Physical Characteristics of Strep Throat
The classic physical examination findings of strep throat include tonsillopharyngeal erythema (with or without exudates), tender enlarged anterior cervical lymph nodes, palatal petechiae, and a beefy red swollen uvula, though none of these findings alone is specific enough to diagnose strep throat without laboratory confirmation. 1
Key Visual Findings on Examination
Throat and Tonsillar Appearance
- Tonsillopharyngeal erythema is the hallmark finding, presenting as marked inflammation with a beefy red appearance of the tonsils and pharynx 1, 2, 3
- Tonsillar exudates appear as patchy yellow or white patches on inflamed tonsils, though many confirmed cases present without exudates 1, 2, 3
- Swollen tonsils with edema of the surrounding tissues are characteristic 2, 3
- Beefy red, swollen uvula appears enlarged and intensely erythematous 1, 2, 3
- Palatal petechiae (sometimes called "doughnut lesions") may appear on the soft palate, which are highly suggestive when present 1, 3
Lymph Node Findings
- Tender, enlarged anterior cervical lymph nodes (lymphadenitis) are strongly associated with streptococcal infection and commonly found on palpation 1, 3
Associated Systemic Findings
- Fever is typically present, often high-grade 1, 3
- Scarlatiniform rash may accompany the pharyngitis in some cases 1
- Excoriated nares (especially in infants) with purulent nasal discharge may be seen in young children rather than classic tonsillar findings 1, 3
Critical Diagnostic Limitations
None of these physical findings is specific for Group A streptococcal pharyngitis—identical appearances can occur with viral and other bacterial infections. 2, 3 Even experienced clinicians cannot reliably distinguish streptococcal from viral pharyngitis based solely on physical examination, with clinical findings alone predicting positive cultures only 80% of the time at best. 2
Features That Suggest Viral (NOT Strep) Etiology
The absence of these findings makes strep throat more likely, while their presence strongly suggests viral pharyngitis:
- Conjunctivitis 1, 3
- Cough 1, 4
- Coryza (nasal discharge/rhinorrhea) 1, 3
- Hoarseness 1, 3
- Discrete ulcerative stomatitis (mouth ulcers) 1, 3
- Viral exanthem 1, 3
- Diarrhea 1
Age-Related Presentation Variations
- School-aged children (5-15 years) are most likely to present with classic exudative pharyngitis 1, 2, 3
- Teenagers and adults often present with atypical findings, making visual diagnosis more challenging 2
- Children younger than 3 years may show less specific findings and classic tonsillar findings may be less apparent 1, 3
Essential Clinical Caveat
Microbiological confirmation with either rapid antigen detection testing or throat culture is required for definitive diagnosis—clinical examination alone is insufficient to make treatment decisions. 2, 3 Testing should not be performed when clinical features strongly suggest viral etiology (presence of cough, rhinorrhea, conjunctivitis, hoarseness). 1, 5