days of symptoms requires urgent evaluation for deep space infection or suppurative complications, particularly given the presence of chills which suggests systemic inflammatory response. The elongated frenulum is an incidental anatomic finding and not the cause of his symptoms. 1

Immediate Red Flag Assessment

The presence of chills without documented fever in a patient with throat pain lasting 4 days warrants immediate consideration of suppurative complications including peritonsillar abscess, retropharyngeal abscess, or early Lemierre disease. 1 While he lacks documented fever at this moment, chills indicate systemic response and potential bacteremia. 1

Critical Physical Examination Findings to Assess NOW:

• Examine for neck swelling or fullness – if present, this mandates immediate contrast-enhanced CT of the neck 1
• Assess for unilateral tonsillar swelling with uvular deviation – suggests peritonsillar abscess 2
• Check for trismus (difficulty opening mouth) – requires immediate CT imaging 1
• Palpate for tender, fluctuant cervical lymphadenopathy – suggests suppurative lymphadenitis requiring further evaluation 1
• Evaluate for neck stiffness or posterior neck tenderness – concerning for retropharyngeal abscess 2

Immediate Laboratory Workup Required

Before considering this simple pharyngitis, obtain:

• Complete blood count with differential to evaluate for leukocytosis (bacterial infection) or thrombocytopenia (Lemierre syndrome) 1
• Blood cultures if any fever develops given concern for bacteremia from deep space infection 1
• Inflammatory markers (CRP, ESR) if deep space infection suspected 1

If No Red Flags Are Present: Risk Stratification Approach

Only after excluding suppurative complications should you apply the Centor criteria for bacterial pharyngitis risk stratification. 3 His presentation includes:

• No fever (0 points)
• No tonsillar exudates (0 points)
• No tender anterior cervical lymphadenopathy mentioned (0 points)
• No cough or minimal cough (1 point)
• Age 50 years (0 points)

With a Centor score of 0-1, antibiotics are NOT indicated as the likelihood of bacterial infection is extremely low. 3 The American College of Physicians and Infectious Diseases Society of America state that antibiotics provide no meaningful benefit in this low-risk scenario. 3

Symptomatic Management

Recommend ibuprofen or acetaminophen for pain relief as first-line symptomatic treatment. 3, 4 This provides modest symptom reduction while the likely viral illness resolves spontaneously over approximately 7 days. 4

Critical Pitfall to Avoid

Do NOT prescribe antibiotics without first ruling out suppurative complications and then applying clinical decision rules. 3 More than 60% of adults with sore throat receive antibiotics despite only 10% having bacterial pharyngitis. 5 The guideline societies explicitly recommend against starting antibiotics immediately without clinical assessment, as there is no difference in complication rates between immediate, delayed, or no antibiotic strategies in low-risk presentations. 3

The elongated frenulum touching the tongue base is an incidental anatomic variant and is NOT causing his symptoms – do not be distracted by this finding.

When to Reevaluate

If symptoms worsen or persist beyond 5-7 days, reevaluate for:

• Suppurative complications that were initially subclinical 1, 2
• Non-infectious causes including malignancy (important in his age group) 2
• Alternative diagnoses such as GERD 2

Urgent ENT consultation is required if any suppurative complication is confirmed on imaging. 1