What is the most likely diagnosis and appropriate management for a 19‑year‑old male with sore red throat, cough, fever 101 °F, no tonsillar exudates and clear lung examination?

Acute Viral Pharyngitis

This 19-year-old male most likely has acute viral pharyngitis, and antibiotics should not be prescribed. The presence of cough combined with the absence of tonsillar exudates strongly argues against Group A Streptococcus (GAS) infection, making microbiological testing unnecessary in this clinical scenario. 1, 2

Why This Is Viral, Not Bacterial

The clinical presentation points overwhelmingly toward a viral etiology:

• Cough is the key discriminating feature. The presence of cough, along with other upper respiratory symptoms (rhinorrhea, hoarseness, conjunctivitis), strongly suggests viral pharyngitis and should preclude testing for GAS. 1, 2

• Absence of tonsillar exudates (white patches) significantly reduces the probability of GAS infection. GAS pharyngitis typically presents with tonsillopharyngeal erythema with or without patchy discrete exudates, tender enlarged anterior cervical lymph nodes, and palatal petechiae. 1, 2

• The fever of 101°F is relatively modest. GAS pharyngitis characteristically presents with sudden onset of severe sore throat and high fever (typically 101-104°F), though this patient's fever does not exclude viral infection. 1, 2

• Viral causes account for the vast majority of acute pharyngitis cases in young adults. GAS accounts for only 5-10% of acute pharyngitis in adults, compared with 15-30% in children aged 5-15 years. 2, 3

Why Testing Is Not Indicated

Do not perform a rapid antigen detection test (RADT) or throat culture in this patient. 1, 2

• Testing patients who display obvious viral symptoms (cough, rhinorrhea) can generate false-positive GAS results due to asymptomatic carriage in 10-15% of the population. 2

• Clinical guidelines explicitly state that when overt viral features like cough are present, swabbing the throat is not recommended because the clinical features reliably discriminate in favor of viral pharyngitis. 1, 2

• Performing GAS testing in the absence of appropriate clinical features leads to over-diagnosis and unnecessary antibiotic use in 50-70% of cases. 2

Appropriate Management

Provide supportive care only:

• Analgesics: Acetaminophen or ibuprofen for pain and fever relief. 1, 2

• Adequate hydration to maintain comfort and prevent dehydration. 1, 2

• Warm saline gargles may provide symptomatic relief. 2

• Topical anesthetics (e.g., throat lozenges) can be offered for throat discomfort. 2

• Reassure the patient that symptoms typically last up to 2 weeks and should resolve spontaneously within 3-7 days. 1, 2

When to Reassess

Advise the patient to return if:

• Symptoms worsen or persist beyond 2 weeks. 1

• High fever develops (>101°F sustained or worsening). 2

• Severe difficulty swallowing or breathing occurs. 2

• Signs of dehydration appear. 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on the presence of pharyngeal erythema and fever alone. Clinical features overlap too broadly between viral and bacterial pharyngitis for diagnosis on clinical grounds alone, but the presence of cough tips the balance decisively toward viral etiology. 1, 2

• Do not test "just to be sure." Testing in the presence of clear viral features yields false-positive results from asymptomatic GAS carriers and drives inappropriate antibiotic use. 2

• Do not assume that fever automatically indicates bacterial infection. Viral pharyngitis frequently causes fever, and the modest temperature in this case is entirely consistent with viral illness. 1, 2