Amanda Angelotti MD

Health - Writing - Tech - Systems Design

Is it Strep or just a sore throat? Here’s how doctors tell the difference.

So you have a sore throat. Should you just rest and gargle, or schlep to the doctor’s office?

Strep throat, or Streptococcal pharyngitis, is a bacterial infection that can be treated with antibiotics to shorten the duration of symptoms and prevent complications. It’s most common in young, school-age children. When an adult gets a sore throat, 90% of the time it’s caused by a common cold or virus that antibiotics won’t help. But they both feel like crap, so how do you tell the difference?

In health care we use an algorithm called the Centor Criteria to make the call. It’s a clinician’s quick-and-easy way to figure out the likelihood that someone with a sore throat has a bacterial infection that should be treated. It’s not usually used by people outside of the medical profession, and it’s filled with jargon meant for doctors and nurses — but I’ve translated it into plain English for you. You’re welcome. :)

If you come down with a sore throat, take the quiz below, add up your points, and find out what your primary care provider would do next.

Sore Throat Quiz

1) How old are you?

  • 3–14 years old (1 point)

  • 15–44 years old (0 points)

  • 45 years or older (-1 point)

2) Do you have white pus (“exudate” in medical jargon) on your tonsils? (1 point)

Have a friend or family member take a look with a flashlight, or open wide and look in the mirror. I won’t post it here because it’s kind of icky, but if you want to know what pus on your tonsils really looks like, check out this Google Image Search for “tonsillar exudate."

Look for clear spots or streaks of white pus on your tonsils (credit: ).

Look for clear spots or streaks of white pus on your tonsils (credit:

3) Do you have swollen, tender lymph nodes on the front sides of your neck? (1 point)

Lymph nodes make immune cells. They swell up and can become tender when they’re hard at work making white blood cells to fight infections. When you have an upper respiratory infection (URI), the lymph nodes on either side of your Adam’s apple will be swollen.

4) Do you have a fever? That’s over 100.4°F or 38°C. (1 point)

It’s common to have low, temporary fevers with viral URIs like the common cold. A higher fever that lasts longer than a couple days is more likely to be caused by a bacterial infection like Strep. If you haven’t checked your temperature but you’re pretty sure you have a fever, that counts, too.

5) Do you have a cough? (0 points if yes, 1 point if no)

If you do, it’s much more likely to be caused by a cold virus giving you sinus congestion that’s draining into your throat. You’re more likely to have Strep if you don’t have a cough.

Total up your points

If you got a 3, 4 or 5, you meet Centor Criteria. This doesn’t mean you necessarily have Strep throat, but  it does mean you should be tested for Strep in the office. Your provider will either do a Rapid Strep Test or take a swab from your throat for a bacterial culture, or both. The results will indicate whether you have Strep and should be treated.

Treating Strep Throat

The treatment for Strep throat is penicillin, usually taken for 10 days (ask your provider about alternative antibiotics if you’re allergic to penicillin). Taking an antibiotic for Strep alleviates your symptoms and makes you less contagious. It also lowers your risk of developing a more serious throat infection or a very rare complication called rheumatic fever, which primarily affects the heart and joints.

Here are some reasons you might not want to take antibiotics, even if you have a strep infection:

  • You’re a healthy adult and you’d prefer to avoid antibiotics. If you rest and drink plenty of fluids, your immune system can actually handle a Strep infection on its own. You’ll get through it more comfortably if you treat your symptoms with the over-the-counter meds suggested below.

  • You want to avoid common side effects of antibiotics such as upset stomach, diarrhea, and, if you’re a woman, yeast infections. Antibiotics can do quite a number on the helpful bacteria in your body.

If you do start antibiotic treatment, remember to take every single dose of the medication all the way to the end, even if you start feeling better earlier, in order to prevent the bacteria from developing resistance to the antibiotics.

