What is the approach to examining a patient with pharyngitis?

Approach to Examining a Patient with Sore Throat

A thorough examination of a patient with pharyngitis should focus on identifying Group A Streptococcal (GAS) infection, as it is the only common bacterial cause requiring antibiotic treatment to prevent complications like rheumatic fever and suppurative sequelae.

Key Elements of the Physical Examination

General Observation

• Assess for fever, general appearance, and signs of systemic illness 1
• Note preferred mouth breathing or elongated facies which may indicate chronic pharyngitis 1

Oropharyngeal Examination

• Inspect for tonsillopharyngeal erythema with or without exudates 1
• Look for a beefy red swollen uvula, petechiae on the palate, and tonsillar hypertrophy 1
• Check for cobblestoning of the oropharyngeal wall and pharyngeal postnasal discharge 1
• Note any oral ulcers, which suggest viral etiology 1

Neck Examination

• Palpate for tender enlarged anterior cervical lymph nodes (lymphadenitis), a key finding in GAS pharyngitis 1
• Assess for thyroid enlargement or tenderness 1

Respiratory Assessment

• Note presence of cough, hoarseness, rhinorrhea, or coryza, which strongly suggest viral rather than streptococcal etiology 1
• These findings may obviate the need for streptococcal testing 1

Other Systems

• Examine eyes for conjunctivitis (suggests viral etiology) 1
• Check ears for tympanic membrane abnormalities that may indicate associated otitis 1
• Assess for scarlatiniform rash, which may accompany GAS pharyngitis 1

Diagnostic Decision Making

When to Test for GAS Pharyngitis

• Testing is NOT recommended when clinical features strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers) 1
• Testing is not indicated for children under 3 years old due to low incidence of GAS and rarity of rheumatic fever in this age group 1
• Consider testing when patients present with:
  • Sudden onset sore throat with pain on swallowing 1
  • Fever 1
  • Tonsillopharyngeal erythema with exudates 1
  • Tender anterior cervical adenopathy 1
  • Absence of cough and other respiratory symptoms 1

Diagnostic Testing Options

• Throat culture remains the gold standard (sensitivity 90-95%) 1
• Rapid antigen detection tests (RADTs) can be used with high specificity but lower sensitivity 1
• For children and adolescents, negative RADTs should be confirmed with throat culture 1
• For adults, backup cultures for negative RADTs are generally not necessary due to lower incidence of GAS and minimal risk of rheumatic fever 1

Common Pitfalls to Avoid

• Relying solely on clinical features to diagnose GAS pharyngitis, as symptoms overlap significantly with viral causes 1, 2
• Overdiagnosing GAS pharyngitis, leading to unnecessary antibiotic use 1
• Failing to recognize that most pharyngitis cases (especially in adults) are viral in etiology 1, 2
• Not considering other bacterial causes of pharyngitis in specific populations (e.g., Neisseria gonorrhoeae in sexually active individuals) 1
• Neglecting to assess for signs of complications or more serious conditions requiring urgent intervention 1

Treatment Considerations

• If GAS pharyngitis is confirmed, penicillin or amoxicillin remains the treatment of choice (10-day course) 1
• For penicillin-allergic patients, first-generation cephalosporins (if not anaphylactically sensitive), clindamycin, clarithromycin, or azithromycin are alternatives 1
• Adjunctive therapy with acetaminophen or NSAIDs may be used for symptom relief 1
• Avoid aspirin in children due to risk of Reye syndrome 1

By following this structured approach to examining patients with pharyngitis, clinicians can more accurately identify those with GAS infection requiring antibiotic therapy while avoiding unnecessary treatment in those with viral etiologies.