[##]-year-old [male/female] with sore
throat with history and exam consistent with likely streptococcal pharyngitis.
Initial consideration in this patient
included streptococcal pharyngitis, mononucleosis, peritonsillar abscess (PTA),
retropharyngeal abscess (RPA), and other viral upper respiratory infections
among others.
Patient presented with sore throat
with evidence of erythema, swelling, and exudate on exam of the posterior
pharynx, no associated cough, anterior lymphadenopathy, and [reported/measured]
fever suggestive of streptococcal pharyngitis.
A rapid strep test [was performed and noted to be positive/not sent due
to highly suggestive features on history and exam]. We discussed risks and benefits of antibiotic
therapy, including the prevention of rheumatic heart disease, limited evidence
of shortened course of illness, and risks of allergic reaction to
antibiotics. After counseling the
patient on these risks and benefits, the patient opted for [intramuscular
penicillin in the ED/discharge with antibiotics/avoiding antibiotics at this
time and treating symptomatically].
Patient reported significant improvement with [treatment] prior to
discharge from ED.
Prior to discharge, we discussed return precautions, specifically
for evidence of worsening infectious symptoms, treatment with [antibiotics and
symptomatic treatment], and follow up with primary care doctor within 1-2 weeks
for further evaluation, and the patient demonstrated understanding and agreement
with this plan
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