What is the most likely diagnosis and appropriate acute management for a healthy 34‑year‑old active‑duty female who developed over one day fatigue, nasal congestion, painful hoarse throat with cough, dysphagia, occasional shortness of breath, low‑grade fever, clear lungs, mild anterior cervical lymphadenopathy, and an erythematous oropharynx with a mildly swollen tonsil but no exudates?

Acute Viral Pharyngitis

This is acute viral pharyngitis requiring only symptomatic management with analgesics, hydration, and supportive care—antibiotics are not indicated and should be avoided. 1, 2

Diagnosis

The clinical presentation strongly supports a viral etiology rather than bacterial pharyngitis:

• Absence of tonsillar exudates is the key distinguishing feature, as streptococcal pharyngitis typically presents with tonsillopharyngeal exudates 1
• Mild tonsillar swelling with erythema but no exudates, combined with the acute onset over 1 day, nasal congestion, cough, and hoarseness, are classic viral upper respiratory infection symptoms 1, 2
• Low-grade fever rather than high fever (>39°C) makes bacterial infection unlikely 2
• Clear lungs on examination rules out pneumonia 2
• Anterior cervical lymphadenopathy with tenderness is consistent with viral pharyngitis, though posterior cervical nodes would suggest infectious mononucleosis 1

The constellation of fatigue, congestion, painful throat, cough, hoarseness, and dysphagia developing suddenly over 1 day represents typical viral upper respiratory tract infection symptoms that peak within 3 days and resolve within 10-14 days 2

Acute Management

Symptomatic Pain and Fever Control

• Acetaminophen or NSAIDs (ibuprofen) for throat pain and fever relief 1, 3
• Continue analgesics only while symptoms of fever and pain are present 1
• Throat lozenges and warm salt water gargles for additional symptomatic relief 1, 2

Supportive Care Measures

• Adequate hydration—drink fluids regularly but no more than 2 liters per day to avoid dehydration 1, 3
• Adequate rest to support immune function 3
• Sleep with head of bed elevated to reduce postnasal drip and throat irritation 3
• Steamy showers to humidify the airway and soothe irritated mucosa 3

Additional Symptomatic Options

• Oral antihistamines (e.g., pheniramine) at standard dosing three times daily for nasal congestion and excessive secretions 2
• Oral decongestants (e.g., pseudoephedrine) for additional nasal congestion relief, barring contraindications like hypertension 2
• Nasal saline irrigation provides minor symptom improvement with low risk 2

Critical Management Pitfalls to Avoid

Do NOT Prescribe Antibiotics

• Antibiotics provide no benefit for viral pharyngitis and cause harm through adverse effects, with a number needed to harm of 8 2
• This contributes to antimicrobial resistance and represents inappropriate antibiotic stewardship 2

Do NOT Use Amoxicillin/Ampicillin if Infectious Mononucleosis is Possible

• If infectious mononucleosis (EBV) is suspected, avoid amoxicillin or ampicillin, as these cause a characteristic maculopapular rash in 80-90% of patients with EBV infection 1
• Given the anterior (not posterior) cervical adenopathy and absence of splenomegaly, infectious mononucleosis is less likely here, but remains a consideration 1

Cautions with Symptomatic Medications

• First-generation antihistamines cause sedation, dry mouth, and urinary retention—use caution in elderly patients 2
• Topical decongestants should be limited to 3-5 days to avoid rebound congestion and rhinitis medicamentosa 2

Patient Education and Expected Course

Timeline

• Symptoms typically last up to 2 weeks, with most patients (approximately 90%) free of symptoms by one week even without treatment 3
• Gradual improvement over 1-2 weeks with supportive care alone is expected 1

Return Precautions

• Seek immediate care if symptoms worsen, including high fever develops (>39°C), difficulty breathing, severe headache, inability to swallow, or neck stiffness 1, 2
• Follow up if symptoms have not improved within 3-5 days or if symptoms persist beyond 2 weeks 3
• Consider monospot or EBV serology if symptoms persist beyond 2 weeks or if splenomegaly develops 1

Preventive Measures

• Practice appropriate handwashing, as direct hand contact is the primary route of viral spread 3
• Avoid cigarette smoke, pollution, and relevant allergens that can prolong symptoms 3