Physical Exam Key Points

1. Vital signs. Fever and tachycardia are common to all conditions in differential diagnosis, but presence of hypotension may signify sepsis or toxic shock syndrome. Significant respiratory distress can be associated with upper airway obstruction from enlarged tonsils, deep neck abscesses, epiglottitis, and bacterial tracheitis.

2. HEENT. Enlarged, erythematous, exudative or nonexudative tonsils and an erythematous pharynx are fairly nonspecific findings when attempting to identify causative organism of pharyngitis. Drooling may be noted with any infection that causes dysphagia. Palatal petechiae are often associated with GABHS and EBV. Coxsackievirus often causes small ulcers on soft palate and buccal mucosa. HSV causes vesicles and ulcers on lips and gingival mucosa. Asymmetric tonsillar enlargement and a deviated uvula are present with peritonsil-lar abscesses. Posterior pharyngeal fullness and fluctuance may be noted with retropharyngeal abscess. Trismus may be noted with lateral neck or peritonsillar abscesses.

3. Neck. Tender anterior cervical lymphadenopathy is often present with GABHS pharyngitis. Posterior cervical nodes are often present with EBV. A preauricular node ipsilateral to the side of conjunctivitis is a clue to adenovirus. Asymmetric neck fullness may be felt with lateral pharyngeal infections. Torticollis is often present with retropharyngeal abscesses or peritonsillar abscess.

4. Skin. Sandpaper or scarlatiniform rash may be noted with GABHS scarlet fever. Nonspecific morbilliform rash can occur after amoxicillin is given to a patient with EBV. Erythroderma may signify toxin-mediated disease.

5. Abdomen. Splenomegaly is associated with EBV. Laboratory Data

1. Rapid streptococcal antigen and throat culture. Perform on patients with a stable airway who have fever and pharyngitis. It is important to diagnose GABHS pharyngitis due to numerous suppurative (deep neck abscesses) and nonsuppurative (see VIII, Teaching Pearl: Answer, later) complications. Obtain throat culture if rapid antigen test is negative, because reported sensitivities of some rapid streptococcal tests are as low as 60%.

2. CBC. Elevated WBC count with predominance of neutrophils suggests bacterial infection. Atypical lymphocytosis suggests EBV or CMV.

3. ESR and C-reactive protein. Marked elevation suggests bacterial process.

4. Blood culture. Obtain if invasive or toxin-mediated disease is suspected.

5. Other workup. Obtain culture and Gram stain of an abscess if surgical therapy is warranted.

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