A 17-year-old male presents to your urgent care center with 3 days of increasing sore throat, subjective fever, and painful swallowing. He is healthy at baseline and has no identifiable sick contacts. There are no complaints of cough or shortness of breath, and he is handling oral secretions without apparent limitation. On examination, he has a temperature of 37.2°C (99.9°F), blood pressure of 115/77 mm Hg, heart rate of 108 beats/min, respiratory rate of 16 breaths/min, and oxygen saturation of 97%. He can speak in full sentences but acknowledges that his voice sounds a bit different. Cardiopulmonary and skin exams are unremarkable. Examination of the oropharynx shows significant asymmetric swelling of the right tonsil, with erythema of the bilateral tonsils, uvula, and soft palate. There is prominent exudate, R>L. Anterior cervical lymphadenopathy is present, also more pronounced on the right. The uvula deviates appreciably to the left.
Which of the following options represents the best choice in managing this patient?
A. Since he is in no distress, he can be treated with oral amoxicillin and IM dexamethasone with follow up in 2 to 3 days.
B. Perform rapid strep testing. If positive, treat with oral penicillin; if negative, treat with NSAIDs, oral hydration measures, and expectant management.
C. Treat with oral clindamycin regardless of rapid strep test result. Give strict return instructions and recommend ENT follow up within 7 days.
D. Arrange STAT ENTÂ referral or send to ED for suspected peritonsillar abscess.
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Answer: D. This case is consistent with right-sided peritonsillar abscess. These patients should be seen urgently by ENT for consideration of drainage. Answers A, B, and C represent management strategies which are overly cavalier for this potentially dangerous suppurative complication of pharyngitis.
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