Risk Management Pitfalls for Urgent Care Management of Pharyngitis

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  1. “It was just a sore throat, so I didn’t think she needed to be transferred for intravenous fluids.” Pharyngitis can be a simple diagnosis, but adequate pain control must be ensured to allow oral rehydration. Failing to assess PO intake initially and prior to discharge can lead to poor outcomes and readmissions. 
  2. “I discharged him with viral pharyngitis after a negative NAAT. I didn’t expect him to end up in the intensive care unit with multiple septic emboli.” Lemierre syndrome is a rare but well-described complication of pharyngitis, normally associated with Fusobacterium species instead of GABHS. It is most commonly seen in adolescent patients shortly outside of the “acute” (3-5 day) pharyngitis window, and results in internal jugular venous thrombosis and sepsis. Patients should always be given clear return precautions and follow-up plans. 
  3. “I didn’t ask about his sexual history.” Gonorrhea can cause an exudative pharyngitis and should be considered in the broad differential for pharyngitis. Chlamydia trachomatis, HIV, and herpes simplex virus can all also produce pharyngeal syndromes and symptoms. Failing to take a good history prevents the diagnosis of these conditions. 
  4. “She told me her voice sounded funny, but it sounded fine to me.” Patients presenting with sore throat can have serious airway complications. Voice change (other than hoarseness associated with postnasal drip and cough) should be taken as a sign of deep space neck infection or epiglottitis; further investigation with direct visualization or imaging to identify a cause should be strongly considered. 
  5. “He had a cough, runny nose, and hoarseness, but I still gave penicillin for his sore throat. He had never had an allergic reaction to an antibiotic before.” Inappropriate use of antibiotics can lead to unnecessary costs, antibiotic resistance, and allergic or other unpleasant reactions for patient. Antibiotic use should be limited to only those patients with a clear indication. Patients with obvious evidence of viral pharyngitis, ≤1 Centor Criteria, or negative POC testing should not be treated with antibiotics.
  6. “I gave antibiotics, but the patient is very upset that she developed a peritonsillar abscess and had to come back.” Antibiotics have been shown to decrease suppurative complications, but complications can still occur. Patients should be counseled on the possible complications of pharyngitis and given strict return precautions and a follow-up plan.
  7. “I never felt under his tongue.” Given the broad differential associated with pharyngitis, the clinician’s best tools for success are a thorough history and physical examination. Ludwig angina (submandibular abscess) results in “woody” induration of the submental space. Forgetting to fully examine the entire oral cavity or other relevant structures (skin, spleen, etc.) can result in missed diagnoses.
  8. “The patient reported a penicillin allergy, so I gave cephalexin. I never asked what the reaction was.” Penicillin is the treatment of choice for GABHS pharyngitis, but in penicillin-allergic patients, there are other options. Cephalosporins have low cross-reactivity to penicillin, have been proven effective against GABHS, and can be used if a patient had a minor reaction. However, if a patient has had a severe allergy to penicillin such as anaphylaxis, Stevens-Johnson syndrome, or other airway involvement, cephalosporins should not be used. 
  9. “It was just a sore throat. Why would I think about cancer?” Infectious pharyngitis should last only 3 to 5 days, and anyone presenting with a longer course needs a broader differential. In older patients or patients with other risk factors for malignancy (smoking, obesity, heavy alcohol use), it must be considered or it will most certainly be missed.
  10. “The patient had an isolated sore throat and negative strep test. It clearly wasn’t a case of COVID-19.” Like other viral respiratory infections, the symptoms of COVID-19 can evolve over the course of illness. Additionally, data on more recent SARS-CoV-2 strains have shown that SARS-CoV-2-positive patients are now more likely to report sore throat as a symptom than patients who had earlier strains of the virus. 
  11. “I saw the patient yesterday and diagnosed her with viral pharyngitis. She didn’t need any treatment. I don’t know why she is back.” Pharyngitis can be very painful for patients, and even if antibiotics are not prescribed, the UC clinicians should counsel the patient on methods for pain control. NSAIDs, acetaminophen, lozenges, and gargles can all be effective. Even though most of these medications are available over the counter, patients should still be instructed on what to use and how to use it in order to prevent repeat visits.

