Improving Patient Care

Making Decisions at the Point of Care: Sore Throat

This evidence-based encounter form can help improve your diagnosis of strep throat.

Mark H. Ebell, MD, MS

Tool Inside

Covered in FPM Quiz

Justin, a 13-year-old patient who has had sore throat, fever and swollen glands for two days, presents to your office. On examination, he has exudative tonsillitis and tender anterior cervical nodes but no posterior cervical adenopathy. What is his probability of having group A beta-hemolytic streptococcal (GABHS) pharyngitis?

The evidence-based answer is at hand

If you don't have all the evidence you need to answer this question already in your mind, you're not alone; physicians simply cannot expect to remember all the latest clinical evidence.^1-4 But you can have the evidence at your fingertips when you need it. The sore throat encounter form below is an evidence-based guide you can implement easily in your practice.

The form incorporates a strep score calculator developed by McIsaac³ - the best one available. It is simple to use, takes age into account and has been tested and found to be accurate in a group of over 600 adults and children presenting with sore throat to family physicians. Using the encounter form, you could quickly calculate Justin's strep score at 5, meaning there is a 52-percent chance that he has GABHS pharyngitis. It would then be reasonable to treat him empirically. Another option for these high-risk patients is to base treatment on the results of a rapid strep test, or to obtain a throat culture and call the patient in two days with the results. If the culture is negative, you could discontinue antibiotics, recognizing the potential for false-negative culture results when the pretest probability is sufficiently high.

The encounter form takes into account the group of signs and symptoms that best help make the differential diagnosis: tonsillar swelling or exudates, tender anterior cervical nodes, history of fever or a measured temperature of >100.4 F, absence of cough and age. A review looking at individual signs and symptoms found that exposure to strep throat infection in the previous two weeks not surprisingly increases the risk of strep. It also found that the presence of a scarlatiniform rash or palatine petechiae is uncommon, but very specific for the diagnosis.⁴

To familiarize yourself with the form - and incidentally to see how well you have been doing in managing GABHS pharyngitis - consider using it to audit chart notes for a few recent visits for sore throat. And keep it close at hand throughout the sore throat season.

Watch future issues of American Family Physician and Family Practice Management for similar forms useful in dealing with other common or important conditions seen in your practice. Their use can help even the busiest of physicians make evidence-based decisions at the point of care.

SORE THROAT ENCOUNTER FORM  A PDF version of this document is available. Download PDF now (1 page/ 42 KB). Patient's name: ____________________________________________________ Age: _________ Medical record #: ___________________ Data collection: Symptom Points History of fever or measured temp >100.4 F 1 Absence of cough 1 Tender anterior cervical nodes 1 Tonsillar swelling or exudates 1 Patient's age <15 years 1 15 to 45 years 0 >45 years -1 Total: _____ Score: 0 to -1 point: Strep throat ruled out (only a 2% risk). 1 to 3 points: Order rapid strep test; treat accordingly. 4 to 5 points: Diagnose probable strep throat (52% risk); consider empiric antibiotic therapy. Suggestive findings Diagnostic considerations Palatine petechiae or scarlatiniform rash Probable strep throat Contact with strep infection in past 2 weeks Duration of illness <3 days Consider strep throat Headache     Petechial rash Stiff neck Consider meningitis Hot-potato voice Sudden/severe symptoms Consider abscess Posterior cervical adenopathy or teenager Consider mononucleosis Rapid strep test: Positive Negative NA Mono spot test: Positive Negative NA Other history: Diagnosis: Probable or confirmed strep throat ________________________________ Viral pharyngitis _______________________________________________ Mononucleosis ________________________________________________ Other: Antibiotic treatment: None needed __________________________________________________ Penicillin V potassium __________________________________________ Cephalexin ___________________________________________________ Erythromycin _________________________________________________ Azithromycin _________________________________________________ Symptomatic measures: Follow-up visit: NSAID     2% lidocaine gargle prn only Sore throat spray    Salt water gargles _____ days Other treatment: Patient education handout given. Developed by Mark H. Ebell, MD, MS. Copyright © 2003 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. "Making Decisions at the Point of Care: Sore Throat." Ebell MH. Family Practice Management. September 2003:68-69; www.aafp.org/fpm/20030900/68maki.html.