SORE THROAT TEST & TREAT TRAINING

OBJECTIVES

By the end of this course, the learner will know how to:

• Take an accurate history from a patient

• Examine the throat using a tongue depressor and lymph node palpation

• Assess the need for a Rapid Antigen Test based upon FeverPAIN or Centor

• Swab a throat and then use a Rapid Antigen Test in order to give positive or negative result

• Consider possible differential diagnosis

•Manage the patient appropriately based on the results

SORE THROATS

Common causes :

Infectious

Viral

Bacterial i.e. Strep A

Non-Infectious

Hayfever

Physical irritation

STRUCTURE OF A CONSULTATION

Initial assessment

Presenting complaint

History of presenting complaint

Physical assessment

Past Medical History

Medications

Allergies

Social History

Management

Safety Netting

Documentation

MAKING A DIAGNOSIS

Diagnosis Made Upon

History Examination Investigations

THE CONSULTATION

• Your consultation room

• Gain a rapport with your patient – introductions, empathy

• Gain consent

• Ensure privacy

• Prepare yourself

•Active listening

INITIAL ASSESSMENT

• Any life threatening problems?

• ABCDE Approach

Airway

Breathing

Circulation

Disability

Exposure

PRESENTING COMPLAINT

• Allow the patient to talk to you in their own words.

•Actively listen

•Most patients will tell you in 1-2 minutes

“I’ve got a really sore throat”

HISTORY OF PRESENTING COMPLAINT

• Lets get the detail

•Closed vs Open questions

•Don’t assume

•OLDCART

O L D C A R TOnset

• When did it

start?

• Was it

sudden /

gradual

• Is it getting

better or

staying the

same?

Location

• Where in the

body does it

occur?

• Does it

radiate or

extend to

other areas?

Duration

• How often

does it

occur?

• How long

does it

last?

Characteristics

• Describe the

symptom

• What does it

feel like?

• How severe is

it 0-10?

Associated

Factors

• Do you

have any

other

symptoms

that may

be

linked?

Relieving /

Aggravating

Factors

• What if

anything

makes it

better or

worse?

Treatment

• What

treatment

have you

tried so

far?

What does the patient think this is?

MORE HISTORY

•Previous medical history

•Medications & allergies

•Social / family history

STREP A CHARACTERISTICS

Strep A infections are characterised by:

•Pain at the back of the throat which feels worse when swallowing,

•Redness in the throat

•Possible exudate on the tonsils

•Fever of over 38.5°C

•Patients do not usually have a cough

FeverPAIN or Centor criteria are clinical scoring tools thatcan help to identify the people in whom this is morelikely.

FeverPAIN

•Fever (during previous 24 hours)

•Purulence (pus on tonsils)

•Attend rapidly (within 3 days after onset of symptoms)

•Severely Inflamed tonsils

•No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5).

• A score of 0 or 1 is thought to be associated with a 13 to 18% likelihood of isolating streptococcus. (No Point of Care Test required)

• A score of 2 or 3 is thought to be associated with a 34 to 40% likelihood of isolating streptococcus. (Advise Point of Care Test)

• A score of 4 or 5 is thought to be associated with a 62 to 65% likelihood of isolating streptococcus. (Advise Point of Care Test)

CENTOR CRITERIA

•Tonsillar exudate

•Tender anterior cervical lymphadenopathy or lymphadenitis

•History of fever (over 38°C)

•Absence of cough

Each of the Centor criteria score 1 point (maximum score of 4).

•A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus. No point of care test required.

•A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus. Advise point of care test.

TAKING A TEMPERATURE

Points to consider:

▪The thermometer will be purchased by the pharmacy

▪ Must meet HB specification

▪Disposal of earpieces – Clinical Waste▪ Collection arranged by HB)

▪Calibration (pharmacy responsibility)

▪Maintenance of equipment/infection control

▪Normal temp 37-37.5°C

INFECTION PREVENTION & CONTROL MEASURES

You will need the following:

• Disposable latex free gloves

• Apron

• To wash your hands both before and after the procedure

• Tongue depressor must be single use only

• Pen torch should be cleaned between patients

• All waste must be disposed of in clinical waste.

EQUIPMENT

You will need the following:

•Gloves

•Apron

•Good lighting source or pen torch

•Tongue depressor

•Strep A kit

ANATOMY & PHYSIOLOGY Hard palate

Soft palate

Uvula

Palatine tonsil

Posterior Wall of the

Oropharynx

PHYSICAL EXAMINATION

LYMPH NODE PALPATION

THROAT SWAB –PREPARING THE PATIENT

• Explain the procedure gain informed consent

• Ask the patient to sit upright, facing a light source, tilt

their head back, open their mouth and stick their tongue

out

• Depress the tongue with a spatula

• Ask the patient to say “Ah”

• Roll the swab over the area of exudate / tonsils /

posterior pharynx

• Carefully withdraw the swab, avoid touching the mouth or

tongue

DIFFERENTIAL DIAGNOSIS

Epiglottitis Abscess Infectious

mononucleosis

DiptheriaLemierre’sSyndrome

Measles Behcet’s

Syndrome

Stevens-Johnson

Syndrome

Kawaskai disease

Hand Foot and Mouth Disease

Oropharyngeal canceer

Aphthous ulcers

RED FLAGS

• Any signs of sepsis

• Breathing difficulties

• Drooling

• Muffled voice

• Stridor

• Dehydration

• Rash

• Prolonged fever in children (over 5 days)

• Non healing lesions

EPIGLOTTITIS

Epiglottitis is inflammation and swelling of the epiglottis caused by infection. Thesymptoms of epiglottitis usually develop quickly and get rapidly worse.

Difficulty and pain when swallowing

Difficulty breathing, which may improve when leaning forwards

Breathing that sounds abnormal and high-pitched (stridor)

High temperature of 38C or above

Irritability and restlessness

Muffled or hoarse voice

Drooling

DO NOT EXAMINE THE THROAT OF ANYONE WITH SUSPECTED

EPIGLOTTITIS AS THIS MAY CAUSE CLOSURE OF THE AIRWAY

PAEDIATRICS

• Consent• People aged 16 or over are entitled to consent to their

own treatment

• Children under 16; are they Gillick competent?

• Consent should be given by someone with parental responsibility:

• Anatomical differences: • Lymph nodes

• Tonsils

• Examining the throat

• How can we get a child to open their mouth?

• Immunisations • (Hib)

MANAGEMENT OF THE PATIENT

POSITIVE

Supply with the appropriate antibiotics as per

the PGD

NEGATIVE

Consider supply of medicine in accordance with

Common Ailments Service – Sore Throat &

Tonsillitis monograph

FOR ALL CASES

Give self care and follow up advice

Follow up interview 10-14 days after the initial consultation

Consultation summary to be forwarded to the patient’s GP within 72 hours