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Sore throat & tonsillitis
FeverPAIN decides — and don’t miss the quinsy or epiglottitis.
Typical consult⏱ 10–15 min
Investigations🔬 None
Usual outcome💊 Analgesia ± penicillin V
0–5Red flags + history5–12Examine12–17Decide17–24Treat + explain24–30Safety-net + document
1Rule out first — red flags
| If you find… | …then |
|---|---|
| Drooling, stridor, unable to swallow saliva, muffled voice | Epiglottitis / airway — don’t examine the throat; ED/anaesthetics |
| Unilateral tonsil swelling, uvula deviation, trismus | Quinsy — ENT same day |
| Severe illness, dehydrated, sepsis features | Admit |
| On carbimazole / clozapine / chemotherapy | Check FBC — neutropenia |
| Stiff neck, swelling in the neck after sore throat | Deep neck space infection / Lemierre’s |
2Focused history
3Focused examination
4Decide — investigate only if it changes the plan
FeverPAIN (1 point each)
- Fever in past 24 h
- Purulence on tonsils
- Attend rapidly (within 3 days of onset)
- Inflamed tonsils (severely)
- No cough or coryza
0–1: no antibiotic. 2–3: no antibiotic or back-up prescription. 4–5: immediate or back-up antibiotic. (Centor 3–4 = more likely to benefit.)
| Investigation | Only if… |
|---|---|
| None | Throat swabs and bloods are not routinely needed |
5Treat & send home
Management & advice
- Most are viral and settle within a week, with or without antibiotics
- Paracetamol or ibuprofen, plenty of fluids
- Medicated lozenges may help adults
- Back-up prescription: use if not better in 3–5 days or worse
Refer / follow-up
- Quinsy, airway signs, unable to swallow fluids → ENT / ED
℞
Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.
| Drug | Dose | Duration / notes |
|---|---|---|
| Paracetamol | 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) | As needed |
| Ibuprofen | 400 mg three times a day with food | 3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy |
| Phenoxymethylpenicillin (if indicated) | 500 mg four times a day, or 1 g twice a day | 5–10 days (NICE NG84) |
| Penicillin allergy: clarithromycin | 250–500 mg twice a day | 5 days |
| Pregnant + penicillin allergy: erythromycin | 250–500 mg four times a day (or 500 mg–1 g twice a day) | 5 days |
6Safety-net
Say it like this
This looks like a viral sore throat, which antibiotics won’t help. It usually gets better within a week. Take paracetamol or ibuprofen regularly and keep drinking. If you struggle to breathe, start drooling, or can’t swallow your own saliva, call 999. Come back if one side becomes very swollen or you can’t open your mouth.
Come back / call 111 — or 999 if severe — if:
- Difficulty breathing, drooling or can’t swallow your own saliva — call 999
- Swelling on one side of the throat or can’t open your mouth
- Not able to drink
- Not improving after 1 week
7Patient leaflets — scan & go
Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.
8Document
Sore throat & tonsillitis — clinic note
A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.
URGENT CARE — SORE THROAT & TONSILLITIS
PRESENTING COMPLAINT:
HISTORY
Duration, fever in past 24 h:
Cough or coryza (suggests viral):
Able to swallow fluids, saliva?:
Voice change, breathing, drooling:
Medications (agranulocytosis risk), immunosuppression:
RED FLAGS (record present / absent)
[ ] Drooling, stridor, unable to swallow saliva, muffled voice
[ ] Unilateral tonsil swelling, uvula deviation, trismus
[ ] Severe illness, dehydrated, sepsis features
[ ] On carbimazole / clozapine / chemotherapy
[ ] Stiff neck, swelling in the neck after sore throat
PMH:
DRUG HISTORY:
ALLERGIES:
SOCIAL (job / who is at home / driving):
OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 )
EXAMINATION
Obs:
Tonsils: inflammation, exudate, symmetry, uvula position:
Anterior cervical lymph nodes:
Trismus:
DECISION RULE — FeverPAIN (1 point each): result ______
INVESTIGATIONS: none required / None — result:
IMPRESSION:
PLAN
Treatment / TTO (drug, dose, duration):
Advice given:
Leaflet given (QR / printed): Sore throat, Tonsillitis
Follow-up / referral:
SAFETY-NETTING (told to return / call 111 / 999 if):
- Difficulty breathing, drooling or can’t swallow your own saliva — call 999
- Swelling on one side of the throat or can’t open your mouth
- Not able to drink
- Not improving after 1 week
Patient understands and agrees with the plan: Y / N
Seen by: Grade: Date/Time:
✓Guidelines
Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.
More ear, nose, throat & eyes
Earache: otitis media & externaMostly no antibiotics — but spot mastoiditis and malignant otitis externa.SinusitisViral until day 10 — and don’t miss the orbit.Nosebleed (epistaxis)Proper first aid, cautery if you can see it, and who needs ENT.Red eye & conjunctivitisConjunctivitis is a diagnosis of exclusion — check acuity and pain first.