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Excerpted from Pochick K. Evaluation and Management of Patients with Pharyngitis in Urgent Care. Evidence-Based Urgent Care. 2022 October 1;1(7). Reprinted with permission of EB Medicine. Learn more about Evidence-Based Urgent Care and get a free sample issue at https://www.ebmedicine.net/urgent-care-info 

Urgent Care Evaluation of Patients with Chest Pain

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No single component of the history, physical examination, or initial diagnostic testing can reliably exclude acute coronary syndrome (ACS), but various clinical risk scores incorporate this information to identify patients at low risk for ACS or serious short-term outcomes. The use of clinical decision pathways is advised by the 2021 American Heart Association/American College of Cardiology chest pain guideline.1 The goal should be to promptly identify and assess patients presenting with chest pain in order to recognize those who are actively having ACS. Time matters in these patients. Intervention before myocardial damage is the desired outcome; the most commonly used metric is a door-to-balloon time of less than 90 minutes.2 It is reasonable to postpone the comprehensive patient check-in process until an initial assessment has been done, with high-risk patients expedited to a higher level of care. Patients who are identified as low risk can return to the standard check-in process and then undergo a full clinical evaluation.3 

History 

A focused history should be obtained from all stable patients. Historical features of a patient’s chest pain cannot reliably rule in or rule out ACS but may be associated with a higher or lower likelihood of ACS. A 2015 review that included 58 studies found that pain radiating to both arms, pain similar to prior ischemia, and a change in the pattern of pain over the past 24 hours were the most helpful historical features in predicting ACS. These features had a positive likelihood ratio (LR) ≥2.0 and a 95% confidence interval (CI) excluding 1.0.4 This review also found that pleuritic pain is less likely to be associated with ACS (positive LR, 0.35-0.61; 95% CI excluding 1.0). Using the same criteria, a 2005 review found that chest pain that radiates to the shoulders or arms, pain that is associated with exertion, or pain associated with diaphoresis was most predictive of ACS. Conversely, pain described as sharp or stabbing, pain not associated with exertion, and pain described as pleuritic, positional, or reproducible with palpation (colloquially referred to as “the 3 Ps”) were least predictive.5 Women, older adults, and patients with diabetes are more likely to present with “atypical” symptoms of ACS (e.g., pain outside of the chest, lack of pain, or symptoms such as nausea or dyspnea).6,7

 Several landmark studies have shown that patients’ age and gender and their description of symptoms are associated with the presence of clinically significant CAD.8-10 However, these studies examined patients who had undergone invasive angiography, a population that differs from most patients presenting to EDs or UCs with chest pain. A more recent study of patients with chest pain who underwent noninvasive CCTA has suggested that these historical features greatly overestimate the actual prevalence of CAD.11 

In general, classic cardiac risk factors (hypertension, hyperlipidemia, diabetes, smoking, and family history of CAD) are not independently predictive of ACS in patients presenting to the ED with chest pain;12,13 however, these classic cardiac risk factors may be more useful in younger patients. A prospective analysis of nearly 11,000 patients found that among those aged <40 years, the presence of zero risk factors had a negative LR of 0.17 for ACS (95% CI, 0.04-0.66), and the presence of 4 or more risk factors had a positive LR of 7.39 (95% CI, 3.09- 17.67).14 