Managing Your Symptoms

Treating your symptoms often doesn’t mean taking antibiotics. Whether your upper respiratory infection is viral like the common cold or bacterial like Strep, the same rules apply for symptom control:

  • For sore throats, fever, headaches, and body aches: Take acetaminophen (Tylenol) or an anti-inflammatory pain reliever like ibuprofen (Advil, Motrin), naproxen (Aleve), or aspirin as directed. Special note: Never give aspirin to kids under 18 due to the risk of developing Reye’s Syndrome.

  • For congestion or sinus pressure caused by a head or chest cold: Try steam inhalation, nasal irrigation with a neti pot, over-the-counter nasal steroids like fluticasone (Flonase), or a strong decongestant like real pseudoephedrine (show your ID at the pharmacy counter to get it).


A version of this article was originally published on the One Medical Blog.

Juice Plus: Candy masquerading as health food


The other day while getting my hair cut, I mentioned I was hungry and a little spacey from low blood sugar, and the nice Marin lady in the chair next to me shared a bite to eat.

I’d never heard of Juice Plus before, so I didn’t realize I was about to get a sales pitch. I opened the package and ate what tasted like fancy fruit snacks. I checked out the ingredients on the back, which were, in order:

  1. Tapioca syrup
  2. Maltodextrin
  3. Organice evaporated cane juice

In other words, the first three ingredients are: sugar, sugar, and sugar.

Dear reader, anything that’s made of mostly sugar fits neatly into a food group that we might call “candy.” Seriously, even a Snickers would be preferable — its main ingredients are milk chocolate, peanuts, and corn syrup. At least you get some protein with your sugar and sugar!

I guess it shouldn’t surprise me that someone from the epicenter of antivaxxers and unflouridated water would believe that these gummies are nutritious.

Here’s the two-minute video my new salon friend had me watch on her iPhone, in which an obviously well-educated M.D./Ph.D. tries to convince you that Juice Plus fruit snacks and chocolate shake powder are “whole foods” that contain more servings of fruits and vegetables than you’d ever be able to eat in a day. LOL.

Please stop going to the doctor for colds, flus, sinus infections, and bronchitis

A Dr. Amanda public service announcement!


One way to really do a solid for our strained primary care system is to stop going to the doctor for viral upper respiratory infections (URIs), including colds, flu, sinus infections, and bronchitis (chest cold).

You do not need our help. Stay home. Rest, drink fluids, and take over-the-counter medications for your symptoms.

Important exceptions

  • You’ve been sick for a while, and then you start feeling much worse
  • You have a sustained fever over 102 degrees Fahrenheit
  • You’re really short of breath or wheezing
  • You’re coughing up blood (not just a little speck)
  • You’re having severe nighttime coughing fits that make you throw up (called post-tussive emesis), and/or you know you were exposed to whooping cough
  • There’s anything else that’s really worrying you

(Different rules apply if you are a baby.)

A Western doctor’s job is to rule out the bad stuff that really needs antibiotic intervention, such as pneumonia, pertussis (whooping cough), or sinusitis that’s become complicated by a bacterial infection.  This happens in LESS THAN 2% of sinus infections, so probably not yours :).

If you’re experiencing any of the above, by all means please call or see your health care provider as soon as you can. Everybody else, read on to learn how to diagnose and manage your own viral URI!

What to expect with a cold

You’ll probably get colds dozens of times in your life. If you don’t already know the typical symptom progression and how to recognize it, now’s the time.

Day 1: Scratchy or sore throat, runny nose, sneezing, some fatigue.

Day 2: Mild-to-moderate nasal congestion kicks in. Low fever and more fatigue.

Day 3–4: Worsening nasal congestion. Sinus and ear pressure as the congestion backs up. Possibly a headache. Your snot might turn yellow or green, which is a normal immune response and, counter to conventional wisdom, doesn’t differentiate a bacterial infection from a viral one.

