What is the appropriate management for a female patient with vomiting and pharyngitis?

Management of Vomiting and Sore Throat

Start with symptomatic treatment using acetaminophen or ibuprofen for pain and fever control, ensure adequate hydration, and only pursue testing for strep throat if specific bacterial features are present—otherwise, this is most likely a self-limited viral illness requiring supportive care only. 1

Initial Assessment: Viral vs. Bacterial Pharyngitis

The combination of vomiting and sore throat most commonly indicates a viral upper respiratory infection, which requires no antibiotics. 1, 2 You should look for these specific features to determine if testing for Group A Streptococcus (strep throat) is warranted:

Features suggesting VIRAL pharyngitis (no testing needed):

• Cough present 2, 3
• Runny nose (rhinorrhea) 2
• Hoarseness 2
• Gradual symptom onset 1

Features suggesting possible BACTERIAL (strep) pharyngitis (testing warranted):

• Sudden onset of symptoms 4
• Fever present 1, 3
• Tonsillar exudates (white patches on tonsils) 1, 4
• Tender swollen lymph nodes in front of neck 1, 4
• Absence of cough 5, 4

Symptomatic Treatment (Start Immediately)

For pain and fever control:

• Ibuprofen (NSAID) is the preferred first-line analgesic as it is more effective than acetaminophen for fever and pain control in pharyngitis 1, 6
• Acetaminophen is an effective alternative if NSAIDs are contraindicated 1
• Never give aspirin to children due to risk of Reye syndrome 1, 6

For additional symptom relief:

• Warm salt water gargles (if old enough to gargle) 2
• Throat lozenges containing topical anesthetics (benzocaine, lidocaine) may provide temporary relief 2, 4

For vomiting:

• Ensure adequate hydration with small, frequent sips of clear fluids 7
• Anti-nausea medication (dimenhydrinate) can be considered if vomiting is severe, though most viral pharyngitis-associated nausea resolves with supportive care 7

When to Test for Strep Throat

Do NOT test if:

• Only 0-1 bacterial features present (fever, tonsillar exudates, tender neck lymph nodes, no cough) 5, 3
• Viral features are prominent (cough, runny nose, hoarseness) 2, 3
• Patient is under 3 years old (strep is rare in this age group) 2, 3

DO test with rapid antigen detection test (RADT) if:

• 2 or more bacterial features present 5, 3
• Age 5-15 years with appropriate symptoms 4, 8

Antibiotic Treatment (ONLY if Strep Test is Positive)

If rapid strep test is positive, first-line treatment is:

• Penicillin V or amoxicillin for 10 full days 1, 3
• The full 10-day course is essential to prevent complications like rheumatic fever 1, 2

For penicillin allergy (non-anaphylactic):

• First-generation cephalosporin (cephalexin or cefadroxil) for 10 days 1, 3

For severe penicillin allergy (anaphylactic):

• Clindamycin for 10 days, OR 1, 2
• Clarithromycin for 10 days, OR 1
• Azithromycin for 5 days 1

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics without confirming strep infection—60% of patients with sore throat receive unnecessary antibiotics, contributing to resistance 9, 10
• Do NOT use corticosteroids routinely—they provide only 5 hours of pain reduction and carry unnecessary risks 1, 6
• Do NOT stop antibiotics early if strep is confirmed—incomplete courses increase treatment failure and complication risk 2
• Do NOT rely on clinical features alone to diagnose strep throat—testing is required as viral and bacterial pharyngitis overlap significantly 1, 10

When to Seek Further Evaluation

Return for reassessment if:

• Fever persists beyond 48-72 hours after starting appropriate antibiotics 2
• Symptoms worsen or last more than 5 days after starting treatment 9
• Severe difficulty swallowing or breathing develops 2
• Signs of dehydration from persistent vomiting 7

Most cases of viral pharyngitis with vomiting resolve within 7-10 days with supportive care alone. 1