Physical Examination 

The physical examination in patients with chest pain is often normal, and abnormalities found on examination are often nonspecific for ACS. Hypotension, the presence of a new mitral regurgitation murmur, and the presence of a third heart sound all increase the likelihood of ACS.15 Chest pain that is reproducible on palpation is perhaps the most useful finding in lowering the likelihood of ACS; a systematic review showed that this finding had a LR of 0.28 for ACS (95% CI, 0.14-0.54).16 However, none of these features can be used to reliably rule in or rule out ACS. As such, the physical examination is perhaps more important for assessing overall hemodynamic function and the likelihood of alternative diagnoses of chest pain. For example, the examination findings of oxygen saturation < 95% or unilateral leg swelling are strongly associated with pulmonary embolism.17 A prospective cohort study of 250 patients found that an aortic regurgitation murmur, pulse differential (absence of unilateral carotid or upper extremity pulse), or blood pressure differential >20mmHg between the arms are independent predictors of thoracic aortic dissection. Focal neurologic signs may also suggest dissection but were seen in only 13% of patients in this study.18 A brief dermatologic examination may uncover vesicular lesions suggestive of herpes zoster.

Excerpted from Johnson L. Identifying Urgent Care Patients with Chest Pain Who Are at Low Risk for Acute Coronary Syndromes. Evidence-Based Urgent Care. 2022 November 1;1(8). Reprinted with permission of EB Medicine. Learn more about Evidence-Based Urgent Care and get a free sample issue at https://www.ebmedicine.net/urgent-care-info 

 

References

  1. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/ CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;144(22):e368- e454. (Consensus guidelines)
  2. McNamara RL, Wang Y, Herrin J, et al. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2006;47(11):2180-2186. (Cohort study; 29,222 patients) 
  3. Johnson L, Smith DL. Implementation of a rapid chest pain protocol in a walk-in clinic. Journal of Urgent Care Medicine. 2022;16(7):19-23. (Cross-sectional study; 26 patients) 
  4. Fanaroff AC, Rymer JA, Goldstein SA, et al. Does this patient with chest pain have acute coronary syndrome?: the rational clinical examination systematic review. JAMA. 2015;314(18):1955-1965. (Systematic review) 
  5. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623-2629. (Review) 
  6. Milner KA, Vaccarino V, Arnold AL, et al. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study). Am J Cardiol. 2004;93(5):606-608. (Retrospective; 2073 patients) 
  7. Culić V, Eterović D, Mirić D, et al. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J. 2002;144(6):1012-1017. (Prospective observational; 1996 patients) 
  8. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300(24):1350-1358. (Review) 
  9. Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). 1981;64(2):360-367. (Retrospective; 8157 patients) 
  10. Pryor DB, Harrell FE, Jr., Lee KL, et al. Estimating the likelihood of significant coronary artery disease. Am J Med. 1983;75(5):771-780. (Retrospective; 5438 patients) 
  11. Cheng VY, Berman DS, Rozanski A, et al. Performance of the traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography: results from the multinational coronary CT angiography evaluation for clinical outcomes: an international multicenter registry (CONFIRM). Circulation. 2011;124(22):2423- 2432. (Prospective; 14,048 patients) 
  12. Jayes RL, Jr., Beshansky JR, D’Agostino RB, et al. Do patients’ coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter study. J Clin Epidemiol. 1992;45(6):621-626. (Retrospective; 1743 patients) 
  13. Body R, McDowell G, Carley S, et al. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the emergency department? 2008;79(1):41-45. (Prospective cohort; 796 patients) 
  14. Han JH, Lindsell CJ, Storrow AB, et al. The role of cardiac risk factor burden in diagnosing acute coronary syndromes in the emergency department setting. Ann Emerg Med. 2007;49(2):145- 152. (Post hoc analysis of prospective cohort; 10,806 patients)
  15. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139-e228. (Consensus guideline) 
  16. Fanaroff AC, Rymer JA, Goldstein SA, et al. Does this patient with chest pain have acute coronary syndrome?: the rational clinical examination systematic review. JAMA. 2015;314(18):1955-1965. (Systematic review)
  17. Courtney DM, Kline JA, Kabrhel C, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multicenter study. Ann Emerg Med. 2010;55(4):307-315.e301. (Prospective cohort; 7940 patients) 
  18. von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med. 2000;160(19):2977-2982. (Prospective cohort; 250 patients)