Author Affiliations: Michigan State University, East Lansing (Drs Ebell, Smith, and Barry, Ms Ives; and Mr Carey); First Consulting Group, Okemos, Mich (Ms Ives).
The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and
Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor
Context Sore throat is a common complaint, and identifying patients with group
A β-hemolytic streptococcal pharyngitis (strep throat) is an important
task for clinicians. Previous reviews have not systematically reviewed and
synthesized the evidence.
Objective To review the precision and accuracy of the clinical examination in
diagnosing strep throat.
Data Source MEDLINE search for articles about diagnosis of strep throat using history-taking
and physical examination.
Study Selection Large blinded, prospective studies (having ≥300 patients with sore
throat) reporting history and physical examination data and using throat culture
as the reference standard were included. Of 917 articles identified by the
search, 9 met all inclusion criteria.
Data Extraction Pairs of authors independently reviewed each article and used consensus
to resolve discrepancies.
Data Synthesis The most useful findings for evaluating the likelihood of strep throat
are presence of tonsillar exudate, pharyngeal exudate, or exposure to strep
throat infection in the previous 2 weeks (positive likelihood ratios, 3.4,
2.1, and 1.9, respectively) and the absence of tender anterior cervical nodes,
tonsillar enlargement, or exudate (negative likelihood ratios, 0.60, 0.63,
and 0.74, respectively). No individual element of history-taking or physical
examination is accurate enough by itself to rule in or rule out strep throat.
Three validated clinical prediction rules are described for adult and pediatric
Conclusions While no single element of history-taking or physical examination is
sufficiently accurate to exclude or diagnose strep throat, a well-validated
clinical prediction rule can be useful and can help physicians make more informed
use of rapid antigen tests and throat cultures.
Ebell MH, Smith MA, Barry HC, Ives K, Carey M. Does This Patient Have Strep Throat?. JAMA. 2000;284(22):2912–2918. doi:10.1001/jama.284.22.2912