Day 5–7: Congestion improves and you’ll start to feel more like yourself, but coughing begins as your sinuses drain all of the goop they’ve produced over the last few days.

Week 2–3: Hacking, post-viral cough that usually goes away within a week or two but can linger for up to three. If you’re still coughing after eight weeks (and you’re a nonsmoker who’s not taking a blood pressure medicine called an ACE inhibitor that can cause a dry cough), then it’s finally time for you to head in to your primary care office for a chest X-ray. Something else may be up.

With influenza (“the flu”), add to the above symptoms a headache and all-over body ache that just about levels you. I’ve never had the flu, but I’ve heard it feels like death warmed over. Seriously, get a flu shot every year.

What actually helps

There are drugstore aisles full of over-the-counter (OTC) cold and flu medications, but what really works?

Interestingly, for a common cold and post-viral cough, the drugs that are together most effective at treating symptoms don’t exist as an OTC combination formula:

  1. Pseudoephedrine, a powerful decongestant, also known by its brand name Sudafed. You have to ask the pharmacist behind the counter and show your ID to get the original pseudoephedrine because unfortunately some people use it to make meth. Don’t get the Sudafed “PE” that’s on shelves in the cold and flu aisle — it’s made with phenylephrine and doesn’t do much.
  2. A first-generation antihistamine such as diphenhydramine (a.k.a. Benadryl), chlorpheniramine, or brompheniramine. Non-drowsy, second-generation antihistamines like fexofenadine (Allegra) are ineffective here. It’s unclear why.
  3. A non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin) or naproxen (Aleve).

This combination is what I’ve taken to calling the secret sauce for the common cold. When you combine an antihistamine with a strong decongestant like pseudoephedrine, it’s a one-two punch that dries up your sinuses. They have totally different mechanisms of action, but both help tighten up your blood vessels to reduce inflammation. It’s this synergy that really does it. Add an NSAID with its own anti-inflammatory effect (plus pain relief), and you’ve got yourself one badass cold remedy. The evidence is pretty solid, so I don’t know why we haven’t made it a thing.

Some other good options for symptom relief are a neti pot (like NeilMed Sinus Rinse) or a steroid nasal spray (like fluticasone, a.k.a. Flonase), both of which you can get over the counter in any drugstore. All evidence aside, the important thing is to find what you think works best for you.

Here’s the closest thing we have to a cure for the common cold: sleep and hydration. Curl up, watch some Netflix, and be patient with yourself and your body.

But say you have a presentation at work tomorrow, or you’re about to hop an international flight for a snorkeling trip in the Caribbean. “Doctor, I just can’t be sick right now.” There’s now research to show that at least a couple of so-called “natural” chemicals lessen the duration of your cold symptoms in addition to their severity, most likely by supporting your immune system: pelargonium (Umcka at Whole Foods) and zinc. For them to really work, you have to start taking them in the first 24 hours of symptoms and exactly as often as directed. Zinc can give you a gross tummy ache, so make sure you always eat at least a snack before you take it. In my personal experience, the “rapid melts” are less offensively metallic than the lozenges.

For the flu, the antiviral, prescription-only Tamiflu works, but only if you start taking it within the first 48 hours. After that it doesn’t do much to alleviate symptoms or shorten the duration of the infection. Clinical guidelines recommend Tamiflu for high-risk patients (over 65, under 2, pregnant women, people with chronic illnesses, etc); otherwise we leave it up to you. And always remember your old anti-inflammatory friends, ibuprofen and naproxen, for symptom relief. (Aspirin works, too, but don’t give it to kids under 18 with a viral infection because it puts them at risk for Reye’s Syndrome.)


In conclusion, save the doctor’s office for when you (and your fellow humans) really need it! Learn to diagnose and manage your own viral upper respiratory infections, and it’ll pay off year after year. Re-read this post and bookmark it for later when you feel that scratchy throat coming on…


Originally published on Medium.