Saturday, March 12, 2011

Family Medicine: Is it Flu, Strep Throat or a "Flep" or "Stru Throat"?

Lots of people are infected with something- coming out of three months of "real" winter in Ohio, during which people were trapped indoors breathing and coughing on one another.  Strep throat is going through the schools, high/ middle/ elementary and pre. Fever, painful throat- a continuous deep red section of redness, with tiny red spots on the rearmost aspect of the roof of the mouth but sparing the nose of redness or swelling in the over six group, are prevailing symptoms in our patients (although with the high numbers of people here with allergic rhinitis including swollen nasal turbinates and clear nasal mucous, it gets more challenging to find the pure presentation of strep throat). The kids under 6 years old may have the same findings as an  adult or deep red conjunctiva, nasal turbinates, pharynx and tonsils, usually without the misunderstood exudates that texts imply have some correlation with strep throat.  They also often have the tender anterior cervical swollen, tender lymph nodes ("glands" a few inches below the jaw bone high on both sides of the neck).  The adults I see with strep seldom have this finding.

I participated in a large strep throat research project in my Newark, OH office about 27 years ago that left a lasting impression.  My "strep mentor", Tennyson Williams, MD, who I interviewed on the Dr Synonymous Blog Talk Radio Show on March 8 and mentioned in the blog post on this site outlining the show,  was the principal investigator of the study based out of the Department of Family Medicine at Ohio State.  In the information gathering for the study, we noted the presence or absence of several findings in the ENT exam, among others.  The appearance of the nasal mucous membranes and the uvula held a lot of power when considering strep infection.  I still look up a lot of noses and carefully note the uvula in the back of the throat as key elements of upper respiratory infection differentiation.

The Flu is now moving in also with five or more days of symptoms including sore throat, body aches/ pains, fever and cough.  On day four to six, the infection is often so annoying that the patient or parents seeks medical attention, convinced of the need for an antibiotic, chest x--ray or cough suppressant.  People with chest tightness from tiring muscles plus or minus wheezing seek relief from their painful misery.  Some people just want to get a note so they can get back to school or work when well.  Employers just don't allow a good illness to follow its natural history without involving physicians.  If you know you don't need medical attention, can't you be trusted to decide when you're recovering or recovered?  Is it a covered benefit under your insurance to use a physician when not ill to get a note to return to work?  Can't your mother just write an excuse for your absence?  (No -according to many employer and school policies.  The now functional worker or student must go to a doctor to get cleared for their illness-caused absence, sitting in a waiting room with the coughing people, before their school or employer will believe them as to why they were absent.  What a waste of resources this type of distrust generates.)

So what if someone was exposed to strep and developed sore/ painful throat for a couple days then they got muscle pains and cough, and shift toward a flu presentation with their symptoms?  When we see folks with a mixed story like that and they have the mixed/combined symptom story with the combined physical findings, we are challenged to fully know which primary infection is driving toward whatever secondary infection might be present.  So we get the Rapid Strep test (throat swab plus five minutes for the test to reveal a positive or negative result) and the flu quick test (nasal swab plus 15 minutes waiting for it to "develop" with the potential to show influenza A or B or none).  I'm not prone to have persons with flu or strep or whatever infection go back to our waiting room until the tests yield their opinion, so we leave them in the exam room, eliminating one fifteen minute visit from happening on time due to the room being occupied.

None of the three tests is perfect.  There is a high chance they'll register the presence of the infection if the infection is in the patient and a high chance it'll be accurate if it implies absence of the infection.  BUT, the physician has to interpret the test and the meaning of the result in light of the patient's findings and story, including an analysis of the probabilities regarding accuracy of the tests and accuracy of all information gathered.  That's where the differential diagnosis further expansion and contraction is "completed."  The tests are not self explanatory and may mislead one to mis-interpret the results.  The information and test interpretation skill is one of the fun challenges in medical practice.  Statistical insights are one of the skills needed to get the best outcome.  Interpersonal skills and an understanding of the natural history of the infections under consideration are critical as the family physician considers how they each might affect the ongoing health of the patient in light of their chronic good, fair or poor health.  The family context and the health and activity of family members is an extra consideration for the family physician.

Yes, the flu finally made it to our area, but it's not showing up in a pure way.  The strep and other infections are clouding the image of the flu.  Is it flu or strep or "flep" or "stru throat", a nasty and confusing combination?


  1. We've been seeing a lot of that stuff down south too! The worst thing is when the patient wants to know what they have and all the tests are negative and all i can say is, "crud".

  2. Thanks for the comment, Dr F2F, the"crud" might be more challenging in TX where everything is bigger than OH. I think we have smaller microbes up here.

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