City and Hackney Urgent Care Pathway

Clinical Presentation History – Sore , swollen glands, cough, coryza, , headache, , , nausea, vomiting, rash, abdominal pain, risk factors of immunosuppression Examination – Temp, HR ,RR, BP, , oedema and/or of , enlarged erythematous (with or without ) laryngeal oedema, petechial spots on hard and soft palate NB. Features favouring bacterial : absence of other upper symptoms, purulent exudate, tender anterior cervical lymph nodes, fever and rash

Secondary Care Management Management Consider immediate referral to hospital if:  Encourage rest, consider for pain or fever,  with stridor, respiratory difficulties or or if preferred and suitable, (these can be upper purchased OTC) and oral rehydration.  If , muffled voice, systemic upset – suspect  Use the Centor or FeverPAIN clinical prediction score and avoid examination of the throat to assist the decision on whether to prescribe an  Vomiting with or inability to tolerate oral . See NICE visual summary fluids Sore throat (): antimicrobial prescribing for  Severe suppurative complications prescribing information of antibiotic choices  Unilateral enlargement (fast track suspected neoplasia)  Peritonsillar or cellulitis  Parapharyngeal or Review  Significant systemic upset  Review patient response (either by phone or in person) within 24-48 hours or earlier if symptoms  At risk of immunosuppression deteriorate.  Severe oral mucositis  Give patients clear advice on indication for review, i.e.  Cavernous sinus thrombosis, sphenoid , Ongoing fever, inability to Tolerate fluids despite meningitis, encephalitis or other conditions or development of more severe systemic symptoms.  If patients respond to treatment ensure full 10-day Suspect severe Suspect abscess Otherwise, refer course of antibiotics is taken and to seek help if formation – the patient to symptoms worsen. e.g. airway Refer to Royal Homerton ED compromise, London Hospital or after calling to severe , Royal National discuss with the intracranial Throat, Nose Doctor in Charge. Sepsis – Call 999 and Ear Hospital

If patient is not responding to treatment, reconsider (see below) or refer to secondary care

Complications of acute tonsillitis: Differential Diagnosis of acute tonsillitis:  Otitis media  Rhinosinusitis  Rhinosinusitis  Epiglottitis   Parapharyngeal abscess  Malignancy (suspect if there is unilateral  Retropharyngeal abscess enlargement and subacute or chronic  Metastatic infection – meningitis, mastoiditis, septicaemia symptoms, or if swelling is painless)  Toxic shock syndrome  Embedded foreign body  t pt al st t l reactive arthritis Authors: May Cahill (GP Clinical Lead), January 2015 Reviewed: Ben Molyneux (GP Clinical Lead) Dr Robin Whittaker (Locum Consultant Microbiologist), April 2019 Review date: April 2021