Case Study 3 – Answers

Answers – Sore throat in community pharmacy

 
A) Initial working diagnosis and differentials:

The patient is presenting with signs and symptoms of acute sore throat. He does not have any risk factors, at risk of deterioration or is not immunosuppressed.

Using the FeverPAIN scoring tool, this patient has a score of 3: it is likely this patient has a sore throat which may have a streptococcal cause.

Ref:
https://clinicalpathways.uk/pharmacy/acute-sore-throat/
https://www.mdcalc.com/calc/3316/feverpain-score-strep-pharyngitis

FeverPAIN scoring system helps to identify those who are most likely to benefit from antibiotics. This tool has not been assessed in children under 3 years.

Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause. FeverPAIN criteria:

  • Fever: no
  • Pus on tonsils: no
  • Attendance within 3 days of onset of symptoms: yes
  • Severely inflamed tonsils: yes
  • No cough or coryzal symptoms present: yes

Score 0-1: Do not offer antibiotic
Score 2-3: Offer delayed antibiotic
Score 4-5: Offer immediate antibiotic prescription

A score of 0 or 1 is thought to be associated with a 13% to 18% likelihood of isolating streptococcus.
A score of 2 or 3 is thought to be associated with a 34% to 40% likelihood of isolating streptococcus.
A score of 4 or 5 is thought to be associated with a 62% to 65% likelihood of isolating streptococcus.

  • DDx: viral upper RTI, allergy, irritation or overuse of throat/voice.

RED FLAG symptoms: the following are screened by questions in the pharmacy to rule out any complications or need for medical referral:

  • Refer to GP if the sore throat is recurrent/repeated episode.
  • Consider referral to hospital if they have acute sore throat associated with severe systemic infection or severe suppurative complications (such as abscess).
  • Immunosuppression: is the patient taking any immunosuppressive medications or have a medical history of same.

 
B) Investigations:

In the pharmacy check patient temperature, ask patient whether they have any of the FeverPAIN signs/symptoms.

You could consider the point of care Strep A throat swab test. The FeverPAIN tool and others such as the Centor score are helpful but have a limited role in detecting strep throat infection. Point of care testing may offer another option to help with the diagnosis and decision-making. This is typically conducted with a FeverPAIN score of 4-5.

 
C) Management plan:

  • Approximately 95% of sore throats are viral in nature; however antibiotics are frequently prescribed for this indication. (Many are caused by rhinovirus, coronavirus, parainfluenza virus, influenza types A and B). Group A streptococcus is the most common bacterial cause and may cause pharyngitis, tonsillitis or scarlet fever.
  • Check with patient what their concerns and expectations are regarding treatment.
  • As per Pharmacy first treatment algorithm, self-care and pain relief are recommended at this stage.
  • Antibiotics make little different to the duration of symptoms
  • Withholding antibiotics is unlikely to lead to complications
  • Advise patient that sore throats usually take 7-8 days to self-resolve – his sore throat may get better without the need for antibiotics.
  • Consider analgesia: paracetamol (or ibuprofen where appropriate).
  • Advise patient about adequate intake of fluids.
  • Patients report symptom relief from using over-the-counter products such as topical anaesthetic sprays and medicated lozenges containing local anaesthetics.
  • To help soothe a sore throat:
    • avoid hot food and hot drinks
    • eat cool, soft food
    • drink plenty of cool or warm liquids
    • avoid smoking
    • gargle with warm, salty water (do not give children salt water to gargle)
  • Explains that antibiotics are not always needed for mild sore throat and that antibiotics can cause harm e.g. affect our gut bacteria, increase our risk of antibiotic resistance and thrush, and may make future infections more difficult to treat.
  • Explains as he has no serious symptoms or background issues that warrant medical review, that watch and wait is appropriate along with supportive management.
  • Information on the following patient information websites may be shared:

    •  
    D) Counselling and Safety netting:

    • The patient should be advised to return to the pharmacy if he sees no improvement in 3-5 days for reassessment. Antibiotics may be considered based on this reassessment.
    • Take the time to carefully explain to the patient that if his symptoms have not resolved or get worse they should come to the pharmacy or visit their GP.
    • TARGET RTI leaflet can be used in the consultation. Seek medical attention if:
      • If your skin is very cold or has a strange colour, or you develop an unusual rash.
      • If you have new feelings of confusion, or drowsiness, or have slurred speech.
      • If you have difficulty breathing. Signs that suggest breathing problems can be:
        • breathing quickly
        • turning blue around the lips and the skin below the mouth
        • skin between or above the ribs getting sucked or pulled in with every breath
      • If you develop a severe headache and are sick.
      • If you develop chest pain.
      • If you have difficulty swallowing or are drooling.
      • If you cough up blood.
      • If you are passing little or no urine.
      • If you are feeling a lot worse. In view of this, recommended care is pain-relief and the symptoms may self-resolve.

     
    Marking pointers (what an excellent answer shows)

    • Conducts a thorough background history and presenting complaint check, including red flag issues, to ascertain all signs and symptoms to enable an accurate diagnosis.
    • Recognises not all sore throats require antimicrobial treatment, able to screen the presenting signs and symptoms in line with the evidence-based guidelines to guide this decision making.
    • Addresses supportive care and safety-netting.
    • Addresses antimicrobial stewardship and takes the time to explain to the patient that antibiotics are not always needed for sore throat.

     

    Case Study 2 – Sore throat – common pitfalls

    1. Not conducting a detailed questioning and check of relevant signs, symptoms and red flag symptoms, not using FeverPAIN criteria.
    2. Jumps to recommending a short-course antimicrobial treatment as the first step in management. As per the screening and FeverPAIN, the patient does not need an immediate antibiotic.
    3. Not providing adequate supportive care and recommendations to relieve symptoms.
    4. Insufficient safety-netting

    • Not outlining about what signs and symptoms to monitor in case infection does not self-resolve or in the event he deteriorates.
    • Not providing a timeframe within which he should see an improvement.