Clinical Assessment and Therapeutic Decision-Making in an Older Adult with Acute Pharyngitis at a Primary Healthcare Facility

Abstract

Acute pharyngitis is a common upper respiratory tract condition encountered in primary healthcare settings. Although most cases are self-limiting, distinguishing between viral and bacterial etiologies remains important for appropriate clinical management and rational antibiotic prescribing. This case report describes the clinical assessment and therapeutic management of acute pharyngitis in an older adult attending a primary healthcare facility in Bandar Lampung, Indonesia. A 69-year-old male presented to Gedong Air Public Health Center with a cough lasting several days. Physical examination revealed pharyngeal erythema, nasal mucosal redness, and tender anterior cervical lymph nodes. Initial clinical measurements showed a blood pressure of 110/80 mmHg, pulse rate of 88 beats/min, respiratory rate of 32 breaths/min, body temperature of 36°C, oxygen saturation of 97%, and body mass index of 17.3 kg/m². Based on the clinical evaluation, the patient was diagnosed with acute pharyngitis. No laboratory or microbiological investigations were performed. Pharmacological management included ciprofloxacin 500 mg, guaifenesin, and cetirizine 10 mg, accompanied by advice on hydration, adequate rest, personal hygiene, and avoidance of respiratory irritants. Clinical improvement was reported following treatment, although the timing and objective findings of follow-up assessment were not specified. This case highlights the importance of systematic clinical assessment in older adults presenting with upper respiratory tract symptoms. The absence of microbiological confirmation limits determination of the infectious etiology, while the documented tachypnea warrants further clinical consideration. The antibiotic selection also raises questions regarding adherence to evidence-based prescribing recommendations for uncomplicated acute pharyngitis. This case illustrates the importance of integrating clinical findings, diagnostic uncertainty, and evidence-based therapeutic decision-making in the management of acute pharyngitis in primary healthcare. Accurate clinical documentation, appropriate antibiotic selection, and structured follow-up are essential for evaluating treatment decisions and patient outcomes.