Creating a differential diagnosis for sore throat
A sore throat could be indicative of a viral infection, such as the common cold or flu or of something more worrisome, such an infection caused by group A streptococcus. Careful assessment and diagnosis must be made in order to treat symptoms effectively.
1) Differential Diagnosis #1- Acute pharyngitis
1) Differential Diagnosis #1- Acute pharyngitis
Clinical presentations
Subjective- Sore throat, fever, headache, nausea, vomiting, and abdominal pain may be present for both viral and bacterial etiologies.
Subjective- Sore throat, fever, headache, nausea, vomiting, and abdominal pain may be present for both viral and bacterial etiologies.
Physical examination findings
Viral- Rhinorrhea, nasal congestion and cough are typically present in viral pharyngitis but absent in bacterial pharyngitis. Pharyngeal ulcerations may be present.
Bacterial- yellow white pharyngeal exudates, anterior cervical adenopathy, lack of cough or rhinorrhea, erythema, tonsil enlargement, sandpaper rash on trunk may be present
Viral- Rhinorrhea, nasal congestion and cough are typically present in viral pharyngitis but absent in bacterial pharyngitis. Pharyngeal ulcerations may be present.
Bacterial- yellow white pharyngeal exudates, anterior cervical adenopathy, lack of cough or rhinorrhea, erythema, tonsil enlargement, sandpaper rash on trunk may be present
Diagnostic tests- rapid antigen test for group A Streptococcus (GAS), if negative but still suspicious of GAS order throat culture.
2) Differential Diagnosis #2-Infectious mononucleosis
2) Differential Diagnosis #2-Infectious mononucleosis
Clinical presentation
Subjective- Fever usually <102°F (38.9°C), sore throat, malaise
Subjective- Fever usually <102°F (38.9°C), sore throat, malaise
Physical examination findings- posterior adenopathy, possible splenomegaly, petechiae may be present on the soft palate.
Diagnostic tests- Serum monospot positive for Epstein-Barr virus infection. CBC- Atypical lymphocytes.
3) Differential Diagnosis #3 Epiglottitis
3) Differential Diagnosis #3 Epiglottitis
Clinical presentation
Subjective-Severe and acute onset of sore throat and fever, dysphagia, difficulty in controlling secretions.
Subjective-Severe and acute onset of sore throat and fever, dysphagia, difficulty in controlling secretions.
Physical examination findings- stridor or tripod position may be evident, difficulty breathing and muffled voice
Diagnostic tests- clinical presentation is highly suggestive of the diagnosis. However, lateral neck x-ray could be used to confirm Dx (under controlled circumstances, with the immediate capability of intubation should the airway close).
Helpful tool to diagnose viral sore throat- The Mistik Score
According to the scoring system, a prediction for positive viral infection can be made based on the following indicators:
- absence of headache
- stuffy nose
- sneezing
- temperature of ≥37.5°C on physical examination
- absence of tonsillar exudate and/or swelling.
A score of 5 carries an 82.1% probability of a positive viral infection
References
References
Donowitz, J. R. (2018). Acute pharyngitis. Epocrates. Retrieved from https://online.epocrates.com/diseases/511/Acute-pharyngitis/Key-Highlights
Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2015). Primary Care: The Art and Science of Advanced Practice Nursing, 4th Edition, Philadelphia: F.A. Davis Company
Mistik, S., Gokahmetoglu, S., Balci, E., & Onuk, F. A. (2015). Sore throat in primary care project: a clinical score to diagnose viral sore throat. Family Practice, 32(3), 263–268.
Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2015). Primary Care: The Art and Science of Advanced Practice Nursing, 4th Edition, Philadelphia: F.A. Davis Company
Mistik, S., Gokahmetoglu, S., Balci, E., & Onuk, F. A. (2015). Sore throat in primary care project: a clinical score to diagnose viral sore throat. Family Practice, 32(3), 263–268.
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