HISTORY. Usually, the symptoms of viral tonsillitis have a gradual onset. Elicit a description of the history and progression of the signs and symptoms. Expect that the predominant symptom is rhinorrhea (a runny nose), which is the key symptom. Ask parents if the child also demonstrates other common symptoms: sore throat, dysphagia, mild cough, hoarseness, and a low-grade fever. Ask if any members of the household have had a cold or upper respiratory infection. Bacterial infections have an abrupt onset without rhinorrhea. Generally, parents will describe fever, weakness, sore throat, dysphagia, nausea, abdominal discomfort, and vomiting.

PHYSICAL EXAM. Children with viral and bacterial infections will have symptoms that reflect the infecting organism (Table 3).

Symptoms of Tonsillitis Based on Causative Agent

MICROORGANISM	TONSIL APPEARANCE	OTHER FINDINGS
Epstein-Barr virus	Exudate on tonsils, petechiae on soft palate	Diffuse adenopathy
Adenovirus	Exudate on tonsils	Cervical adenopathy
Enterovirus	Vesicles and sores on tonsils	Vomiting, diarrhea, rhinorrhea
Herpesvirus	Tonsil ulcers	Diffuse adenopathy
Bacteria (group A beta-hemolytic Streptococcus [GABHS] is most common)	Red tonsils and uvula, exudates on tonsils	Anterior cervical adenopathy, rash

PSYCHOSOCIAL. The parents and child will be apprehensive. Assess the parents' ability to cope with the acute situation and intervene as appropriate. Note that many children are treated at home rather than in the hospital; your teaching plan may need to consider home rather than hospital management.

Diagnostic Highlights

General Comments: Diagnostic testing involves identifying the causative organism, determining oxygenation status, and ruling out masses as a cause of obstruction.

Test	Normal Result	Abnormality with Condition	Explanation
Throat culture	Negative for bacteria	Positive for bacteria	To differentiate between viral and bacterial infections (particularly viral from group a beta-hemolytic streptococcus)

Other Tests: Complete blood count, heterophil antibody test to rule out mononucleosis.