Family Medicine · Year 3 · from Family Medicine
Case 1: Sore Throat - Is It Strep?
Patient Demographics
- Age: 19 years old
- Sex: Female
- Occupation: College student
Chief Complaint
"My throat has been killing me for 2 days. I think I need antibiotics."
History of Present Illness
Ms. Aisha Johnson is a 19-year-old college student presenting with severe sore throat for 2 days. She reports difficulty swallowing, subjective fever (felt "hot" last night), and fatigue. She denies cough, congestion, or runny nose. Her roommate had a similar illness last week and was treated with antibiotics. She has midterm exams this week and wants to "get better quickly."
Review of Systems
- Positive: Sore throat, fever, fatigue, decreased appetite, mild headache
- Negative: No cough, no nasal congestion, no rhinorrhea, no rash, no joint pain, no abdominal pain
Past Medical History
- No chronic conditions
- No prior history of strep throat
- No allergies to medications
Physical Examination
- Vital Signs: Temp 101.2F (38.4C), HR 88, BP 110/70, RR 16
- General: Uncomfortable-appearing, but not toxic
- HEENT:
- Oropharynx: Bilateral tonsillar enlargement with white-yellow exudates
- No palatal petechiae
- Uvula midline, not edematous
- Neck: Tender, enlarged bilateral anterior cervical lymphadenopathy
- Lungs: Clear to auscultation
- Skin: No rash
Clinical Image
Image: Culture-positive streptococcal pharyngitis showing enlarged tonsils with white exudates, characteristic of Group A streptococcal infection.
Image Source: Wikimedia Commons Attribution: James Heilman, MD, CC BY-SA 3.0 URL: https://commons.wikimedia.org/wiki/File:Strep_throat2010.JPG
Modified Centor Score Assessment
| Criteria | Present? | Points |
|---|---|---|
| Tonsillar exudates | Yes | +1 |
| Tender anterior cervical lymphadenopathy | Yes | +1 |
| Fever (history or measured > 38C) | Yes | +1 |
| Absence of cough | Yes | +1 |
| Age 15-44 years | Yes | 0 |
| Total Score | 4 |
Interpretation: Score of 4 indicates high probability of Group A Streptococcal pharyngitis (approximately 50-60% pre-test probability). Testing is still recommended before treatment.
Diagnostic Testing
- Rapid Strep Test: Positive
Assessment
- Group A Streptococcal pharyngitis - Confirmed by positive rapid strep test
Management Plan
Antibiotic Therapy:
- Amoxicillin 500 mg PO twice daily for 10 days
- Alternative if penicillin-allergic (non-anaphylactic): Cephalexin 500 mg twice daily for 10 days
- Alternative if severe penicillin allergy: Azithromycin 500 mg day 1, then 250 mg days 2-5
Supportive Care:
- Acetaminophen or ibuprofen for pain and fever
- Salt water gargles
- Throat lozenges
- Adequate hydration
- Rest
Patient Education:
- Symptoms should improve within 1-2 days of starting antibiotics
- Complete the full 10-day course to prevent rheumatic fever
- Contagious until 24 hours after starting antibiotics; avoid close contact
- Return if worsening symptoms, difficulty swallowing liquids, or drooling
Return Precautions:
- Difficulty breathing or swallowing
- Inability to swallow saliva (drooling)
- Severe neck swelling or stiffness
- Symptoms not improving after 48-72 hours of antibiotics
Follow-Up
- No routine follow-up needed if symptoms resolve
- Return if symptoms persist or worsen
Teaching Points
- Modified Centor Score: Useful for estimating strep probability and guiding testing decisions. Even with a score of 4, testing is preferred before treatment due to significant false-negative clinical prediction.
- Antibiotic stewardship: Antibiotics for pharyngitis are only indicated for confirmed or highly suspected GAS infection. Most pharyngitis is viral.
- Treatment goals: Primary goal of treating strep throat is preventing rheumatic fever, which requires completing the full antibiotic course.
- Test before treat: Rapid strep testing is recommended even with high clinical suspicion to avoid unnecessary antibiotics for viral pharyngitis.