Free Sample FNP Practice Question
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Your Free FNP Practice Question
A 6-year-old female presents at the pediatric clinic with her father who reports a two-day history of fever and sore throat. Her medical and surgical history is otherwise negative and she has no known drug allergies. Vital signs demonstrate a temperature of 102° F, pulse 90 beats per minute, blood pressure 100/70 mmHg, and respirations 12 per minute. A physical exam is remarkable for tender cervical lymphadenopathy, bilateral tonsillar hypertrophy with exudate, and a body rash as shown below.
Assuming a rapid antigen test is positive, which of the following is the best option for treating this patient?
- A. Cefdinir
- B. Clindamycin
- C. Doxycycline
- D. Penicillin V
- E. Supportive management only
The Answer and Explanation
Did you get it right? The correct answer is: D
Acute pharyngitis is a highly common diagnosis in the outpatient setting. While the vast majority of cases are of viral etiology, the identification and appropriate management of group A beta-hemolytic streptococcal (GABHS) pharyngitis is crucial, as untreated infection can lead to serious sequelae, including rheumatic heart disease. The incidence of GABHS pharyngitis is roughly twice as common in children as it is in adults. While viral pharyngitis commonly presents with cough and coryza, the most suggestive clinical findings for GABHS are the absence of cough, fever (greater than 100.4°F), tonsillar exudates, and tender anterior cervical lymphadenopathy. In fact, it is common practice to utilize one of several clinical criteria to justify the collection of a throat culture (See Table 1 and Table 2). Several other highly indicative exam findings include palatal petechiae and scarlatiniform rash (demonstrated above), though these are uncommon.
Table 1. Modified Centor criteria for predicting strep throat
| Criteria | Points designated | Sensitivity (%) | Specificity (%) |
| Cough absent | 1 | 51 to 79 | 35 to 68 |
| Tender anterior cervical adenopathy | 1 | 55 to 82 | 34 to 73 |
| Temperature > 100.4°F | 1 | 25 to 58 | 53 to 92 |
| Hypertrophic or exudative tonsils | 1 | 36 | 85 |
| Age 3 to 14 years | 1 | – | – |
| Age 15 to 44 years | 0 | – | – |
| Age 45 years or older | -1 | – | – |
Table 2. Pretest probability of GABHS pharyngitis by Centor score
| Score | Risk of GABHS pharyngitis (%) | Recommendation |
| ≤ 0 | 1 to 2.5 | No further testing, no antibiotics |
| 1 | 5 to 10 | Optional throat culture |
| 2 | 11 to 17 | Throat culture or rapid antigen detection test |
| 3 | 28 to 35 | Throat culture or rapid antigen detection test |
| ≥ 4 | 51 to 53 | Empiric antibiotic treatment |
Current guidelines still recommend penicillin as first-line treatment for confirmed or highly suspected GABHS pharyngitis. More specifically, this may include a 10-day course of oral penicillin (V), amoxicillin, or a single intramuscular injection of benzathine penicillin. To date, this antibiotic class endures as a highly effective, low-cost option, and is the only antibiotic documented to prevent rheumatic fever. Amoxicillin is commonly used due to its preferable flavor profile. For those with a penicillin allergy, a first-generation cephalosporin or erythromycin are the recommended alternatives. Unfortunately, recurrence and chronic streptococcal carriage are possible even with appropriate antibiotic therapy, but tonsillectomy or adenoidectomy have not been proven to carry a substantial enough benefit to outweigh the associated risks of the procedure.
Incorrect Answer Explanations
Answer A: Cefdinir is not correct. According to current guidelines, penicillin remains the recommended first-line treatment for streptococcal pharyngitis. For those with a penicillin allergy, a first-generation cephalosporin (such as cephalexin) is an acceptable alternative. Cefdinir is a third-generation cephalosporin and should not be considered in the treatment of this infection.
Answer B: Clindamycin is not correct. According to current guidelines, penicillin remains the recommended first-line treatment for streptococcal pharyngitis. For those with a penicillin allergy, a first-generation cephalosporin (such as cephalexin) or erythromycin are acceptable alternatives. Clindamycin is not recommended in the treatment of strep throat.
Answer C: Doxycycline is not correct. According to current guidelines, penicillin remains the recommended first-line treatment for streptococcal pharyngitis. For those with a penicillin allergy, a first-generation cephalosporin (such as cephalexin) or erythromycin are acceptable alternatives. Doxycycline is not among the recommended alternative for treatment. Further, its use in the pediatric population is discouraged due to the risk of drug-associated tendon injury.
Answer E: Supportive management is not correct. The clinical scenario presented is consistent with strep throat. Failure to promptly treat with an appropriate antibiotic carries a risk of significant complications, including abscess formation, sepsis, rheumatic fever, and glomerulonephritis.
Bottom Line
Penicillin, in any of its several forms, remains the drug of choice for the treatment of Streptococcal pharyngitis. To date there is no evidence of resistance to this drug class and its use is shown to virtually eliminate the incidence of acute rheumatic fever.
For more information, see:
Dietrich ML, Steele RW. Group A Streptococcus. Pediatr Rev (2018) 39 (8): 379–391.
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