What history questions should I ask a patient with suspected group A Streptococcus (GAS) pharyngitis?

History Questions for Suspected Group A Streptococcal Pharyngitis

When evaluating a patient with suspected GAS pharyngitis, focus your history on distinguishing bacterial from viral etiology by asking about symptom onset, fever pattern, associated respiratory symptoms, and epidemiological risk factors.

Core Symptom Characteristics

Onset and Timing

• Ask about sudden versus gradual onset of sore throat – GAS pharyngitis typically presents with sudden onset of throat pain, which is a key distinguishing feature 1
• Inquire about pain with swallowing (odynophagia) – this is a common presenting complaint in streptococcal infection 1
• Determine the season and timing – GAS pharyngitis is most common in winter and early spring (November–May) in temperate climates 1

Fever and Constitutional Symptoms

• Ask specifically about fever presence and severity – fever is a hallmark of GAS pharyngitis 1, 2
• Inquire about headache – commonly reported in streptococcal pharyngitis 1, 2
• Ask about nausea, vomiting, or abdominal pain, especially in children – these gastrointestinal symptoms may accompany GAS pharyngitis in pediatric patients 1, 2

Critical Questions to Suggest VIRAL Rather Than Streptococcal Etiology

The absence of fever or presence of the following symptoms strongly suggests viral pharyngitis and may obviate the need for testing:

• Ask about cough – presence suggests viral etiology 1
• Ask about runny nose/nasal congestion (coryza) – indicates viral infection 1
• Ask about hoarseness or voice changes – suggests viral cause 1
• Ask about conjunctivitis or eye symptoms – points to viral etiology 1
• Ask about mouth ulcers or sores – discrete ulcerative lesions suggest viral infection 1, 3
• Ask about diarrhea – more consistent with viral illness 1

Epidemiological and Exposure History

Age and Risk Factors

• Document patient age – GAS pharyngitis primarily affects children 5–15 years of age; it causes only 5–15% of adult pharyngitis cases 1, 2
• For adults, ask about occupation and household composition – parents of school-age children and those working closely with children have higher risk 1
• For children under 3 years, assess risk factors – classic GAS pharyngitis is uncommon in this age group unless there are risk factors like an older sibling with GAS infection 1

Contact and Exposure History

• Ask about close contact with documented cases of strep throat – recent exposure to a confirmed case increases likelihood of GAS infection 1, 2
• Inquire about community or school outbreaks – awareness of high GAS prevalence in the community is helpful 1
• Ask about shared living spaces or close-contact activities – dormitories, athletic teams, and close-contact sports increase transmission risk 4

History Related to Recurrent Episodes

For Patients with Recent or Multiple Episodes

• Ask about recent antibiotic treatment – if symptoms return shortly after completing therapy, consider treatment failure, noncompliance, reinfection, or carrier state with viral superinfection 1
• Inquire about medication compliance – noncompliance is a common cause of apparent treatment failure 1
• Ask about frequency and pattern of recurrent episodes – multiple episodes over months to years suggest possible chronic carrier state with intercurrent viral infections 1
• Document whether the patient had asymptomatic intervals – presence or absence of GAS during symptom-free periods helps distinguish carriage from repeated infections 1
• Ask about household members with recurrent infections – may suggest "ping-pong" transmission within the family 1

Clinical Decision-Making Based on History

The IDSA guidelines emphasize that clinical scoring systems predict positive throat cultures only ≤80% of the time, so laboratory confirmation is essential unless the diagnosis can be confidently excluded on clinical and epidemiologic grounds 1.

When Testing Is Indicated

Testing should be performed when clinical and epidemiological features suggest GAS pharyngitis – specifically when patients have suggestive symptoms (sudden-onset sore throat, fever, odynophagia) WITHOUT viral features (no cough, coryza, hoarseness, conjunctivitis) 1, 3.

When Testing May Not Be Needed

Testing usually need not be performed when clinical and epidemiological features do not suggest GAS etiology – particularly when viral symptoms predominate 1.

Important Clinical Pitfalls

• Do not test asymptomatic contacts – even with known exposure to documented strep throat, testing asymptomatic individuals leads to identification of carriers rather than true infections 5
• Recognize that physicians often overestimate the probability of GAS pharyngitis – laboratory confirmation prevents unnecessary antibiotic use 1, 3
• Be aware that up to 20% of school-age children may be asymptomatic GAS carriers during peak season – positive tests in patients with predominantly viral symptoms may represent carriage, not acute infection 1